Primary bone lymphoma is a very uncommon malignancy, which is responsible for 3% of all bone tumors. We report a case of an 80-year-old patient with chronic back pain associated with a pathological T9 fracture. During admission, spinal cord compression with paraparesis was detected and managed with radiotherapy. After investigation, it was discovered to be caused by a primary bone lymphoma. Staging showed multiple bone lesions compatible with polyostotic lymphoma. Histopathology revealed a diffuse large B-cell lymphoma, which was treated with chemotherapy . In this case report, imaging modalities used to diagnose and stage the disease are discussed. Traditional and new prognostic tools and treatment are also reviewed. Lymphomas are cancers of B, T, and natural killer cells that originate in lymphoid tissue  or in tissues outside the lymph nodes . The presence of Reed-Sternberg cells is one of many characteristics of Hodgkin lymphoma. All other lymphomas are classified generally as non-Hodgkin lymphomas. Extranodal disease has been described in many locations, namely craniofacial, thyroid, breast, and bone .Lymphomas can affect the skeleton either as a solitary lesion or as part of disseminated disease. The definition of primary bone lymphoma (PBL) has evolved during the last few decades. The current WHO classification of Soft Tissue and Bone Tumors describes PBL as a neoplasm composed of malignant lymphoid cells, producing one or more lesions within the bone, with no lymph node involvement or other extranodal lesions . While tPBL is a rare disease encompassing only 3% of all malignant bone tumors and less than 5% of all extranodal non-Hodgkin lymphomas .An 80-year-old active man  presented with midline, lower back pain. His past medical history included arterial hypertension, type 2 diabetes, and osteoarthritis. His usual medication was perindopril and indapamide, sitagliptin, and glimepiride. The back pain begun insidiously six months prior, with progressive increasing intensity. The pain was dull and worse with active movement. Symptomatic medication with paracetamol and nonsteroidal anti-inflammatory drugs, previously prescribed, was insufficient for pain control. Upon questioning, he mentioned involuntary weight loss of 8 kg . There were no complaints of muscular weakness, paresthesia, or previous episodes of trauma (including minor events). Absence of fever, nights sweats, constipation, or urinary incontinence was noted.On examination, the patient was alert and cooperative. An assessment of the respiratory and cardiovascular system did not reveal any abnormalities. There was no palpable lymphadenopathy hepatomegaly or splenomegaly. Visual inspection of the thoracic and lumbar spine revealed no masses or swelling.9/L, and platelet count of 276 x 109/L. Further investigations yielded an erythrocyte sedimentation rate of 87 mm/hour (reference range 0-22 mm/hour), lactic acid dehydrogenase (LDH) of 187 U/L (reference range 100-190 U/L), alkaline phosphatase of 123 U/L (reference range 44-147 U/L), normal albumin levels, and protein electrophoresis, as well as a prostate-specific antigen value of 2.33 ng/mL . Contrast-enhanced computed tomography (CT) scan revealed a soft tissue mass in the ninth thoracic vertebrae, with lytic destruction and collapse of the vertebral body  revealed edema and compression of the spinal cord, in addition to extensive infiltration to the posterior arch of T8, T9, and T10 Figure .The patient underwent five sessions of decompressive radiotherapy to reduce the spinal cord pressure. However, he only recovered partially and became dependent of some assistance . A CT-guided biopsy was performed. Histopathological examination revealed intense diffuse infiltration by lymphoid cells of medium to large size, with irregular nucleus and multiple nucleoli. There were numerous images of apoptosis and mitosis. In the immunohistochemical study, cells were immunoreactive for CD20, CD10, BCL-2, BCL-6, MUM1, and vimentin. Also, the proliferative index was high (approximately 90%) and compatible with diffuse large B-cell lymphoma (DLBCL) of non-germinal center B type.The whole-body positron emission tomography (PET) scan showed high radiopharmaceutical uptake at the level of T9 and T10 vertebra Figure .Chemotherapy with an age-adjusted R-CHOP  regimen was initiated. The patient was discharged to the outpatient hematology clinic and continued chemotherapy. The patient passed away several days later from an acute myocardial infarction.Current knowledge regarding clinical characteristics, treatment, and prognostic factors of PBL is limited due to its low incidence. Available data are derived solely from case series and retrospective studies. A slight male predominance  has been consistently present, with a median age at diagnosis ranging from 45 to 60 years [Pain is the most prevalent symptom followed by the presence of a tumor mass and a pathologic fracture . The aveSymptoms of spinal cord compression are the presenting features of 16% of cases . In our PBL is typically associated with non-specific radiographic findings. On plain X-rays, lesions are more often lytic, but osteoblastic lesions and mixed patterns can be present. Contrast-enhanced CT is used to better define the extraosseous extension of lesions as well as cortical tumor breakthrough. MRI provides further detail on disease extension and tumor invasion, especially when involving the central nervous system. Usually, abnormal intensity areas are visible. They are hypointense on T1-weighted and hyperintense in T2-weighted imaging .Functional imaging assessment with 18FDG-PET scan is used to identify high uptake lesions. The addition of 18FDG-PET to CT scan enabled the upstaging of 42% of lymphoma patients in one study . The comThe diagnosis of bone lymphoma is histologic. DLBCL is the most common subtype of lymphoma not only as PBL (>80%) but also as secondary invasion of the skeleton . Tumor cImmunohistochemistry analysis is positive for B cell markers CD19, CD20, and CD79a, with variable reactivity for CD10 and CD75. T cells markers are usually absent, but small CD3+ cells can be present. BCL-2 and BCL-6 immunoreactivity is variable. The Hans algorithm uses immunohistochemistry markers to further subdivide DLBCL into germinal-center B-cell (GCB) phenotype and non-GCB phenotype. This subclassification has prognostic implications .Staging of PBL is mandatory as it determines prognostic and therapeutic options. The Ann Arbor modified criteria suggested by the IELSG group are usually used . Stage IThe prognosis of patients with primary bone DLBCL is dependent on disease staging. The five-year overall survival (OS) ranges from 82% for patients with stage IE to 38% in patients with stage IV DLBCL with skeletal involvement. The traditional International Prognostic Index has predictive value in patients with disseminated DLBCL with skeletal involvement. However, it is incapable of accurate prognostic prediction in a single lesion or polyostotic PBL. The IELSG14 study found patient age, performance status, and serum LDH levels to be independently associated with OS in patients with PBL . AdvanceThe rarity of PBL hinders the planning of randomized clinical trials. Treatment strategies are derived from retrospective studies. Approaches including chemotherapy, immunotherapy, surgery, and radiotherapy have been implemented. Surgery may be warranted to sample for histopathological diagnosis (if unsuccessful biopsy), stabilization, and internal fixation of unstable fractures, as well as decompression for spinal cord compression. In our patient, the involvement of multiple vertebrae (T8 to T10) associated with age and comorbidities justified the use of radiotherapy instead of surgery to manage spinal cord compression as described elsewhere .The IELSG and the Rare Cancer Network studies suggest an anthracycline-based chemotherapy as the first-line treatment followed by field radiotherapy ,17. ThisThe use of radiotherapy following primary chemotherapy in patients with primary bone DLBCL is controversial. Some studies show improvement, while others fail to show better outcomes when compared with chemotherapy alone . These dPatients with polyostotic lymphoma have an almost identical clinical presentation to patients with disseminated DLBCL with skeletal involvement. However, the prognosis is significantly better in patients with polyostotic DLBCL, with a five-year OS of 75% and 37% (p= 0.008), respectively [This case highlighted a rare cause of low back pain due to a primary bone DLBCL. More than 90% of all vertebral tumors are metastatic disease. However, PBL should be included in the differential diagnosis of male patients above the fifth decade of life. Biopsy of the lesion is essential for accurate diagnosis. In parallel with lymphoma-related investigations, careful monitoring of possible site-associated complications, such as spinal cord compression or hypercalcemia, should be performed. Usual treatment modalities are chemotherapy with or without consolidation radiotherapy. Tailored treatment, which accounts for patient frailty, should be considered.


Hepatocellular carcinoma (HCC) typically presents in patients with a chronic liver disease and rarely develops in healthy liver, especially within an accessory liver lobe. We present a case of a healthy 64-years-old woman who showed a serum alpha-fetoprotein (AFP) value of 226.3 µg/mL during a screening blood test. Past medical history was negative for chronic liver disease or cirrhosis. Intraoperative finding was an ovaloid mass connected with the second hepatic segment by a thin pedicle of hepatic tissue. Lesion was safely resected by laparoscopic approach. Histopathology analysis showed a trabecular hepatocellular carcinoma. After a 6-month follow up, there was no evidence of recurrent disease. This case report showed how serum AFP remains a highly sensitive marker, although the presentation of HCC was unusual. To our knowledge, this is the second case reported in the literature. Hepatocellular carcinoma (HCC) is the most common primary liver cancer and accounts for the fifth most common cancer worldwide and the third most common cause of cancer mortality .HCC largely occurs within an established background of chronic liver disease and cirrhosis . Hepatocarcinogenesis is linked tightly to chronic liver damage but rarely develops in healthy liver during normal aging .Accessory liver lobes (ALL) are defined as morphologic variations of the liver due to excessive development of hepatic tissue ,4. ALL iALL is usually asymptomatic. The presence of an ALL is often discovered occasionally and revealed by imaging. When symptomatic, ALL presents typically with abdominal pain due to its torsion, especially when the lobe is pedunculated . To our Herein, we present a case of HCC arising from an asymptomatic ALL.A 64-years-old woman in regular follow up after a microscopic transphenoidal surgery for pituitary adenoma was referred to our Unit due to an elevation of serum alpha-fetoprotein (AFP). Laboratory tests revealed serum AFP value of 226.3 µg/mL . Serologic markers were negative for hepatitis B or C viruses infection. Past medical history was negative for chronic hepatitis, alcohol abuse, or liver cirrhosis as well as family history for hepatocarcinoma. Patient was asymptomatic and physical examination showed normal findings, especially no evidence of hepatomegaly or weight loss. Contrast enhanced computed-tomography (CT) scan of the abdomen showed an ovaloid-shaped solid mass in the epigastrium very closed to the fundus of the stomach .Esophagus-gastroduodenoscopy revealed an imprint of the gastric mucosa of the fundus, compatible with gastro-intestinal stroma tumor (GIST). Furthermore, an ultrasound endoscopy was performed showing an oval-shaped mass of 40 mm by 20 mm compatible with gastric leiomyoma.After these preoperative investigations, the patient went to the operation room and laparoscopy was performed. Intraoperative finding was an ovaloid mass located in the left hypochondrium connected with the second hepatic segment by a thin pedicle of hepatic tissue.  The massThe value of serum AFP was 219.6 UI/mL immediately after surgery and 93.9 UI/mL on postoperative day 7, respectively. The value of serum AFP returned to normal values gradually. Oncologic consultation did not recommend adjuvant chemotherapy.Primary liver cancers, of which majority are HCCs, are now the fifth and ninth most frequent cancer in men and women, respectively . HCC devPathological alterations of liver parenchyma and hepatic perfusion, as seen in fibrotic changes by cirrhosis, lead to a decrease in hepatocyte function and a growth in transhepatic perfusion resistance, resulting in portal hypertension and significantly increase in mortality and morbidity .The occurrence of accessory liver lobe is caused by an error in the formation of the endodermal caudal foregut during the third gestational week and segmentation of the hepatic bud .An accessory liver lobe is a rare congenital anomaly, usually asymptomatic. An observational laparoscopic study revealed that the incidence of intraoperative accessory liver lobe and ectopic liver was 0.7% . Such ecThe association between accessory liver lobes and pedunculated tumors has not been clearly shown. Pathophysiology of HCC is assumed to be the same regardless of its growth on the accessory lobe and its association with liver cirrhosis, although no clear evidence is currently available . Some auIntraoperative findings were more consistent with a case of ALL than pHCC and histopathology analysis confirmed.The literature does not give any indication concerning prognosis of HCC within ALL as compared to intrahepatic parenchymal tumors. Of the three largest series in the literature comparing pedunculated to non-pedunculated hepatocellular carcinomas, evidence is poor to determine whether the prognosis of resected pedunculated tumors is comparable with non-pedunculated tumors ,22,23.Treatment of HCC would not differ whether the tumor is located in ALL. When feasible, surgical resection remains mandatory.This case report shows that HCC may grow within ALL and could often remain asymptomatic or can be misdiagnosed. Evaluation of serum neoplastic markers is useful to direct diagnosis. Laparoscopy remains mandatory both in diagnosis and surgical treatment.The development of HCC may occur within an ALL and is an extremely rare presentation. The diagnosis is mostly accidental and the treatment is surgical resection. Serum AFP remains an extremely sensitive marker.


Primary pulmonary angiosarcoma (PPA) is a rare malignant vascular tumor, of which early diagnosis is challenging due to lack of specific clinical manifestations and a low level of suspicion. Here, we report a case of PPA presented with advanced brain metastasis. A 21-year-old patient with 1 week history of headache and mild cough was hospitalized for a head injury. Head MRI showed multiple intracranial lesions with brain edema. Chest CT displayed bilateral pulmonary infiltrates with mediastinal lymph node enlargement. After 2 months of anti-tuberculosis treatment, the patient was readmitted for persistent headache and cough with occasional hemosputum along with worsening pulmonary and intracranial lesions. Despite seizure prophylaxis and control of intracranial pressure and brain edema, his symptoms progressively aggravated, accompanied by cough with bloody sputum, frequent epileptic seizures, and hypotension. He eventually developed coma and died within 3 months of onset of symptoms. An autopsy confirmed PPA with brain metastasis. Angiosarcoma is an uncommon malignant endothelial tumor originated from blood or lymphatic vessels, accounting for about 2% of all soft tissue sarcomas. The tumor can arise in any organ, most often in the head and neck cutaneous tissue . It is aThe patient was a 21-year-old male non-smoker without significant past medical history other than alcohol drinking (150 g/day). One week before admission, the patient developed a swelling headache without obvious inducement. The headache progressively intensified, accompanied by minor coughs without hemoptysis or other neurological symptoms. Two days before admission, the patient was admitted to a local hospital for head trauma and found to have multiple intracranial space-occupying lesions on a head CT scan. He was transferred to our hospital for further diagnosis and treatment.9/L, neutrophil 8.18 × 109/L and eosinophil 0.51 × 109/L, normal coagulation tests, normal tumor markers (CEA and AFP), and negative PPD test. Plain and enhanced head MRI revealed bilateral multiple intracranial lesions suggesting tuberculosis or possible metastatic tumors (On admission, the patient’s vital signs were stable, mental status normal and physical examinations unremarkable. Laboratory tests showed WBC 11.42 × 10c tumors . An enhac tumors . The patThe patient continued suffering from intermittent headache, cough with phlegm and occasional hemosputum. When he returned for follow-up 1 month later, his head MRI showed bilateral lesions wider than those of the previous one . Chest CPPA is a malignant tumor originating from pulmonary vascular endothelial cells and is a type of deep soft tissue angiosarcoma. The occurrence of the disease is extremely rare . The aveet al. reported a solitary PPA with large soft tissue masses in the left upper lobe, with mediastinal invasion and left parabronchial lymph node enlargement on the CT (Imaging is important in the diagnosis of pulmonary angiosarcoma, however, chest X-ray usually fails to detect fine changes of pulmonary angiosarcoma. PPA may present as multifocal or solitary nodular lesions on CT scans, with or without ground-glass changes, or with solidity changes . It is en the CT . At admiPPA accounts for 9.3% of total angiosarcomas  and tendLung biopsy and immunohistochemistry are the gold standards for the diagnosis of pulmonary angiosarcoma. Percutaneous fine needle aspiration cytology, bronchoscopic lung biopsy and thoracotomy/thoracoscopic biopsy are important means to obtain tissue specimens . PatholoAt present there is no unified treatment regimen for PPA. Surgical resection, radiotherapy, chemotherapy, immunotherapy and combined radiotherapy and chemotherapy have been reported in the literature . No treaIn conclusion, PPA is an extremely rare malignant tumor with a very poor prognosis. Because of the lack of specific clinical manifestations, timely diagnosis is difficult. The PPA patient reported here presented with early and advanced brain metastasis and was diagnosed after autopsy using histopathology and immunohistochemistry biomarkers. This case cautions us that PPA should be considered when a patient’s MRI shows multiple mixed signals accompanied by obvious brain edema of unknown origin. Once the disease is suspected, biopsy combined with immunohistochemistry should be used to confirm the diagnosis as soon as possible.


Gastric glomus tumor (GGT) is a rare neoplasm that is difficult to distinguish from other gastric submucosal tumors due to a lack of diagnostic experience. The goal of this study was to better understand GGT by looking at its clinicopathological features, computed tomography (CT) features, and differential diagnosis.The clinical data and CT findings of 21 pathologically confirmed GGT patients were examined. The clinical characteristics and CT findings of benign GGT were compared to gastric stromal tumors (GST) (n = 30) and heterotopic pancreas (n = 30).The 21 cases included six males and fifteen females ranging in age from 42 to 64 years. The lesions were found in the gastric body in four cases and the antrum in seventeen. GGT was diagnosed as benign in 20 cases and malignant in one. In benign cases, the glomus cells were small, uniform, showed perivascular hemangiopericytoma‑like or solid nest‑like structures. Obvious mitotic figures were observed in the malignant case. SMA staining was positive in the tumor cells. A quasi-round or round solid mass protruded into the gastric cavity in 20 benign cases, with a clear and smooth edge. The long to short diameter ratio was 1.01 ± 0.15. All of the benign cases had obvious enhancement, with homogeneous enhancement in ten cases and heterogeneous enhancement in ten cases, as well as central filling enhancement in 12 cases. The ratio of CT value of lesion to abdominal aorta in arterial phase and venous phase were (0.41 ± 0.11) and (0.81 ± 0.20), which were significantly higher than GST and heterotopic pancreas. The irregular mass broke through the gastric wall and invaded liver with poorly defined boundary and internal necrosis, heterogeneous persistent moderate enhancement with thickening blood supply arteries was seen in one malignant case with a long diameter of 150 mm and a thick diameter of 30 mm.CT enhancement usually shows persistent obvious enhancement, especially in arterial phase, which provides important value for the diagnosis. CT findings can help in the differential diagnosis of GGT and other submucosal tumors. Glomus tumors (GTs) are rare benign mesenchymal neoplasms originating from the glomus of the anastomoses of small arteries, usually occurring in the peripheral soft tissues, especially in the distal parts of fingertips or toes . Glomus This is a retrospective study that was approved by the Ethics Committee of Zhengzhou University’s First Affiliated Hospital, which waived the requirement for written informed consent due to the patients’ anonymity. Between January 2008 and June 2021, patients who met the following criteria were collected retrospectively in our hospital. Inclusion criteria: ① GGT confirmed by postoperative pathology; ② Abdominal CT plain scan and contrast-enhanced scan were performed preoperatively. The clinical and pathological data were complete. Exclusion criteria: ① There were obvious artifacts on the image; ② The lesion was too small to be recognized. All patients’ clinical manifestations and tumor marker results were documented.A total of fifteen cases were examined using the GE Discovery 750 HD CT and six using the Toshiba 320 CT. The scanning parameters for the former machine were: tube voltage of 120 kV, automatic mA, pitch of 0.984, thickness of 5 mm; and the scanning parameters for the latter machine were: tube voltage of 120 kV, tube current of 350 mA, pitch of 0.813, scan thickness and the increment of 5 mm. After an intravenous injection of nonionic iohexol  through a dual-head pump injector , contrast-enhanced images of the arterial phase and portal venous phase of each patient were acquired at 25 s and 60 s respectively.According to the gender, age (± 3 years) and diagnosis year of each GGT patient matched with GST and heterotopic pancreas patients, 30 GST and heterotopic pancreas patients were retrieved from picture archiving and communication system of our hospital. Two radiologists with 10 years and 30 years of experience interpreted the CT images independently. All images were uploaded to the GE ADW 4.6 workstation, and the coronal and sagittal images were reconstructed using the Multi-Planar Reformation (MPR) technique with slice thickness of 3 mm and slice spacing of 3 mm. The degree of enhancement of the tumor was based on dynamic CT imaging using HU attenuation, in which “obvious enhancement” was defined as > 40 HU, “moderate enhancement” as > 20 HU and “mildly enhancement” as < 20 HU.H. pylori infection. Fourteen of the 20 benign cases had abdominal pain, two had blood in their stool, two had acid regurgitation and heartburn, and two were discovered during physical examination. The median time from symptom onset to diagnosis was 9 months (3–60 months), and none of them had a history of digestive diseases or a family genetic history. The detection of tumor markers was not increased in the benign cases. In this group, 16 cases were treated surgically, and 4 cases were treated with gastroscopic resection. Table There were 21 GGT patients in total, with 6 males (28.6%) and 15 females (71.4%), a male to female ratio of nearly 1:2, and age range 42–64 (54.70 ± 7.27) years. Two of the patients had a history of For the malignant case, a 63-year-old woman, the main complaint was upper abdominal pain and the time from symptom onset to diagnosis was 4 months. Among tumor markers, CA-125 (42.60 U/ml) was elevated. In this case, a distal gastrectomy was performed, as well as postoperative chemotherapy. There was no evidence of recurrence during the follow-up 16 months after the surgery.Twenty cases of GGT were found to be benign, with only one case being found to be malignant. Microscopically, tumor interspersed and grew between the muscularis propria of the gastric wall and contained many blood vessels, and one case had small focal calcification. The tumor boundary was distinct without capsule formation. The glomus cells were small, uniform, round, and showed perivascular hemangiopericytoma-like or solid nest-like structures without nuclear pleomorphism or mitotic figures. The tumor cells of the malignant case showed diffuse growth and high density. Obvious enlargement of nuclear volume, prominent cellular atypia, mitotic figures was observed Fig. E, F, G, Endoscopic ultrasound was performed on 12 patients, 6 of whom were hypoechoic (Fig. All the 21 patients were single lesion. Among the 20 benign cases, 4 were in the gastric body, 16 were in the gastric antrum. One malignant case was located at the gastric antrum. 20 benign cases were quasi-round or round protruding into the gastric cavity with well-defined boundary, with no ulcers on the surface or signs of invasion Fig. ig. F. 12. In this group, 15 cases were middle-old females in this group, and the clinical symptoms of GGT were similar with other gastric submucosal tumors, with no statistical difference of clinical symptoms found when compared with GST and heterotopic pancreas respectively. The vast majority of GGT are benign, malignant GGT is extremely rare [. In our group, one case presenting with upper abdominal pain was confirmed as malignant GGT. The etiology and mechanism of GGT are still not clear, while a few cases are familial and may be related to 1p21-22 [GT is rare in stomach which accounts for approximately 1% of gastric mesenchymal tumors , 9 and wely rare . In our  1p21-22 .Glomus tumors are classified as vascular pericyte tumors in the WHO classification of soft tissue tumors. GT is classified into bulbar tumor, bulbar hemangioma, bulbar hemangiomyoma, and a few special types such as myxoid hemangioma, eosinophilic hemangioma, epithelioid hemangioma, and others based on the proportion of smooth muscle cells, globular cells, and vascular components. However, tissue classification is not related to the biological behavior of the tumor. Folpe et al. divided GT into benign tumor, malignant tumor or tumor with uncertain malignant potential . The hisGGTs are usually located in the submucosa and muscularis propria of the gastric wall. In our study, 12 patients had ultrasound gastroscopy, which revealed a low-echo or high-echo mass with homogeneous or inhomogeneous echo. Ultrasound gastroscopy can show the location of the tumor in the gastric wall, however, it is easily confused with other gastric submucosal tumors due to the lack of specificity. The upper gastrointestinal radiography showed round or quasi-circular filling defects with smooth boundary. Non-contrast CT images show single soft tissue lesion in the submucosa of gastric antrum with endophytic, exophytic or mixed growth. In our study, endophytic growth and mixed growth were more common. Most of GGTs are benign with smooth edge and well-defined boundary. Peri-gastric fat space is clear with no lymph node enlargement. Some literatures have reported spotty calcification in GGT due to the deposition of micro-phlebolith . HoweverMalignant GGT is extremely rare and has been reported only in a few literature , 19, 20.CT examination can provide a wealth of valuable information on the morphology, size, internal structure, growth pattern and blood supply of the lesion, while MPR can show the accurate location of the GGT. Due to lack of typical clinical and endoscopic characteristics, GGT needs to be differentiated from other similarly manifesting gastric submucosal tumors such as GST and heterotopic pancreas , 22. GSTGGT is rare and most commonly occurs in the gastric antrum of middle-aged and elderly women with atypical clinical manifestations, multiphase CT enhancement usually shows persistent obvious enhancement especially in arterial phase which provide important value for the diagnosis of GGT. The enhanced degree and pattern are based on its histological features. CT findings can help in the differential diagnosis of GGTs and other submucosal tumors of the stomach. The final and correct diagnosis, however, is dependent on the pathological and immunohistochemical results. It is critical to continuously report and collect newly diagnosed GGT in order to improve clinical and imaging understanding of GGT.


Moyamoya disease (MMD) is a rare, chronic cerebrovascular disease affecting the cerebral arteries, leading to the development of unique collateral vessels. Few cases were reported from Saudi Arabia; however, the incidence rate is not well-defined. Hence, we present a case of a 13-month-old child who presented to the emergency room with first onset focal seizures with relatively unremarkable past medical and family history. Investigations were ordered accordingly including head computed tomography (CT) scan, brain magnetic resonance imaging (MRI), and cerebral angiogram, and he was diagnosed with MMD and considering a broader variety of differential diagnoses for seizures in children is highlighted in our case. Furthermore, considering their predominance in east Asian countries, it highlights a rare presentation in the middle eastern race. Moyamoya disease (MMD) is a rare, chronic cerebrovascular disorder that is characterized by progressive stenosis of the intracranial internal carotid artery (ICA) and its main branches with the formation of an abnormal vascular network or collaterals at the base of the brain . ImagingThe most common initial presentation of moyamoya is ischemic stroke and recurrent transient ischemic attacks (TIAs). Patients may infrequently present with seizures due to underlying ischemic damage, and the rate of seizures may be more frequent in children than in adults . CerebraDefinitive diagnosis of MMD or syndrome is based on the following conventional angiographic criteria: (1) Stenosis of the terminal portion of the intracranial ICA or proximal portions of the anterior cerebral artery (ACA) and/or the middle cerebral artery (MCA). (2) Development of vascular collaterals near the stenotic lesions in the arterial phase. (3) Bilateral lesion. After the Research Committee on Spontaneous Occlusion of the Circle of Willis (MMD) in Japan revised the diagnostic criteria in 1995, definitive diagnosis of MMD has also been made by meeting all of the following items by MR imaging/angiography without conventional catheter angiography: (1) MR angiography (MRA) shows stenosis or occlusion of the intracranial ICA's terminal segment, as well as the ACA and/or MCA's proximal segments. (2) MRA showing two or more flow voids in the basal ganglia on each hemisphere, or MR imaging indicating abnormal vascular networks near occlusive or stenotic lesions .Finally, comparable cerebrovascular lesions linked to the following underlying diseases must be ruled out: atherosclerosis, autoimmune disorders, meningitis, brain tumors, Down syndrome, neurofibromatosis type-1, traumatic brain injury, cranial irradiation, and so on .In Saudi Arabia, MMD has rarely been reported and roughly around 20 scattered cases have been reported . Herein,A 13-month-old Syrian baby boy born to a non-consanguineous couple was admitted to our hospital with complaints of sudden onset focal tonic-clonic seizure, mainly on the right side, for further evaluation and management. The seizure attack lasted approximately a few minutes. The second attack was associated with loss of consciousness and uprolling of the eyes. There was a history of sudden falls during playing. However, there was no history of fever, head trauma, headache, vomiting, or ear discharge. He had normal growth parameters. there was no significant family history of early stroke, ischemic heart disease, or autoimmune disease. His past medical history was significant for right arm weakness one month before his presentation and resolved without treatment. Upon presentation, he was vitally normal except for HR of 128, and RR of 28.A head CT revealed nonspecific hypodensity, bilateral periventricular white matter, and the left parietofrontal subcortical area requiring further workup.An MRI Figure  revealedEncephalo-duro-arterio-synangiosis (EDAS) surgery was performed due to failure of the first attempt of cerebral angiography. The baby was discharged home in a stable condition on Tegretol and aspirin for follow-up in the clinic and revascularization surgery on the right side was scheduled three months after the first one.Three weeks later, the child presented with lethargy, weakness in his left arm, and vomiting. Upon admission, he was afebrile, maintaining room air. Physical examination findings were normal apart from bilateral chest rhonchi, and weakness of the left upper and lower limbs. Hematologists recommended starting the patient on clexane and continuing with aspirin.Conventional cerebral angiography Figure  was perfA post-operative MRI brain Figure  was perfThe clinical and radiological findings were suggestive of a progressive vascular occlusive disease that could be seen in MMD. Several investigations including factor V, factor VII, antithrombin activity, protein C, protein S, and EEG were carried to rule out associated medical conditions. The patient was discharged in a stable condition with residual left side weakness. Therefore, an appointment with physiotherapy was reserved.MMD is a progressive vasculopathy of ICA. Subsequently, compensatory collaterals are formed gradually resembling "puff of smokes," hence the name moyamoya . FemalesMMD is more common in children and rarely occurs in adults. MMD has a bimodal age of presentation. Children present at around five years of age with clinical symptoms of brain ischemia. Additionally, adults present at around 40 years with hemorrhagic symptoms due to rupture of fragile vessels. Children with MMD usually have recurrent TIAs or infarction in the territory of the ICA, particularly in the frontal lobe, as opposed to adults who usually have subarachnoid or intraparenchymal hemorrhage .Additionally, MMD has an increasing incidence in East Asian countries, particularly Japan and Korea. The occurrence rate in Saudi Arabia is not yet determined. To the best of our knowledge, less than 200 cases have been reported worldwide, and roughly less than 20 cases from Saudi Arabia .The reported incidence of pediatric strokes ranges from 1.2 to 13 cases per 100,000 children under the age of 18; however, recent studies suggest that the incidence is rising . BecauseMMD primary treatment is surgical revascularization, without which around two-third of the patients will have poor outcomes . Direct Our case brings forth the importance of having a high index of suspicion and considering a wider range of differential diagnoses when managing pediatric patients with seizures. Furthermore, it highlights a rare presentation in Asian Caucasian/middle eastern race, despite the predominance in east Asian countries. Early diagnosis and prompt intervention will improve the prognosis and life expectancy of pediatric MMD patients. The gold standard for diagnosing and making surgical decisions in MMD is conventional cerebral angiography. There is currently no standardized surgical approach for the treatment of MMD in children, and numerous revascularization procedures have been used with relatively good results in hindering disease progression.


Schistosomiasis is very common in the southern part of the Yangtze River Basin in China. It is mainly manifested as appendicitis, ulcers, hematomas, and thickening of the intestinal tract. Schistosomiasis of the appendix is rare, mainly manifested as appendicitis, which is easy to be misdiagnosed.Here we report a rare case of a Chinese female whose intestinal mass manifested as intestinal polyps and was eventually diagnosed pathologically as schistosomiasis infection (appendix schistosomiasis). So far, there are rare relevant cases reported.Intestinal schistosomiasis is easily misdiagnosed, and appendix schistosomiasis is rare. The final diagnosis requires pathology, especially surgical pathology. Schistosoma. In the public health sense, it is second only to malaria, infecting more than 200 million people worldwide, causing severe consequences of 20 million people and 100,000 deaths each year [Schistosomiasis is a parasitic disease caused by the trematode of the genus ach year . Among t, the remaining colonic mucosa had no lesions or inflammation. The histopathology of the ileocecal area showed severe chronic inflammation and lymphoid follicular hyperplasia. The entire abdominal CT scan before the colonoscopy showed a soft tissue approximately 2.3 cm × 1.8 cm in the ileocecal area with irregular borders, and moderately continuous enhancement after enhancement .A 65-year-old female from Chaohu, Anhui, China attended our hospital, complaining of slimy stool with mucus for more than 10 years. She had no history of schistosomiasis epidemiology and exposure. She had no family history of colon cancer. The patient did not have any organomegaly on examination. Her blood tests  and stool tests were normal. Colonoscopy revealed a polypoid-like hump of approximately 2.5 cm × 3.0 cm behind the ileocecal valve, with a thickened superficial duct opening, congestion, and exudation of purulent discharge. The surrounding mucosa was hyperemic, and the appendix was not visible We initially diagnosed the bulge of the ileocecal as intestinal polyps and prepared to undergo endoscopic submucosal dissection (ESD) surgical resection, however, during the operation we found that the lesions may not be completely cleared, the patient finally decided to undergo surgery. In this colonoscopy, we performed the pathological examination of the same part, and the results were similar to the previous results. Laparoscopy showed no ascites in the abdominal cavity, rich omentum tissue, no metastasis in the liver and peritoneum, and the ileocecum and ascending colon omentum were wrapped inside the abdominal wall. The tumor was located at the opening of the appendix in the ileocecal region, which was also the root of the appendix, without invading the serosa.(Fig. The tumor markers of the patient were normal, but the malignant tumor could not be ruled out. The surgeon and his family decided to completely remove the right half colon after consultation. Histopathology clearly showed that there were a large number of schistosome eggs deposited in the ileocecal region and the appendix, with a lot of lymphocytes, plasma cells, eosinophils, and neutrophils infiltrated, lymphoid tissue proliferation, and lymphoid follicle formation Fig. . We carrSchistosomiasis is still prevalent in China. An epidemiological survey in the Chaohu area of Anhui Province shows that schistosomiasis is still prevalent there –6. OncomThe diagnosis of intestinal schistosomiasis is very difficult, and it is almost impossible to confirm the diagnosis before surgery. It may help to diagnose by asking for the previous history. The gold standard for the diagnosis of an ongoing schistosome infection has for decades been the detection of eggs in a fecal smear. However, the positive rate of fecal worm eggs is very low, histopathology and serology can also help diagnosis . The lowSchistosome eggs can invade many parts of the gastrointestinal tract, urinary tract, etc., but mainly cause lesions in the liver, spleen, and colon, causing tissue fibrosis or bleeding . IntestiAcute patients present with immune complex disease, while chronic patients present with T lymphocyte-mediated delayed allergies, which may be accompanied by the deposition of antigen-antibody complexes to form eosinophilic granuloma. With the degeneration, necrosis, and calcification of worm eggs, infiltrating cells were replaced by monocytes and fibroblasts to form chronic granulomas .The disease was easily misdiagnosed as colon cancer, ulcerative colitis, and intestinal tuberculosis. Isolated schistosomiasis infections are rare. Colonoscopy findings and repeated biopsy from the suspected lesions were essential for getting the correct diagnosis, but the positive rate was low, sometimes surgery was needed to confirm the diagnosis. The prevention and control of schistosomiasis are very important, and medical staff needs to strengthen their understanding of schistosomiasis to avoid missing diagnosis.


The complex anatomy and similarity of imaging features of various pathologies in the pelvis can make accurate radiology interpretation difficult. While prompt recognition of ovarian cancer remains essential, awareness of processes that mimic ovarian tumors can avoid potential misdiagnosis and unnecessary surgery. This article details the female pelvic anatomy and highlights relevant imaging features that mimic extra-ovarian tumors, to help the radiologists accurately build a differential diagnosis of a lesion occupying the adnexa. Adnexal masses have an incidence of 0.17% to 5.9% in asymptomatic women and 7.1% to 12% in symptomatic women, and less than 25% of these masses are diagnosed as malignancy . UltrasoLocalization of pelvic masses can be challenging, notably when anatomic landmarks are obscured or distorted. Identification of the ovaries is an initial step in discerning an intraovarian or extra-ovarian location. Each ovary is suspended in the pelvic peritoneal cavity by three structures: the mesovarium, anchoring the ovary to the posterior surface of the broad ligament; the ovarian ligament, anchoring the ovary to the uterus; and the suspensory ligament, anchoring the ovary to the pelvic sidewall  5]. Bot. Bot5]. The pelvis is divided into intraperitoneal and extraperitoneal spaces. The peritoneum is a thin membrane that divides the pelvis into these two spaces. The pelvic peritoneum forms this partition as it drapes over the surfaces of the bladder dome, uterus, and anterior upper third of the rectum . In femaThe pelvic extraperitoneal space surrounds the intraperitoneal space. This space contains the bladder, uterus, pelvic ureters, lower two-thirds of the rectum, iliac vessels, pelvic lymph nodes, and pelvic sidewall. The pelvic extraperitoneal space can be divided into the anterior, middle, and posterior compartments. The anterior compartment contains the prevesical (retropubic space of Retzius) and perivesical spaces. The prevesical space is a potential space anterior to the urinary bladder, between the infraumbilical abdominal wall and the umbilicovesical fascia. The perivesical space surrounds the bladder. The middle compartment contains the vagina, cervix, and uterus, whereas the posterior compartment contains the perirectal (mesorectum) and presacral  spaces  7]..7].Identification of a normal ipsilateral ovary, as described above, excludes ovarian origin of a mass. In cases of masses abutting the ovary, multiple imaging signs help to assess the origin of the mass. Signs suggestive of ovarian origin include a “beak” sign, which is a sharp angle between the ovary and the mass, forming a beak shape at the edge of the ovary; the “ovarian vascular pedicle” sign, which is a depiction of a direct joining of the normal or asymmetrically enlarged gonadal vein to the mass; the “phantom organ sign”, which is an undetectable ovary provided that there is no history of surgical resection or transposition; and the “embedded organ sign”, which is when the ovary appears embedded in the mass ,8,9. On The direction of organ displacement can often be a clue to the origin of a pelvic mass. Intraperitoneal masses will result in lateral or posterior displacement of the uterus, rectosigmoid colon, and iliac vessels. Masses in the rectouterine pouch of Douglas will result in anterior displacement of the uterus and posterior displacement of the rectum. In contrast, extraperitoneal masses can result in anterior or central displacement of the uterus, rectosigmoid colon, and iliac vessels. Extraperitoneal masses can also efface the pelvic sidewall muscles. Prevesical masses can displace the bladder posteriorly . AccuratUltrasound (US) imaging is considered a first-line modality to image female patients with pelvic symptoms. US is relatively inexpensive and easily accessible. However, it is limited in assessing the extent of disease and is operator dependent. Computed tomography (CT) is increasingly used in emergency and ambulatory settings, so it may be the initial modality for many patients. Limitations of CT include its use of ionizing radiation and a relatively low contrast resolution. Magnetic resonance imaging (MRI) reigns supreme in characterizing pelvic lesions secondary to excellent anatomic depiction and soft-tissue contrast. Sequences like diffusion-weighted imaging (DWI) and dynamic contrast enhancement bolster its capabilities in lesion evaluation ,10. BothQuantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a valuable complementary tool in the characterization of complex adnexal mass. The values of relative signal intensity and the volume transfer coefficient (Ktrans) can differentiate benign adnexal masses from ovarian malignancy with accuracy, sensitivity, and specificity of 79.6%, 96%, 66.7% and 80%, 86%, 74%, respectively . A type The fallopian tubes are located at the superior margin of the broad ligament . The falHydrosalpinx most often occurs due to adhesions from pelvic inflammatory disease. Hydrosalpinx can be asymptomatic but may result in infertility or pelvic pain . On US, Hematosalpinx can occur in the setting of endometriosis, ectopic pregnancy, adnexal torsion, malignancy, or trauma. On US, hematosalpinx appears like hydrosalpinx but will show internal low-level echoes reflecting blood products. On MRI, hematosalpinx demonstrates an abnormal signal on a T1-weighted image (T1WI) and T2-weighted image (T2WI), depending on the age of blood products, and lack of T2 shading can differentiate hematosaplinx from an endometrioma .Neisseria gonorrhoeae and Chlamydia trachomatis, for which 30–40% of cases have polymicrobial infection, whereas tuberculosis and actinomycosis are much less common causes ..7].Disseminated peritoneal leiomyomatosis, also known as leiomyomatosis peritonealis disseminata, is a benign hormone-responsive process often found incidentally among premenopausal women . These sPeritoneal carcinomatosis occurs due to metastatic malignant cells seeding the peritoneal cavity. Notably, peritoneal carcinomatosis can occur in the setting of metastatic ovarian cancer. Initially, small, irregularly spiculated soft tissue nodules stud along the peritoneal surface. On CT, peritoneal implants typically demonstrate soft tissue density. However, mucinous peritoneal deposits can demonstrate low attenuation. MRI has an improved detection sensitivity due to the superior soft tissue contrast. Specifically, DWI and postcontrast sequences are beneficial in identification ,40. AsciMycobacterium tuberculosis bacteria by hematogenous seeding of the peritoneum from a pulmonary source [Peritoneal tuberculosis represents 37.2% of pelvic masses mimicking ovarian tumors [y source . Less fry source . The vasy source .Inflammation of the appendix (appendicitis) in the right lower quadrant can abut or involve the right adnexa, particularly with disease progression and abscess formation. Inflammation of diverticula from the cecum or sigmoid colon (diverticulitis) can also present similarly. Acute appendicitis presents with nausea and vomiting, accompanied by poorly defined periumbilical pain localized to the right lower quadrant. The inflamed blind-ending tubular appendix will be dilated with wall thickening. Transabdominal US of the right lower quadrant with graded compression can help identify appendicitis, but this is operator dependent and limited in patients with a large body habitus . When thAppendiceal mucocele represents chronic cystic dilatation of a mucin-filled appendix. Mucocele is histologically classified as a simple mucocele , focal or diffuse mucosal hyperplasia, mucin cystadenoma (approximately 50% of cases), and cystadenocarcinoma ,29,45. AAppendiceal cystadenoma and cystadenocarcinoma have a greater propensity to rupture due to their relatively larger size . FollowiGIST is the most common mesenchymal tumor of the gastrointestinal tract and represents approximately 20% of soft tissue sarcomas . GIST haAnatomic localization of extraperitoneal lesions is essential as these lesions are not seen on laparoscopy and require a posterior approach. Knowledge of the anatomy and pelvic extraperitoneal spaces can narrow the differential diagnosis . Please Clinical features of lymphoma include fever, night sweats, and weight loss. On imaging, lymphoma appears as multi-station adenopathy and splenomegaly. Occasionally, bulky pelvic masses can appear as an ovarian mass. On CT, lymphoma usually appears as mild to moderately enhancing homogenous masses. Lymphomatous adenopathy tends to encase vessels without compression. On MRI, lymphoma appears isointense in T1WI, iso- or hyperintense on T2WI, and moderately enhancing on postcontrast T1WI ,54,55.Retrorectal cysts are part of a general category of lesions occupying the perirectal and presacral spaces. Lesions in these spaces are commonly classified in the literature based on etiology  . These lIn general, these cystic structures can be unilocular or multilocular. Most lack soft tissue components or internal enhancement , but canEpidermoid cyst is an unilocular cyst containing a clear fluid with high signal on T2WI and characteristic restricted diffusion on DWI . DermoidTailgut cysts, also known as retrorectal cystic hamartomas, are developmental tumors arising from the ectodermal layer. Tailgut cysts often appear multilocular but can be unilocular . On MRI,Rectal duplication cysts are relatively rare cysts. Best appreciated on MRI, these cysts communicate with the anorectal lumen and are lined by intestinal mucosa and submucosa. Surgical removal of this lesion is also recommended as approximately one of every five cases has malignant potential .Neurogenic cysts arise from the nerve root or spinal column and may be confused with cystic ovarian or adnexal mass if there is no apparent neural involvement . Spinal Anterior sacral meningocele is a congenital disorder secondary to agenesis of the anterior sacrum, resulting in a scimitar-shaped sacral osseous defect. CT and MRI demonstrate a bony defect of the sacrum with an associated cystic lesion communicating with the thecal sac . Dural ePelvic extraperitoneal neurogenic tumors can arise from the nerve sheath (schwannoma and neurofibromas), the sympathetic nerve (ganglioneuroma), and the paraganglionic tissues (paraganglioma) . All of Extraperitoneal schwannoma is an encapsulated well-defined nerve tumor. On CT, this tumor may contain calcifications. On MRI, schwannoma has low signal on T1WI, high signal on T2WI, and heterogeneous contrast enhancement on postcontrast T1WI. When large, schwannoma can contain regions of cystic necrosis or hemorrhage. Schwannoma has a low risk of recurrence or malignant transformation. Treatment includes surgical resection for symptomatic patients .Neurofibroma is a benign unencapsulated nerve sheath tumor that arises along the course of the nerve ,70. NeurGanglioneuromas arise from the sympathetic ganglia. On CT, ganglioneuromas appear as a well-defined soft tissue masses with occasional punctate calcifications. On MRI, they are hypointense on T1WI with a “whorled” appearance on postgadolinium images secondary to internal collagen and Schwan cell components .Paraganglioma, also referred to as extra-adrenal pheochromocytoma, contains neural crest elements. Nearly 40% of paragangliomas can produce clinically significant catecholamines, resulting in elevated biochemical markers, including urine metanephrine and vanillylmandelic acid. On CT imaging, paraganglioma appears as a well-defined soft tissue mass that avidly enhances following contrast administration. On MRI, paraganglioma may contain signal voids on T1WI. The classic description of a “light bulb” bright hyperintensity on T2WI is not often seen due to hemorrhage . SurgicaHematoma can occur following trauma, surgery, interventional procedures, or aneurysm rupture. Depending on the location, it may be challenging to distinguish the ovary from the pelvic hematoma. Imaging of hematoma varies temporally as blood products break down and are reabsorbed. On US, acute hematoma starts as an echogenic collection, then progressively becomes hypoechoic with septations and thickened walls. On CT, acute hematoma starts as a hyperattenuating collection that becomes cystic with thickened walls in about two weeks. On MRI, acute and subacute hematomas have high signals on fat-suppressed T1WI and do not demonstrate enhancement on postcontrast T1WI . As the Lymphocele is a lymph-containing fluid collection contained within the walls of thin fibrotic tissue. Clinical history is essential as pelvic lymphoceles occur approximately three to eight weeks following lymphadenectomy or renal transplant surgery . DependiSeroma is a fluid collection containing serous fluid that can occur following surgery or trauma. Akin to a lymphocele, seroma can exhibit a mass effect on the adjacent pelvic structures and appears as a non-enhancing simple fluid collection.Urinoma is a fluid collection that contains extravasated urine. Urinoma can result from urinary tract obstruction  or iatrogenic causes, such as following an intervention or surgery. On US, urinoma appears as anechoic simple fluid collection. On CT imaging, urinoma shows fluid attenuation on unenhanced images but may have increased attenuation on excretory or further delayed phase imaging. CT or MR urography can depict the presence and site of extravasation .Pelvic abscesses represent 17.7% of pelvic masses mimicking ovarian tumors  and can Imaging features that mimic ovarian tumors present a diagnostic challenge due to the complex pelvic anatomy and overlapping imaging features of various pelvic lesions. Identifying a normal-appearing ovary is crucial in distinguishing an extra-ovarian pelvic mass from an ovarian tumor. Understanding pelvic anatomy and knowledge of key imaging features can help in anatomic localization and narrowing the differential diagnosis to determine the origin of lesions in the female pelvis. Ultrasound is the primary modality for diagnosis of adnexal lesions and MRI is a problem-solving modality, given it superior soft tissue contrast, guiding optimal patient management.


Background: A ligature mark is a common injury in cases of hanging or strangulation. Estimation of age and vitality of the ligature mark can be crucial for differentiating antemortem and postmortem wounds and to distinguish between simulated suicidal hanging or accidental strangulation to conceal a crime and not simulated events. The immunohistochemistry has been recommended by several Authors as a reliable tool to determine whether an injury was sustained during life or not. Unfortunately, no general agreement on the immunohistochemical markers to be used has been found among the scientific community. The aim of the study was to detect the type and function of the immunohistochemical markers useful in the assessment of the vitality and age of the ligature marks for routine diagnostics. Methods: Papers available on Pubmed, Scopus, and Web of Science were reviewed according to the PRISMA statement. Results: Only eight papers satisfied all the following inclusion criteria: full texts in English dealing with human ligature marks and immunohistochemistry published on impacted or indexed scientific journals. Conclusions: The assessment of the vitality of a ligature mark is still a challenging topic in forensic science. Under ideal conditions and in compliance with autopsy protocols, the diagnosis of death by hanging or strangulation on fresh bodies can be better supported by autopsy findings other than a ligature mark. The validation of immunohistochemical markers on large series could be of help in doubtful cases and differential diagnoses. A ligature mark is a well-known pressure mark on the neck underneath a ligature. It is a common injury in cases of hanging and strangulation, and sometimes, it is the only one recognized at autopsy. Except for ligature marks, often in these cases, there are no other external marks or internal injuries. The appearance of a ligature mark on the neck is subject to considerable variation, mostly depending on the nature and texture of the ligature . A wide In hanging, the ligature mark generally does not completely encircle the neck, and it is deepest opposite the point of suspension because the noose commonly consists of a single loop. The corresponding furrow is usually located above the larynx, running obliquely, discontinuous towards the suspension point in an inverted V configuration. In ligature strangulation, in contrast to hangings, the ligature mark completely encircles the neck in a horizontal plane often overlying the larynx or upper trachea. Therefore, it is continuous and homogeneous, since the ligature is wrapped all around the neck surface and tightened by an external force to produce neck compression. Rarely, scratch marks can be seen above and below the ligature mark, although they can occur when the victim tries to remove the ligature or relieve the pressure or when the assailant places his hands around the ligature.The determination of a vital reaction of human skin wounds is still a challenge for forensic pathologists. In forensic medicine, the term “vital reaction” describes the complex physiological events that occur at a systemic and local level when an extraneous force or noxa came into contact with a living organism . MacroscOne vitality marker alone is often of limited value, since it may be partly explained by resuscitation attempts or events that occurred during the supra-vital period . AdditioThe research area has recently focused on local vital signs through immunohistochemistry more than systemic reactions .A systemic review of the literature dealing with the vital reaction of ligature marks in hanging or in ligature strangulation was performed. The review of the literature was carried out according to the PRISMA statement . The resThe absence of a control group was also considered as an exclusion criteria. Additional exclusion criteria were the following: (1) studies on animal models; (2) without a control group; (3) case reports or case series; (4) full text not available. For duplicate studies, only the article with more detailed information was included.The search of PubMed, Scopus, and Web of Science databases provided a total of 401 articles, and after adjusting for duplicates, 116 studies were discarded. The review of the 285 abstracts resulted in an inclusion of eight papers in the present review. The search provided a total of 285 articles. Once removing all the duplicates (116 studies), the abstracts of 169 articles were reviewed by two of the authors. Only 10 out of 169 studies were coherent with the aim of the review, and they were not case reports or cases series. However, after reviewing the full text of these 10 studies, only eight papers satisfied the inclusion criteria, providing a control group for the immunohistochemical analyses performed .The results of this systematic review show that (1) only a little research has been carried out on a large series of ligature marks; (2) validated immunohistochemical markers do not yet exist, and (3) the histological morphology of the skin and other organs sampled at autopsy, along with the circumstances of the death investigation, are still crucial for the diagnosis of vitality and age of a skin wound. In fact, the histology of a skin vital lesion, when compared to undamaged vital skin, shows more or less evident abrasions, with loss of the epidermal layer and presence of red blood cells on the surface. In the dermis, the vascular congestion and the erythrocyte extravasation are observed with a focal inflammatory rate that can be useful in dating the time of agony in atypical hangings or in ligature strangulation. The deep dermis, the hypodermis, and the striated muscle portion of the neck region often appear fragmented and associated to evident erythrocyte extravasations as classic signs of trauma. All these microscopic findings are considered signs of vitality and are useful in demonstrating whether the injury was sustained during life and when . The proVisceral congestion is a classical sign in asphyxial deaths commonly associated with cyanosis and capillary hemorrhages (petechiae) often located distant from the site of injury  due to the intravascular rise of pressure. Along with the multi-organ congestion, common histological findings are erythrocyte extravasations, especially in the parenchymatous organs, but also in the laryngeal tract, with the loss of mucous membranes. Signs of initial neuronal hypoxic degeneration with a white halo or signs of more prolonged hypoxia with a red neuronal appearance may also be observed in the brain. These aspects are fundamental for a differential diagnosis between initial acute hypoxic injury and prolonged hypoxic injury that occurs in chronic hypoxia. Common pulmonary changes are mainly represented by vascular congestion, endo-alveolar erythrocyte extravasations, rupture of the alveolar septa, and emphysema due to mechanical respiratory difficulties and tissue damages produced by the lack of oxygen . The morThe inflammation process can be assessed based on the lymphocyte populations, as well as of the cytokines. It is a very good marker of the time-course of any wound healing. In fact, there is wide agreement in literature that for every tissue damage, an “inflammation” response is established with almost always the same mechanism .Attention to the microscopic expression of inflammation in the skin samples of hanging have been identified by few studies. The molecules analyzed which have yielded satisfactory results include tryptase, IL15, CD-15, MHC-II, CD1a, AQP1, AQP3, fibronectin, cathepsin D, P-selectin, and IL1beta. Turillazzi et al. (2010)  also stuThe relationship between the vitality of skin wounds and miRNA expression has been investigated by Neri et al. . An overIn the diagnosis of vitality, it is worth of mentioning the role of aquaporins ,23. ThesThe distribution of MHC class II cells, Langerhans cells, and mast cells in ligature marks has been also investigated immunohistochemically ,14. ThesThere are also other markers that could be considered indicative signs of wounds vitality. The expression of Fibronectin, Cathepsin D, and P-selectin was analyzed in two different experimental studies ,25. FibrThe aim of this systematic review was to detect how useful the immunohistochemical markers can be in the assessment of the vitality of the ligature marks. Based on our results, the application of immunohistochemistry for the age estimation and vitality of skin wounds can be useful but still challenging. Caution is also needed in the interpretation of the results. Several factors can affect the reliability of immunohistochemical results, like the supra-vital reactions and the post-mortal changes. False negatives and false positives can occur in immunohistochemical reactions due to inadequate fixation of tissue samples and insufficient antibody incubation because of cross-reactivity. Unfortunately, it is still a long and winding road to get validated immunohistochemical markers for a reliable diagnosis in order to distinguish, with certainty, vital ligature marks from skin lesions that occurred after death . The effIn the future, immunohistochemical methods and/or molecular biology can be a comfort to histological diagnosis. At the base of any damage inflicted in life, the key to understanding the mechanisms of vital reaction is still inflammation . The mosThe assessment of the vitality and age of a ligature mark is still a challenging topic in forensic pathology. One immunohistochemical biomarker alone is of limited value, as it would be studied according to all systemic vital reactions, like those of the circulatory and respiratory systems, and in the light of all factors that can affect the reliability of immunohistochemistry.The state of art in the vitality of skin wounds shows that most of the relevant markers can be successfully observed by traditional histology (H&E staining). They are still the most reliable morphological criteria for assessing the vital reaction and for estimating wound age. In the future, immunohistochemical markers could be of use to basic diagnosis, and we look forward tto new tools to determine whether a human skin wound has been sustained during life or not, especially in cases where the mechanism and mode of death are controversial.Validation protocols to promote consistency and comparability among immunohistochemical markers and to improve their reliability in routine diagnostics of vital reaction are still needed.


TERT promoter mutations but distinct IDH1 mutations, with a non-canonical IDH1 R132G mutation identified in the infratentorial lesion and a R132H mutation identified in the cortical lesion. Initiation of Temozolomide led to complete response of the supratentorial lesion and durable disease control, while Temozolomide with subsequent radiation therapy of 54 Gy in 30 fractions resulted in partial response of the pontine lesion. This case report supports possible distinct molecular pathogenesis in supratentorial and infratentorial oligodendrogliomas and raises questions about the role of different IDH1 mutant isoforms in explaining treatment resistance to different chemotherapy regimens. Importantly, this case suggests that biopsies of all radiographic lesions, when feasible and safe, should be considered in order to adequately guide management in multicentric oligodendrogliomas.Infratentorial oligodendrogliomas, a rare pathological entity, are generally considered metastatic lesions from supratentorial primary tumors. Here, we report the case of a 23-year-old man presenting with a histopathologically confirmed right precentral gyrus grade 2 oligodendroglioma and a concurrent pontine grade 3 oligodendroglioma. The pontine lesion was biopsied approximately a year after the biopsy of the precentral lesion due to disease progression despite 4 cycles of procarbazine-CCNU-vincristine (PCV) chemotherapy and stable supratentorial disease. Histology and genetic analysis of the pontine biopsy were consistent with grade 3 oligodendroglioma, and comparison of the two lesions demonstrated common 1p/19q co-deletions and  IDH1 mutations have been identified with a higher frequency in AYA gliomas compared to the adult patient population [Oligodendrogliomas represent approximately 5% of all glial tumors in the US adult population . Those apulation . The rolIDH1 mutations, in driving multicentric gliomas remains elusive. The clinical utility of classifying multiple concurrent gliomas as either multifocal or multicentric remains unclear. In the absence of specific guidelines, management largely resembles that of solitary lesions despite the worse prognosis associated with multifocal/multicentric gliomas [The simultaneous presence of multiple lesions, especially lesions with supratentorial and infratentorial components, is a rare occurrence in gliomas of all type . Concurr gliomas , 14.TERT mutations but have different IDH1 mutations: a canonical IDH1 R132H was identified in the precentral lesion while a noncanonical IDH1 R132G mutation was identified in the pontine lesion. Importantly, the two lesions differed in their response to four cycles of procarbazine-CCNU-vincristine (PCV) chemotherapy. The case illustrates one possible pathogenesis of multifocal/multicentric oligodendrogliomas, via early subclonal divergence and parallel evolution, and suggests the possible importance of performing biopsies of all radiographically visible lesions, when safe and technically feasible, as it may impact subsequent treatment decisions.Here, we present a rare case of a 23-year-old man with synchronous, genetically confirmed right precentral grade 2 and pontine grade 3 oligodendroglioma. The two lesions harbored similar 1p/19q-codeletions and The patient, a previously healthy 23-year-old man, first presented to an outside hospital with complaints of intermittent diplopia, tinnitus and occipital pain. Due to persistent headache, he underwent an MRI scan which revealed synchronous, non-enhancing, T2/FLAIR hyperintense lesions in the right precentral gyrus and pons as well as increased signal along the right 8th cranial nerve. Initial serial scans were stable and the patient remained in stable condition during that time but eventually presented to our institution 8 months later for a second opinion. By this time, he developed headaches, mild photophobia, left-sided weakness, and left facial numbness. Initial in-house imaging at the time demonstrated a 3.9 × 3.1 × 4.4 cm heterogenous, but primarily T1 hypointense, T2 hyperintense, infiltrating, and mildly expansile pontine lesion with minimal patchy contrast enhancement and diffusion restriction that was larger in size compared to imaging obtained from the outside hospital. Extension into the floor of the fourth ventricle, compression of the prepontine cistern, and obstructive hydrocephalus was noted. Extension into the middle cerebellar peduncles and encasement of the basilar artery was also noted. MR spectroscopy revealed elevated choline peak and reversal of the choline/NAA ratio, and was overall consistent with a glial tumor. A second infiltrating and expansile, non-enhancing lesion, measuring 2.7 × 2.2 × 1.5 cm, in the right precentral gyrus with similar imaging characteristics to the pontine lesion was also seen and noted to have increased in size compared to imaging studies obtained from the outside hospital  and confirmed the IDH1 R132H mutation (VAF of 19%), while consistent with immunostain result, no mutation in H3F3A was seen  identical to the peri-rolandic lesion and an IDH1 R132G mutation (VAF 46%) not seen in the patient’s supratentorial tumor. No other mutations were identified on this laboratory-developed platform which includes assessment of IDH1, IDH2, H3F3A and HIST1H3B . The MGMT promoter was partially methylated  performing biopsies on all radiographically visible lesions if safe to do so, (2) performing biopsies of treatment resistant lesions, even later in the treatment course and (3) sequencing the response . Furtherresponse  note thaIDH1 mutations, and differential response to PCV chemotherapy. This case illustrates one potential evolutionary trajectory of multicentric oligodendrogliomas and provides insight into best management practices for these rare tumors. We speculate that the infratentorial lesion may be a metastatic, higher grade lesion arising from the supratentorial mass, and that the non-canonical IDH1 mutation marked sub-clones with increased tumor invasiveness and/or chemoresistance which diverged early on in tumorigenesis. Alternatively, the supratentorial and infratentorial oligodendrogliomas may represent completely separate, synchronous lesions with distinct genetic alterations. Irrespective of time course in gliomagenesis, this case report highlights the importance of performing individual biopsies of all radiographic lesions, both for therapeutic decisions and for prognostication. Overall, infratentorial low-grade oligodendrogliomas remain a rare and poorly understood pathological entity. Further studies are needed to gain more insight into gliomagenesis and best management practices.We present here a rare case of multifocal high grade oligodendroglioma with supratentorial and infratentorial lesions, distinct


Patients with vascular Ehlers–Danlos syndrome (vEDS) have a defect in the formation of type III collagen. This defect puts patients at risk of vascular rupture, uterine rupture, and bowel perforations. The segmental absence of intestinal musculature is a rare histopathologic finding, wherein there is a lack of a muscularis propria layer in the intestinal wall. Although typically documented in the literature in neonates or adults, it can be seen in children of other ages. This is a case report of a patient who exhibits both rare entities, which has not been described in the literature to date. The segmental absence of the intestinal musculature (SAIM) is a rare clinicopathological entity characterized by the partial or complete absence of the muscularis propria and is associated with intestinal obstruction and perforation ,2,3. SAIAlthough the true pathophysiology of SAIM is unknown, theoretical classifications of the disease include primary idiopathic and secondary acquired ,2,3. PriHerein, we present a case of perforated SAIM in a patient with newly diagnosed vascular Ehlers–Danlos syndrome (vEDS). Although vEDS is a relatively rare condition, spontaneous intestinal perforation is a well-documented complication of the disease . With ouA previously healthy 16-year-old female presented with left lower quadrant abdominal pain that had acutely intensified reported episodes of abdominal pain over the last two years prior to presentation. Her stools alternated between constipation and diarrhea, and she was previously diagnosed with irritable bowel syndrome. Her pain on presentation was severe and was associated with non-bloody, non-bilious emesis.On admission, she was afebrile but diaphoretic and tachycardic with a heart rate of 150, which improved with fluid resuscitation. Her abdomen was soft but tender throughout, with voluntary guarding on palpation on the left and hypoactive bowel sounds. A rectal exam demonstrated a good rectal tone and no stool in the rectal vault.Initial laboratory investigation included urinalysis, complete blood count, and basic metabolic panel and were unremarkable. An abdominal CT was notable for a stool burden through the distal left colon and to the mid sigmoid with collapsed distal sigmoid and rectum, for which Hirschsprung’s disease was suggested as a differential diagnosis . There wOn hospital day 2, she developed a fever and right shoulder pain, prompting an abdominal X-ray that showed pneumoperitoneum. She was taken to the operating room for an exploratory laparotomy. She was found to have a large perforation in the sigmoid within a necrotic segment and fecal peritonitis. Friable mesentery and surrounding tissue was also noted. Her sigmoid colon was resected to grossly healthy tissue and a colostomy was created.The patient recovered from the operation after a short stay in the intensive care unit. On further review of her history, it was found that she often experiences joint dislocation in the hips, although her siblings do not. There was also previously unknown family history of elastic skin or joint dislocations in the maternal grandmother.On histopathology, there was a loss of the muscularis propria consistent with SAIM, with preservation of the muscularis mucosa, which was more prominent near areas of the perforation . There wDue to intraoperative findings of the friable mesentery and fragile colonic tissue, there was concern about a connective tissue disorder. Our patient demonstrated characteristic facies of EDS, with translucent skin, thin vermilion of the lips, and a narrow nose. There was no documented family history of any connective tissue disorders. Genetic testing resulted with a heterozygous mutation of COL3A1 with a pathogenic variant of the c.1511 defect consistent with vEDS. Cardiology was consulted and carried out an echo, showing mild aortic root dilation.EDS is a connective tissue disorder characterized by hypermobile joints, easy bruising, and fragile skin, but can also include changes in stature, clubfoot, small chin, mitral valve prolapse, and spontaneous pneumothorax ,13,14. IOne subtype of EDS, classified as the vascular type, is due to a defect in type III collagen ,14. It iA bowel perforation is a known complication in patients with vEDS, but usually occurs later in life with an average age of 21 years ,14. ColoMortality for vEDS patients falls under their risk for visceral or vascular perforation, including aortic rupture, uterine rupture, and bowel perforation . ApproxiThere are no clear guidelines on the management of these patients or on preventing their risk of recurrent bowel perforation . ConstipPatients with SAIM present with abdominal distension, diminished bowel sounds, and eventual bowel obstruction or perforation ,3. It reCases of SAIM are more commonly documented in the literature in the neonate and adult population; however, there have been reports of it in older children and adolescents, such as our patient here. One case report documented a four-year-old who initially presented with imaging concerning inflammatory bowel disease and small bowel wall thickening leading to concerns of stenosis . PatholoAlthough it is well documented that patients with vEDS are at risk of intestinal perforation, the link between vEDS and SAIM is not, to the best of our knowledge, explicitly documented in the literature thus far. Type III collagen is an important structural protein for the integrity of blood vessels, the uterus, and the bowel wall . It alsovEDS patients are at high risk of vascular, uterine, and intestinal perforations. Due to the type III collagen defects of this condition, it is possible that there is a link between this rare disease and another rare entity, SAIM, due to defects in cell adhesion and migration.


Gastric-type endocervical adenocarcinoma (GAS) is considered a distinct and clinically important entity because it is unrelated to human papillomavirus infection and has aggressive behavior and worse clinical outcomes than the usual type of endocervical adenocarcinoma (ECA). The preoperative diagnosis of GAS is often difficult because of its nonspecific clinical manifestations and special lesion location. We report the case of a 50-year-old Chinese woman who presented with intermittent left lower abdominal pain for 1 year. Preoperative images showed left hydrosalpinx and a lesion that was mainly located in the lower part of the uterine cavity. We considered the lesion to be a polyp before surgery. During hysteroscopic surgery, we suspected that it may be a submucosal myoma. However, pathology revealed that it was a GAS. GAS may be located in the upper endocervix or even reach the uterine cavity. The appearance is occasionally similar to that of submucosal myoma, resulting in difficult preoperative diagnosis and even misdiagnosis. Cervical cancer is the fourth most common gynecological malignancy worldwide . Most ceThe patient was a 50-year-old premenopausal female, gravida 2, para 1. Cesarean section followed by right adnexectomy, which was performed due to a right ovarian cyst, was performed in 1995. On June 15, 2021, the patient visited our hospital for “intermittent left lower abdominal pain for 1 year.” In May 2020, pelvic ultrasound was performed in another hospital because of left lower abdominal pain and fever. The results showed a cystic mass in the left adnexa, about 7.6 × 1.4 cm, with a high possibility of hydrosalpinx; an intrauterine device (IUD) and liquid dark area in the uterine cavity, and Nabothian cysts in the cervix. Her symptoms were relieved after anti-inflammatory treatment, but slight intermittent pain persisted in the lower abdomen. The patient underwent pelvic ultrasound again on May 26, 2021. The results showed left hydrosalpinx, about 7.5 × 3.4 cm, and in addition to the IUD and cervical Nabothian cysts, a slightly strong echo mass was seen in the uterine cavity. Then the patient was referred to our hospital. On gynecological examination, the vulva and vagina were normal, a small amount of secretion could be seen, the cervix was of normal size with a smooth surface, the uterus was normal, the left adnexa were thickened and accompanied by slight tenderness. Pelvic ultrasound revealed that a mass around 2.3 × 1.8 × 1.7 cm was seen in the lower part of uterine cavity. The internal echo was uneven, and the boundary was clear . Color DAfter the second admission, the patient's medical history was recorded. The patient said that she began having intermittent watery vaginal fluid approximately 1 year prior. She did not care for it or inform the doctors because she thought it was vaginitis. Gynecological examination showed that the cardinal and uterosacral ligaments were not thickened. Pelvic contrast-enhanced magnetic resonance imaging (MRI) showed that the cervix was plump, with an uneven equal T1 and slightly higher T2 signal shadow, which was mainly located in the posterior lip of the cervix. Weak enhancement was seen on contrast-enhanced scan, with a range of about 3.5 × 2.7 cm, in which there were many small circular long T1 and long T2 signal shadows . No defiGAS, first described by Kojima et al. , was incsitu are the precursors of GAS . The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.JW was responsible for the data collection and drafting of the manuscript. QY and DW participated in providing knowledge of the disease. ML analyzed the literature. NZ was responsible for critical revision of the manuscript. All authors read and approved the final manuscript.This work was supported by the Natural Science Foundation of Liaoning Province, China (no. 2021-MS-186), the 345 Talent Project of Shengjing Hospital, and the National Natural Science Foundation of China (no. 81872125).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.


Testicular germ cell tumors account for 95% of testicular cancers in men with approximately 71,000 patients being diagnosed with testicular cancer every year. The overall survival of testicular germ cell tumors is approximately 95%. However, the prognosis becomes less favorable when distant metastasis is present. Gastrointestinal (GI) tract metastasis occurs in less than 5% of patients with non-seminomatous tumors, and in less than 1% in patients with pure seminomas. GI metastasis usually involves the colon, esophagus, and stomach with the most common symptoms of GI metastasis being diarrhea, nausea, vomiting, and obstruction. We discuss the case of a 42-year-old male patient with GI manifestations as the first presentation of testicular seminoma with metastasis to the small bowel. Computed tomography of the abdomen and pelvis revealed a small bowel mass, and the diagnosis was confirmed with histopathologic examination of endoscopic biopsy samples. The patient subsequently underwent chemotherapy treatment with close surveillance. Clinicians should maintain a high index of suspicion in the differential diagnosis of abdominal pain in young male patients, especially when associated with symptoms like unexplained weight loss, constitutional symptoms, and testicular pain or swelling. Metastasis to the GI tract from the testis should be promptly diagnosed and managed, as the overall survival rates can significantly decrease with the delay of diagnosis. Testicular malignancies account for 1% of cancers in men, and most commonly affect young males between 15 and 35 years of age, with germ cell tumors accounting for the majority of testicular cancers ,3. TestiA 42-year-old male without significant past medical or surgical history was admitted to a satellite hospital with complaints of progressive, intermittent right upper quadrant abdominal pain of one-month duration that increased in intensity and severity three days prior to his admission. The patient denied nausea, vomiting, heartburn, dysphagia, and overt GI bleeding. The patient also reported constipation and unintended weight loss of about 20lbs with loss of appetite over the past two months. Physical examination was only remarkable for a mildly distended abdomen with no rebound or guarding. The patient’s Initial laboratory results showed a white blood count of 8.2 K/mL, hemoglobin of 10.4 g/dl, and a hematocrit of 35.3%. His liver functions tests were normal. Computed tomography of the abdomen and pelvis with contrast on admission showed a mass-like thickening in the proximal small bowel with dilated segments and scattered enlarged proximal retroperitoneal and mesenteric lymph nodes (Figure The patient then underwent push enteroscopy revealing a mass-like lesion in the duodenum with lymph node involvement Figure . HistopaWe describe an unusual case of a 42-year-old man, who presented with abdominal pain as the initial manifestation of testicular seminoma with small bowel metastasis. Seminomas commonly metastasize to the lungs, bone, liver, and the retroperitoneal lymph nodes . TesticuThe most common sites of metastasis involving the GI tract reported were the colon, esophagus, and stomach. Jejunal and iliac involvement were also found to be more common than duodenal involvement in these patients. The most frequently reported symptoms include diarrhea, nausea, vomiting, abdominal pain, and iron deficiency anemia ,7. One cAlthough chemotherapy showed success in the treatment of metastatic seminoma, patients with GI metastasis are considered higher risk and generally are associated with poor outcomes . The treIn conclusion, we report a unique case of small bowel metastasis as the initial presentation of testicular seminoma diagnosed by endoscopic tissue sampling. The metastasis to the small bowel in our patient was an isolated metastasis in the duodenum, which adds to the rarity of the presentation. Metastasis to the GI tract from the testis should be considered in the differential diagnosis of abdominal pain in young male patients, especially when associated with symptoms like unexplained weight loss, constitutional symptoms, and testicular pain or swelling. Furthermore, this case illustrates the importance of prompt diagnosis and treatment of such patients, as the delay in diagnosis can significantly impact the prognosis and survival in this patient population.


Foreign body granuloma is a rare surgery-related complication that can masquerade as cancer recurrence during postoperative surveillance. It may therefore deceive clinicians and lead to unnecessary interventions. The case presented herein demonstrates how a foreign body granuloma can be misleading in preoperative radiological studies and why this condition should not be ignored in differential diagnoses during surveillance of patients with previous history of abdominal surgery of any kind.We report a case of suture granuloma mistaken for recurrent colon cancer, including the clinical history, imaging data, and histopathological photographs. A 60-year-old man was followed up at our institution after open right hemicolectomy 2 years earlier for ascending colon carcinoma. Contrast-enhanced computed tomography and magnetic resonance imaging revealed an infiltrative heterogeneous soft tissue lesion at the right mesenteric root, adjacent to the ileocolic anastomosis. Local recurrence was therefore suspected. We performed exploratory laparotomy, excised the tumor, and sent it for histopathological examination, which confirmed suture granuloma.Foreign body granuloma is a rare surgery-related complication that should be considered during surveillance following colectomy. Its radiological features may mimic recurrent lesions, thus misleading clinicians and causing unnecessary interventions or further complications. Postoperative surveillance following radical colectomy is vital to the successful treatment of colorectal cancers, and various imaging modalities are used for this purpose . HoweverIn this report, we describe a rare case of a patient with a history of ascending colon carcinoma after right hemicolectomy, who developed a silk suture granuloma mistaken for local cancer recurrence.The patient was a 60-year-old man with a history of hypertension. He had been diagnosed with adenocarcinoma of the ascending colon with bowel obstruction  and had undergone open right hemicolectomy approximately 2 years earlier. The surgery was done with ligation of right colic artery and ileocolic artery and vein. We encountered several small bleeders near the mesentery, and some of them were secured with silk suture ligations. We performed ileocolic anastomosis with hand-sewn technique with silk sutures and 3-0 Monocryl sutures. Oral tegafur and uracil had been administered as adjuvant chemotherapy, and no complications had been observed. After surgery, he had been regularly followed up at our institution every 3 months. However, recent abdominal computed tomography (CT) revealed a newly developed infiltrative heterogenous soft tissue lesion near the right mesenteric root Fig.  and adjaDuring surgery, we observed a 4 cm × 4 cm × 3 cm tumor arising from the mesentery near the previous ileocolic anastomosis, with involvement of the small intestinal wall approximately 50 cm from the ileocecal valve. We excised the tumor en bloc with a LigaSure® Vessel Sealing System  scalpel, including the part contacting the small intestinal wall, and then repaired the small intestinal wall defect. The specimen was sent for histopathological examination. Grossly, the tumor appeared grayish and included fragments of silk suture. Under a microscope, the specimen revealed an abscess and foreign body-type granulomatous inflammation. The tumor featured chronic and acute inflammatory cell infiltration, fibrosis, necrosis, aggregation of degenerative leukocytes, foreign body-type giant cells, and granulomas , or MRI , 5. PET/Suture granuloma is a rare surgery-related complication that should be considered in patients with previous abdominal surgery of any kind. Diagnosing suture granuloma can be challenging because of its nonspecific clinical manifestations and radiological features, which make it difficult to distinguish from other conditions, such as adhesion, abscess, or malignancies. Successfully identifying a suture granuloma that appears as a malignant lesion may prevent further unnecessary intervention.


Tumors of the salivary glands constitute 3% of all head and neck tumors. The parotid gland (PG) is the most common site involved in 85% of cases. PG tumors' size varies from a few millimeters to several centimeters and is about 2-6 cm on average. However, because of insidious growth and asymptomatic nature, untreated tumors of the PG can attain large size. Pleomorphic adenoma (PA), as large as 33 cm in size or 26.5 kg in weight, has been reported in the literature. Similarly, untreated Warthin’s tumor (WT) rarely becomes giant, size up to 20 cm is reported. Giant PG tumors are commonly symptomatic and have a rare tendency to become malignant.We are reporting two giant PG tumors with different histopathological diagnoses, PA and WT of size 15x15 cm and 10x8 cm, respectively. Therefore, with a size of 10 cm, our case is the second-largest WT reported in the literature. Both the giant PG tumors were present for 15-20 years, and mild pain and discomfort were the only symptoms. We had the differential preoperative tissue diagnosis in fine-needle aspiration cytology (FNAC) because of varying consistency. Contrast-enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) of the neck were done for these cases for preoperative planning. Compared to the former, the latter was more informative about nerve involvement preoperatively. Both the patients underwent superficial parotidectomy, and meticulous dissection was done to identify and safeguard the facial nerve and its branches. We had a challenge in closing the flaps, which was achieved with an acceptable cosmetic outcome. Both the patients were discharged in stable condition with minimal facial nerve weakness. Pleomorphic adenoma (PA) is the most common salivary gland tumor (70%), followed by Warthin’s tumor (WT) 6%-10%) [0% [1]. TCase summary 1A 60-year-old male presented with complaints of swelling over the right side of the face for 20 years. The swelling remained static initially, which gradually increased in size for the last five years and was not associated with any sudden increase in size. He had no pain complaint, difficulty in mouth opening, facial weakness, facial paraesthesia, halitosis, altered salivary flow, or discharge from the swelling during its progression.On local examination, an ovoid mobile swelling of size 15x15 cm was noted below, behind, and in front of the right ear with obliteration of the retro-mandibular furrow and lifting of the right ear lobule with no local warmth or tenderness. The swelling had well-defined margins, a smooth surface, a variegated consistency predominantly fluctuant cystic area, and a firm solid area in its posterosuperior part. There were two soft outpouchings noted on the surface of swelling, which were compressible. The swelling was not fixed to the underlying muscles or the overlying skin except in the area of outpouching nodules. The skin over the swelling had normal facial hairs and had no dilated veins, scars, sinuses, or fistulae  revealed a well-defined, hyperdense, fluid-attenuating cystic lesion of size 11x13x12 cm with an eccentric enhancing nodular solid component of size 4x5 cm in the right parotid region. The deep lobe of the parotid was normal. There was no involvement of the deeper structures and vessels of the neck. There was no significant lymphadenopathy  from the lesion showed features suggestive of PA. The patient underwent a right superficial parotidectomy. Blair’s incision was given with a 5 cm extension in the cervical skin crease because of significant swelling. Intraoperatively, the facial nerve's zygomatic branch was found to be traversing through the cyst and was sacrificed. The rest of the branches were identified and preserved. There was an excess of thinned and redundant skin, which was trimmed to achieve cosmetically acceptable closure. Postoperative microscopic examination revealed PA without any evidence of malignancy Figure .Case summary 2A 63-year-old male presented with complaints of swelling in the right side of the neck extending to the right cheek for 15 years. There was no sudden increase in the size of the swelling. He had no other complaints similar to Case 1.On local examination, an irregular, non-tender, mobile swelling of size 10x8 cm was noted below, behind, and in front of the right ear with obliteration of the retro-mandibular furrow and lifting of the right ear lobule. The swelling had well-defined margins, a smooth surface, and variable consistency with cystic and solid areas admixed. It was not fixed to the masseter, sternocleidomastoid, or overlying skin. The skin over the swelling and his intraoral examination were clinically unremarkable. There was no evidence of facial palsy or lymph nodes in the neck.2) with possibilities of mucoid content was also noted. The lesion was abutting the retromandibular vein and displacing it anteriorly. There were no suspicious deep cervical lymph nodes noted  of the neck showed a well-circumscribed, solid-cystic lesion within the posteroinferior part of the right parotid gland's superficial lobe with no extension to the deep lobe measuring 8.5x6.4x8 cm. Peripheral solid areas of the lesion along the superior and medial aspects show diffusion restriction with post-contrast enhancement. There was a presence of T2 intermediate to hyperintense signal with scattered T1/T2 hyperintense cysts. A T2 hypointense T1 intermediate to mildly hyperintense cystic component of the lesion  is the initial investigation of choice. But USG has certain limitations such as difficulty studying the deep parotid lobe because of the mandible acoustic shadow, inability to visualize the facial nerve, retropharyngeal and deep neck lymphadenopathies, and the difficult to identify the involvement of surrounding tissue ,11. ThisFNAC is a rapid and useful tool for cytological diagnosis. The risk of dissemination of neoplastic cells along the needle tract and facial nerve injury is also negligible . HoweverAlthough benign, tumors of the salivary gland, such as PA and WT, mandates excision because of the risk of malignant transformation. The risk of malignant transformation in PA increases from 1.6% in tumors with less than five years duration, to 9.5% for those presenting for more than 15 years ,5. The sPG tumors usually remain untreated and grow to an enormous size due to various factors such as poor socioeconomic conditions, lack of access to healthcare, and fear of surgery. GtPGTs can be benign as well as malignant. Also, long-standing GtPGTs become symptomatic and have more risk of malignancy, thus mandating surgical excision. Therefore, excision with uninvolved margins should be considered for all GtPGTs. Surgery needs proper preoperative planning to minimize intra and postoperative complications.