Right iliac fossa abdominal pain is a common reason for emergency ward admissions, its etiology is difficult to diagnose. It can be facilitated by an imaging examination, such as a Computerized Tomography scan which exposes the patient to ionizing radiation and implies delays. A bedside ultrasound performed by emergency physicians could avoid these issues. The aim of our study was to assess the performance of ultrasound carried out at the patient’s bedside by an emergency physician compared with a clinical-laboratory examination for the diagnosis of a surgical pathology in right iliac fossa pain.This is a single-center prospective cohort study conducted in an Emergency Department receiving 19,000 patients per year. All patients presenting pain in the right iliac fossa were included by four (out of ten) emergency physicians certified in an ultrasound examination. A full grid pattern scan ultrasound of the abdominal cavity with analysis of the right iliac fossa was performed. The primary outcome was to compare the diagnosis performance of bedside ultrasound and clinical-laboratory examination to detect a surgical pathology. Two emergency physicians who did not participate in the study made the final diagnosis  by reviewing the entire medical chart of each patient.p < 0.001).From January 2011 to July 2013, 158 patients with a median age of 17 [13–32] years were analyzed. The diagnosed cases were: appendicitis (53), non-specific abdominal pain (48), lymphadenitis (22), ileitis (11), complicated ovarian cysts (7), neoplasias (5), inflammatory or infectious colitis (5), inguinal herniations (3), bowel obstructions (2), and salpingitis (2). The accuracy of ultrasound diagnoses was 0.89 (95% CI 0.84–0.94) versus 0.70 (95% CI 0.57–0.82) for diagnoses based on clinical-laboratory examination only (Bedsides, ultrasound allows an accurate diagnosis of a surgical pathology in 89% of cases, which is more efficient than the clinical-laboratory examination. Abdominal pain is the third most common reason for attending a hospital emergency ward . Even thThe aim of our study was to assess the performance of abdominal ultrasound carried out at the patient’s bedside by an emergency physician compared with a clinical-laboratory examination, for the diagnosis of a surgical pathology in right iliac fossa. Our hypothesis was that ultrasound would improve diagnostic performance.This prospective cohort study was carried out in the emergency ward of a general hospital center that has 19,000 admissions per year.The protocol for the study was approved by the Ethics Committee of Lourdes hospital (PV N°14244) and follows the World Medical Association’s Declaration of Helsinki. It did not require written consent since the standard treatment procedures were not altered in order to perform the study.From January 2011 to July 2013, all patients (children and adults) presented to the emergency department with as main symptom an acute pain of the right iliac fossa were included if a physician trained in use of ultrasound was present.The history of the patient and the clinical examination strived to characterize the surgical origin of the pain by relying on standard functional and physical symptoms . Urological and/or gynecological symptoms were also probed for, depending on the symptoms. A point of care urinalysis was also performed at the admission.Systematic common laboratory testing upon admission was composed of a blood count, a test for C-reactive protein levels, as well as a blood electrolytes test, and a test of kidney function. Depending on the patient history and clinical findings, a Human Chorionic Gonadotropin (β-HCG) test, a liver and pancreatic assessment, a hemostasis assessment, a blood group typing, or any other laboratory test deemed to be of use by the emergency physician were added.Upon assessment of all these items, the physician had to make a suspected clinical-laboratory diagnosis: surgical pathology  or medical pathology .After having undergone basic training in the use of abdominal ultrasound imaging, the emergency physicians who included patients for this study had to have at least 2 years of experience with emergency ultrasound use. This was first broken down into training sessions in a certified center over 7 days and then by e-learning for 1 year. This training was based on the specifications of the American College of Emergency Physicians . This coFollowing the clinical examination and the laboratory testing, the emergency physician performed an ultrasound at the patients’ bedside .The examination consisted of an initial grid pattern of the abdominal cavity using a convex abdominal probe (3.5 MHz), which permitted to search peritoneal effusion, masses. A scan of the two kidneys, liver, biliary tracts and aorta was equally performed. Because of the lack of a vaginal probe, pelvic analysis was performed by an abdominal probe. The emergency physician used the surface probe (7.5 MHz) to complete the scan, guided by the site of the pain, the analysis then focused on the right iliac fossa. Gradual compression was applied as described by Ooms , 24: theOther pathological images can also be seen, such as an intra-peritoneal effusion, an obstruction syndrome, inflammatory adenopathies, and complicated ovarian cyst –27 Fig..Fig. 1ExIn all cases, the emergency physician attempted to adequately discern the appendix. A diagnosis of appendicitis was made in conjunction with more than two of the following images: a double cockade cross-sectional appearance of the appendix of more than 6 mm in diameter, ending as a sleeve in a longitudinal section, a non-compressible nature, and association or not of a peri-appendicular effusion. In case of normal appendix viewed (none of previous images), this diagnosis was excluded Fig. .Fig. 2UlUpon completion of the examination, the practitioner provided a full written report regarding the ultrasound that fully detailed all of their findings. In case of a visually diseased appendix, intestinal occlusion, or peritoneal effusion, the ultrasound indicated a surgical pathology. In case of a normal appearing appendix, or other images indicative of pathologies, the ultrasound indicated a medical pathology.After making the clinical-laboratory diagnosis, and the ultrasound diagnosis, the emergency physician in charge of the patient could ask for an abdominal CT scan and/or the opinion of a surgeon if he deemed it necessary, in particular to decide on the continuation of the patient’s care.The final diagnosis was the etiologic diagnosis of right iliac fossa pain . A surgical pathology was defined by a pathology requiring surgical treatment like laparoscopy or laparotomy which was decided and performed by the surgeon. Medical pathology was defined by a pathology requiring medical treatment .Two emergency physicians who did not participate in the study made the final diagnosis by reviewing the entire medical chart of each patient, taking into account their evolution. They had to classify patients into two groups: surgical or medical pathology. In each group, the etiologic diagnosis was investigated.For the patients who underwent surgery, the final diagnosis relied on an analysis of the surgical report and of the histological examination in case of surgical exeresis. For the patients who were hospitalized without undergoing surgery, the final diagnosis was based on the final hospitalization report. When patients were not hospitalized, they were contacted 2 months after discharge, and the diagnosis made when they left the emergency ward was then confirmed or not by their medical progress. Indeed, a surgical pathology was excluded if there was no re-hospitalization in our institution or another. In case of discrepancy between the two emergency physicians, the opinion of a surgeon from our institution could be taken into consideration.Consequently, the performance of abdominal ultrasound was compared to the performance of clinical-laboratory examination for the diagnosis of a surgical pathology.The quantitative variables were expressed as mean ± SD for normally distributed variables and otherwise as a median with interquartile range. Qualitative variables were expressed as numerical values and as percentages.The diagnostic performances of the ultrasound and the clinical and laboratory examination were expressed as sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) with their [confidence intervals at 95%]. A Youden’s index and an accuracy were calculated. The Youden’s index is defined by (sensitivity + specificity − 1), and the performance of the examination was deemed to be better when the Youden’s index is close to 1. Accuracy was defined as the percentage of properly classified cases upon completion of examinations for which the performance was tested.p = 0.05.The relative accuracies of the ultrasound and of the clinical-laboratory diagnosis were compared using a McNemar’s test, with a threshold for significance set at No power analysis was performed because of the absence of previous studies comparing abdominal ultrasound by emergency physician and standard examination (clinic + laboratory) in the management of right iliac fossa pain.Four emergency physicians (of ten in the department) met the training requirements and thus participated in the study.−2.Ultimately, 158 patients were analyzed (sex ratio = 1) who were 17 [13–32] years old. Of these, 69 patients (44%) were hospitalized and 89 (56%) were sent home. The time spent in the emergency ward was 167 ± 51 min. The mean Body Mass Index was 21 ± 4 kg mThe final diagnoses made included 53 cases of appendicitis (33%), 48 (31%) cases of non-specific abdominal pain (NSAP), 22 cases of adenolymphitis (14%), 11 cases of ileitis(7%), 7 complicated ovarian cysts (5%), 5 (3%) newly discovered neoplasias , 5 (3%) cases of inflammatory or infectious colitis , 3 (2%) inguinal herniation’s, 2 (1%) bowel obstructions (one by a bridle and one by a neoplastic growth) and 2 (1%) salpingitis.The sample characteristic is presented in STARD flow diagram Fig. .Fig. 3STDetailed images viewed on ultrasound compared to the final diagnosis are reported in Table Out of the 56 patients with an appendicitis diagnosed by ultrasound, 44 (84%) were taken directly to the operating room after surgical advice in the emergency department. There were four false-positive ultrasounds where the final diagnosis turned out to be one NSAP and three adenolymphitis.None of these four patients underwent an operation, because they were examined by the surgeon on duty. This one decided to supervise three patients in the surgery department. Concerning the fourth he asked for a CT scan.Among the 89 patients for whom the bedside ultrasound did not find a surgical pathology, there were four false negative. The diagnosis was corrected by surgeon on duty for two of them and by a CT scan for two others. For the other eighty-five patients (true negative), none had to later undergo an operation or be re-hospitalized.The clinical-laboratory diagnosis compared to the final diagnosis is shown in Table The compared performances of bedside ultrasound and clinical-laboratory approach according to the diagnosis of a surgical pathology are reported in Table In our study of patients exhibiting pain in the right iliac fossa, an ultrasound performed by the emergency physician allowed for the diagnosis of a surgical pathology with an accuracy rate of 89%. This amounts to a significant gain in performance relative to clinical-laboratory examinations, since the latter has an accuracy rate of 70%.The performance of the clinical-laboratory approach is relatively modest, perhaps because there is still ample room for improvement in terms of the clinical examination. This is indeed suggested by studies of this approach, and Alvarado or AIR score also yields extremely variable results –31. ThesAs for the 13 patients for whom the ultrasound diagnosis indicated a surgical pathology, although the final diagnosis was in fact a non-surgical pathology, none incorrectly underwent surgery. This was thanks to reassessment by the surgeon on duty, who either monitored them in the surgery department, or who ordered a CT scan that allowed the diagnosis to be corrected or to be made with a greater degree of accuracy. In case of discordant ultrasound/clinical–biological results, the reassessment of the surgeon evaluation was considered as the reference method.The performances of the ultrasound carried out by the emergency physician are comparable to those found in the literature when a radiologist performed the ultrasound: i.e., a specificity of 70 to 90% and a sensitivity of 85 to 100%. These works compared accuracy of an ultrasound with the surgery results or a CT scan only in appendicitis diagnosis , 32. By The fact that the emergency physician performs the ultrasound themselves will strengthen the notion of the pain in the right iliac fossa being innocuous when they do not see an abnormal image and, by contrast, tend to confirm or give rise to suspicion of a serious diagnosis when they obtain an abnormal image. This is the case for appendicitis, unlike with other pathologies, where a typical image usually is enough to confirm a diagnosis. Indeed, colonic afflictions  translate into a non-specific thickening of the wall. Similarly, a peritoneal effusion, even when in isolation, is reason for the practitioner to be cautious since it should be considered as a sign of a surgical pathology until proven otherwise. These elements are reason to prescribe complementary assessments or to seek specialist advice.Thus, this strategy allowed scanning to be optimized, with the irradiative examination given to 28% of the patients in our study, whereas in North American register, a CT scan was performed for 43% of patients who suffered from abdominal pain , 37.Furthermore, this ultrasound-clinical process optimizes the processing of the patient by avoiding incorrect conclusions being made with regard to the cause of harmless abdominal pain, and by unnecessarily resulting in invasive procedures or hospitalization. As such, none of the 86 patients who were processed by the emergency department secondarily presented surgical pathologies.With regard to the 60 patients in our cohort who underwent a surgical treatment, the use of an ultrasound resulted in rectifying the diagnosis for 14 (23%) patients for which the clinical-laboratory approach concluded with a non-surgical pathology.These findings could encourage a two-step approach, with first clinical-laboratory and bedside ultrasound examination and secondarily a CT scan and/or surgical advice for management of right iliac fossa pain .As this is a monocentric study with a relatively limited number of participants, it is difficult to extrapolate the results of this work to the entire specialty.Our results are probably not transferable to less well-trained operators. Nonetheless, the results of this work are reason to encourage further training efforts.In the present sample of patients, no pyelonephritis or ureteral colic was observed. This could be related to strict inclusion criteria (main symptom of acute pain of the right iliac fossa). The number of patients included in the study did not reflect the prevalence of right iliac fossa pain in the emergency department over 30 months because only 4 of 10 EP could participate in the study.Despite a good performance by the ultrasound-clinical strategy, there were still 17 diagnostic errors .Three of the four surgical pathologies not detected by the ultrasound were strangulated inguinal hernia, probably explained by the fact that the ultrasound scan was not carried out in this area. It should be noted that clinical examinations for this affliction were equally inadequate. This highlights the importance of systematically exploring this area, with a careful physical examination and a focus with an ultrasound probe.The 13 false positives were largely dominated by the presence of a non-specific peritoneal effusion in eight (61%) cases. Indeed, the cohort included only two cases out of 10 where those in fact revealed a surgical pathology. This is why it seems reasonable to retain this warning sign, since it motivates further exploration. Regarding the four false positives for appendicitis, it was the reassessment by the surgeon that allowed a cutoff decision to be made. The latter hence has a central role in the assessment of acute abdominal pains , 40.Our analysis of the performance of the ultrasound was based on whether an anomaly was seen rather than whether an accurate diagnosis was made. This is particularly true in case of peritoneal effusion which can be indirect sign of a surgical pathology. This choice potentially leads to an overestimation of the merit of the ultrasound performed by the emergency physician.As this study was not comparative, it does not allow for the contribution of the ultrasound to the diagnostic performance of the emergency physician to be appraised. For that it would have been necessary to compare the treatment with a typical process whereby the examinations were performed by a radiologist.Similarly, it was not possible to assess the gain in terms of the effect on the duration of the stay in the emergency department.The emergency physicians were aware of clinical-laboratory results when ultrasounds were performed. This could have influenced the results. Indeed, confirmation of the final diagnosis by the two independent doctors was performed retrospectively, as was the case for the complementary examinations, of which the bedside ultrasound could influence the diagnosis. Yet this is so for all the complementary examinations (laboratory tests and CT scans) which form an integral part of the diagnostic process. Furthermore, this limitation does not apply to the patients who underwent surgery. Aside from surgical, anatomical–pathological, or scan-based findings, confirmation of the final diagnosis was not supported by items that could not be questioned. Indeed, it is ethically questionable to perform a CT for all patients or to make surgical exploration like laparoscopy in order to exclude a surgical pathology in case of adenolymphitis, ileitis or NSAP for example. Yet this limitation can be found in most of the studies treating abdominal pains, and particularly in the case of a non-surgical diagnosis , 42.The diagnosis accuracy of an abdominal ultrasound performed by an emergency physician is 89% compared to an accuracy of 70% by a clinical-laboratory examination alone, for the diagnosis of a surgical pathology in case of right iliac fossa pain.


Basic and Clinical Neuroscience published an article by Co-occurence of Pituitary Adenoma with Suprasellar and Olfactory Groove Meningiomas. They claimed it as the first case of co-occurence of these two malignancies. However, to our knowledge, this is not the first case reported in this regard. We reported the same case scenario in a 61-year-old woman referred to our outpatient clinic in 2007. In this commentary, we are going to discuss our reported case and present a brief review over co-occurence of intracranial meningioma with pituitary adenoma.Recently,  We read with interest the case report by However, in a paper published in Pituitary, we reported the first case ever diagnosed of simultaneous occurrence of GH-secreting pituitary adenoma, intracranial meningioma and two intracavernous asymptomatic aneurysms in a 61-year-old woman who was referred to our outpatient clinic reporting severe obesity and appearance of typical acromegalic features 13 years after a right frontal craniotomy for a pituitary tumor . EndocriIn the case by In our case, not cited in the case report by Lim, MRI showed a homogeneously enhancing intrasellar pituitary macroadenoma (12×10 mm) extending superiorly with visual pathways compression and bilateral intracavernous invasion, and simultaneous coexistence of a large intracavernous aneurysm of the right Internal Carotid Artery (ICA) adjacent to the pituitary adenoma. The presence of the right ICA aneurysm was confirmed by MRI angiography with 3D evaluation by Maximum Intensity Projection (MIP) reconstruction. Somatostatin Analog (SSA) treatment normalized GH and IGF-1 levels in a few weeks. Eight months later, the patient underwent a balloon ICA occlusion by endovascular approach with disappearance of the right ICA aneurysm. After one year, a new MRI confirmed the presence of the pituitary adenoma along with the appearance of a right frontal meningioma and a new ICA aneurysm on the left side. The patient preferred an expectation management refusing the surgical option. The last MRI confirmed the presence of three distinct lesions, showing the growth both of meningioma and of the left ICA aneurysm.Coexistence of pituitary lesion and other brain diseases has been frequently reported in literature. Moreover, an elevated co-prevalence of independent primary tumors has been found in patients with benign and malignant pituitary tumors and in their relatives . AssociaIn conclusion, in literature the association of intracranial meningioma with pituitary adenoma is a rarely reported surgical entity, but the simultaneous occurrence of multiple meningiomas and pituitary adenoma is an even more rare clinical event. Our case, described in 2007, represents the first case of an equally rare simultaneous occurrence of pituitary adenoma, intracranial meningioma and two intracavernous aneurysms adjacent to the pituitary adenoma and the first in which MRI allowed preoperative identification. In the presence of concomitant brain morbidities  treatment must be tailored to each patient. For this reason, the adequate knowledge of these coexistences, based on their location, is an essential precondition to plan a correct surgical approach, and to avoid life-threatening complications.


Localized malignant mesotheliomas, defined as sharply circumscribed tumors of the serosal membrane with the microscopic appearance of diffuse malignant mesothelioma, are rare tumors; their behavior and prognosis are uncertain. Intrahepatic mesotheliomas are postulated to arise from mesothelial cells of Glisson's capsule. A 69-year-old female with no history of asbestos exposure presented with a one-month history of increasing abdominal pain associated with constitutional symptoms. Computerized Tomography (CT) scan of the abdomen and pelvis revealed a sizable soft tissue mass within the right paracolic gutter, abutting the inferior hepatic margin, the lateral abdominal wall, and descending colon. Ultrasound-guided biopsy of the mass suggested a poorly differentiated hepatocellular carcinoma. There was no disease elsewhere on PET scan. Surgical resection of the mass was performed. Pathological assessment suggested the tumor to be arising from the liver with invasion of the liver, abdominal wall musculature, and the adventitial surface of the ascending colon. A final diagnosis of localized biphasic malignant peritoneal mesothelioma with rhabdoid features was rendered based on morphology and the result of immunohistochemical studies. The abdominal wall margin was positive. The patient progressed over the course of 6 months despite receiving adjuvant chemotherapy and immunotherapy with metastases and a decline in performance status and was transitioned to hospice. Localized malignant peritoneal mesotheliomas are rare tumors that may present clinically as a liver mass and simulate primary hepatic or secondary tumors. Definitive diagnosis is obtained by surgical resection in most cases. The clinical outcome is variable with most cases having a poor outcome. Malignant mesotheliomas are rare tumors that reportedly account for 0.2% of all malignant tumors. Malignant peritoneal mesotheliomas occurring in the peritoneum have an even lower incidence . Most caA 69-year-old female with a past medical history of coronary artery disease, hypertension, hyperlipidemia, and polymyalgia rheumatica presented with a one-month history of increasing abdominal pain associated with weakness, fatigue, weight loss, and loss of appetite. She had no known history of malignancy nor was she exposed to asbestos in the past.Laboratory findings revealed a WBC count of 25.8 (reference range: 3.5-12.0 x 109/L) with absolute neutrophil and monocyte counts of 23.05 (reference range: 3000-5800 x 106/L) and 1.67 (reference range: 300-500 x 106/L), a hemoglobin level of 7.7  with an MCV of 78 (reference range: 76-100 fL), an RDW of 20.7 (reference range: 11.5-14.3%), a platelet count of 729 (reference range: 150-400 x 109/L), a globulin level of 5.3 (reference range: 1.5 - 3.9 g/dL), and a globulin/albumin ratio of 0.4 (reference range: 1.0 - 1.8 ratio).Computed Tomography (CT) scan of the abdomen and pelvis showed a soft tissue mass of 9.5 x 8.5 x 7 cm within the right paracolic gutter, abutting the inferior hepatic margin, the lateral abdominal wall, and effacing the descending colon with an extensive solid component and low attenuation, possibly representing necrosis Figures .Additional findings included a left adnexal cystic mass measuring 8.5 x 6.7 cm without calcifications or a discrete solid wall component. The finding of a left adnexal mass prompted the measurement of serum CA-125, which was within normal limits. The patient underwent a colonoscopy which did not show any intrinsic involvement of the colon.Ultrasound guided biopsy of the mass suggested a poorly differentiated hepatocellular carcinoma.A preoperative PET scan showed increased uptake in the mass only, with no evidence of uptake in the left adnexal mass or any other area.The patient then underwent surgical debulking of the mass for therapeutic purposes and further characterization of the tumor in the form of a laparoscopic assisted wedge resection of segment 6 of liver, right colectomy, and an abdominal wall resection with a partial omentectomy after confirming the absence of metastatic disease on laparoscopy. Gross examination revealed a 9 x 8.0 x 6.0 cm tan-pink, soft, centrally necrotic tumor within the left lobe of the liver, abutting the overlying liver capsule, extending through the capsule into the attached abdominal wall, resulting in retraction of the abdominal wall, and extending into the adjacent omental fat. The tumor also appeared to retract and abut the right colon without grossly extending into the bowel wall Figures .Microscopically, the tumor was comprised of three components, one component consisting of sheets of pleomorphic polygonal (epithelioid) cells with occasional intracytoplasmic vacuoles intimately associated with fascicles of pleomorphic spindled cells which formed the second component, with interspersed large areas of geographic necrosis. The third component was focal, consisting of cells with eccentrically located nuclei, intranuclear cytoplasmic inclusions, and an abundant amount of glassy, eosinophilic cytoplasm, consistent with rhabdoid cells. The tumor appeared to arise from the surface of the liver and focally invaded the liver and invaded abdominal wall musculature, omental fat, and adventitia of the ascending colon Figures .A battery of immunohistochemical markers was performed on viable sections of the tumor. The tumor showed diffuse and strong positivity in all three components for calretinin, CK 5/6, AE1/AE3, D2-40, CD10, CK5D3, vimentin, and focally EMA, which was supportive of a mesothelial phenotype Figures . CEA, MOGiven this constellation of findings, a diagnosis of localized biphasic malignant peritoneal mesothelioma with rhabdoid features was appropriate. The abdominal wall margin was extensively positive by more than 2 cm. The liver and colonic margins were negative. Over the course of six months, the patient completed three cycles of adjuvant chemotherapy with cisplatin and pemetrexed. Follow-up CT scan showed disease recurrence and progression with multiple liver and peritoneal metastases, as well as a soft tissue mass at the site of ileocolonic anastomosis. The patient additionally received 2 doses of pembrolizumab but had a significant decline in performance status and, due to poor prognosis, was transitioned to hospice.Uncertainty remains as to whether localized malignant mesothelioma is merely a gross variant of diffuse malignant mesothelioma with a similar behavior and clinical course or whether localized malignant peritoneal mesothelioma is distinct from diffuse malignant mesothelioma, sharing with it its mesothelial origin and microscopic features only . Some auWhile asbestos is also the best defined risk factor for malignant peritoneal mesothelioma, the link is weaker than in malignant pleural mesothelioma . Other pPatients with localized malignant peritoneal mesotheliomas usually present with nonspecific symptoms; pain and weight loss are common, and fever can occur secondary to tumor necrosis . The tumMalignant peritoneal mesotheliomas can be of epithelioid, sarcomatoid, or biphasic types. The presence of rhabdoid cells in localized malignant peritoneal mesotheliomas has been reported by Matsukuma et al. . The difThe histological diagnosis of malignant mesothelioma is challenging. To confirm a diagnosis of epithelioid malignant mesothelioma, the current recommendation is to use at least two mesothelial markers  and two carcinoma markers with greater than 80% sensitivity and specificity . Additional markers would be needed if any of the results are discordant . In WT-1Most malignant peritoneal mesotheliomas are diffuse and difficult to resect, therefore, the treatment in those cases consists of chemotherapy. This is in contrast to localized peritoneal mesotheliomas, which are amendable to surgical resection . SurgeryA detailed search of relevant publications of localized malignant peritoneal mesothelioma was conducted using PubMed and MEDLINE and is summarized in 90% of the tumors arose either in the liver or in close proximity to the liver, and 50% of the tumors were epithelioid with the remaining 50% of the tumors comprising both sarcomatoid and biphasic types, of which two cases contained rhabdoid features (one sarcomatoid and one biphasic). 75% of the cases had no prior history of asbestos exposure, including 3 cases with no reported history of asbestos exposure. Based on the follow-up data reported, the clinical course is variable with 5 cases having no recurrence postsurgery, 2 cases resulting in the death of the patient, one case with distal recurrence postoperatively, 2 cases with postoperative disease progression in the form of either nodal, peritoneal, or liver metastases, and 1 case with tumor rupture and subsequent deterioration in the clinical condition of the patient, preventing tumor resection in that case. The tumors appear to affect the older population and have no gender preference.Localized malignant peritoneal mesotheliomas are rare tumors that may present clinically as a liver mass and simulate primary hepatic or secondary tumors. They have nonspecific signs and symptoms and need a high index of suspicion and an extensive workup prior to surgery. Not all patients have a history of asbestos exposure. Due to limitations of sampling and the rarity of the tumor, the diagnosis may be difficult to confirm on biopsy or may be overlooked. Definitive diagnosis is obtained by surgical resection in most cases. These patients have a variable clinical course with an unfavorable outcome reported in the majority of cases; however, accumulation of more cases is necessary to characterize the biological behavior and prognosis of these uncommon tumors.


Urachal mucinous tumors are rare neoplasms with behaviour that can range from relatively benign to malignancy that can spread distantly or throughout the peritoneum as pseudomyxoma peritonei or peritoneal carcinomatosis. Here we describe a unique case of urachal mucinous cystic tumor of low malignant potential confined to an intact cyst at the dome of the urinary bladder, without rupture or peritoneal spread. The urachal mucinous tumor was an incidental finding on a staging CT scan performed for sigmoid colon adenocarcinoma. We believe that this case illustrates a potential diagnostic pitfall which could have prognostic and therapeutic implications. Due to the intestinal phenotype of these neoplasms, a urachal tumor of low malignant potential could be mistaken for metastatic spread from a colonic adenocarcinoma in the rare situation such as this case, where the two neoplasms occur concurrently. Urachal neoplasms are thought to arise from neoplastic transformation of remnant urachal tissue left from incomplete regression of the urachus in fetal development –11. MostCare was provided at a tertiary care teaching hospital and the patient provided written consent for a review of medical records and for publication of a case report, in accordance with institutional policy. Data regarding clinical history, diagnostic imaging, and pathology were collected retrospectively.The patient, a 67-year-old male, underwent a colonoscopy after a positive Fecal Immunochemical Test result in the province's colon cancer screening program. On review of systems, the patient reported a change in bowel habits, specifically cramping and a sense of urgency. His past medical history was unremarkable apart from hypertension and hyperlipidemia. Colonoscopy revealed a stricturing malignancy in the distal sigmoid colon. Biopsies were diagnostic of colonic adenocarcinoma. A CT scan of the chest, abdomen, and pelvis demonstrated a 6.5 cm segment of circumferential wall thickening in the sigmoid colon, 20 cm from the anal verge. The CT scan also identified an incidental, 6.9 x 4.8 cm rim calcified cystic lesion arising from the dome of the urinary bladder, suspected to represent a bladder diverticulum or a urachal cyst , partially calcified, and lacked any grossly identifiable papillary projections or solid component. The cyst content was mucin. On H&E microscopy, the epithelial lining consisted of a single layer of cuboidal to columnar epithelial cells with an intestinal phenotype, including scattered goblet cells , the patient had no further evidence of metastasis or local recurrence.The urachus is a vestigial remnant derived from the embryonic tissue connecting the allantois to the urinary bladder . In fetaForty-two cases of urachal mucinous cystic neoplasms have been described in the literature, in eighteen case reports and a case series of 24 patients, summarized in The most significant potential pitfall in this case would have been a pathologist interpreting the urachal mucinous neoplasm as a cystic metastasis from the colon cancer, perhaps due to a lack of awareness of urachal mucinous neoplasms. The potential risks of such an interpretation could include unnecessary systemic therapy, or a potential second surgical procedure for peritoneal cytoreduction and intraperitoneal chemotherapy (Sugarbaker procedure). This patient has been treated with only one abdominal surgery. He developed lung metastases that were surgically resected. There has been no evidence of local recurrence or peritoneal spread on surveillance imaging. We hope that this case will prove informative to pathologists, surgeons, and oncologists managing a similar scenario in the future, and we hope that this story will support those teams' decisions to manage a case like this as two independent, concurrent neoplasms.


Primary central nervous system (CNS) small lymphocytic lymphoma (SLL), as a type of low-grade lymphoma, is extremely rare. The diagnosis of CNS SLL is challenging due to its variable clinical and radiological features, which may overlap with those of diffuse large B-cell lymphoma (DLBCL). Primary CNS SLL differs from DLBCL in that it has an indolent clinical course and a good prognosis. Thus, it is important to distinguish SLL from DLBCL. By reviewing the literature, only two cases of low-grade SLL, primarily located in the CNS and involving the brain parenchyma and dura, have been reported. To our knowledge, primary CNS SLL in the bilateral ventricles has never been reported. Interestingly, the two cases in our report are identical in terms of the clinical presentations, magnetic resonance imaging (MRI) features, pathological results and prognoses.Both patients presented with headaches. MRI suggested solid lesions located in the bilateral ventricles that were isointense on T1-weighted images and hypointense on T2-weighted images. After the injection of contrast agent , the intraventricular lesions were homogeneously enhanced and hyperperfused. CSF cytology revealed malignant cells. Brain biopsy revealed diffuse proliferation of small lymphocytes with positive labelling of B-cell immunomarkers. The primary origin in the CNS was confirmed with no evidence of systemic lymphoma. Two patients were given high doses of methotrexate-based chemotherapy and were free from symptoms and progression for more than 1-year of follow-up.The presence of homogeneously enhanced intraventricular MRI lesions should raise the suspicion of primary CNS SLL. Primary central nervous system lymphoma (PCNSL) is a rare type of extra-nodal non-Hodgkin lymphoma (NHL) that can be found in the brain, leptomeninges, eyes or spinal cord without evidence of systemic lymphoma. PCNSL constitutes 4% of primary brain tumours, and approximately 90% of cases are aggressive, diffuse large B-cell lymphoma (DLBCL) with a poor outcome. Other lymphoma categories, such as low-grade subtypes and T cell lymphomas, are extremely rare .Small lymphocytic lymphoma (SLL), as a type of low-grade NHL, is different from DLBCL in that it has an indolent clinical course, has less aggressive features and has a good prognosis –4. There6/L) and significantly elevated CSF protein at 1773.1 mg/L  and IgG at 235 mg/L . CSF cytology revealed malignant cells   and slightly elevated CSF protein . Simultaneously, follow-up MRI showed that the lesions were similar in terms of their location, size and shape compared with prechemotherapy values. Thereafter, she was followed as an outpatient and underwent MRI every 3 months. The last follow-up was performed in May 2019. The patient described no clinical symptoms, and there was no significant change in the lesions compared with prechemotherapy values. The overall follow-up period was more than 1 year.A 45-year-old woman presented to the neurological department with a 6-month history of headache. The patient described her headache as generalized, slightly dull, not persistent and without any exacerbating or relieving factors. She denied fever, dizziness, nausea or vomiting. She also had no ocular complaints such as blurred vision, floaters, decreased acuity, pain, photophobia and diplopia. There was also no history of cognitive decline and personality changes, seizures, loss of coordination and gait disorders, immunosuppressive drug intake, radiation exposure, and systemic infection or other autoimmune diseases. Her family history was unremarkable. Neurologic examination did not show any focal neurological signs. MRI demonstrated solid lesions in the bilateral ventricles and fornix, which were isointense on T1-weighted images (T1WI) and hypointense on T2-weighted images (T2WI) without diffusion restriction in diffusion-weighted imaging (DWI). Furthermore, the thalamus and callosal splenium demonstrated bilaterally symmetric swelling and hyperintensity on T2WI  with 82% lymphocytic cells and significantly elevated protein  and IgG at 286 mg/L (reference range: 0–34 mg/L). CSF cytology revealed malignant cells (Fig. A 49-year-old man presented to the neurological department with headache and dizziness for the past 5 years. He described an episodic left-sided headache without aura. Each symptom lasted 2 min, and there had been 2–3 attacks within 1 month. The symptoms were not severe, and there was no interference with daily routines. He denied fever, nausea, vomiting, or neck stiffness. He also had no visual symptoms and no history of cognitive decline, personality changes, and focal neurological deficits. His family history was unremarkable. Neurologic examination did not show any focal neurological signs. MRI revealed solid lesions involving the bilateral ventricles, thalamus and callosal splenium. Intraventricular lesions were isointense on T1WI (Fig. Primary CNS SLL is extremely rare. By review of the literature, only two cases of primary SLL involving the brain parenchyma and dura have been reported so far , 6. In tThe main presenting symptom of these two cases was a slight headache without cognitive impairment, abnormal behaviour, personality changes or ocular complaints that are frequently observed in DLBCL. In addition, these 2 patients were free from symptoms and progression after high-dose methotrexate-based chemotherapy for over one-year of follow-up. These results indicate that the clinical course of primary CNS SLL is indolent and less aggressive, which is consistent with a report from Jahnke and colleagues . Among tDue to the rarity of low-grade PCNSL and the limited data derived from a few case reports and pathological series, no standard therapy is currently available. Most treatment protocols come from the results of high-grade PCNSL. Front-line therapy for high-grade PCNSL consists of high-dose methotrexate-based poly-chemotherapy. In addition, radiotherapy alone or in combination with chemotherapy is always considered . Our patRadiologically, in contrast to DLBCL and other reports of SLL, the lesions in the present cases showed hypointense T2WI, isointense T1WI and homogeneous enhancement , 9. As iLow-grade PCNSL with homogeneously enhancing intraventricular lesions should be differentiated from other common ventricular neoplasms, such as choroid plexus papilloma, meningioma, subependymoma and metastasis. In addition, differential diagnosis must be made with other types of PCNS lymphoma involved in the ventricles , 11. AltIn conclusion, the presence of homogeneously enhanced intraventricular MRI lesions should raise the suspicion of primary CNS SLL.


When the management of an anterior mediastinal tumor requires general anesthesia, airway narrowing and obstruction may occur secondary to muscle relaxation.Two men  presented with a giant anterior mediastinal tumor and central airway obstruction. We used Dumon stents to effectively secure the airway in both patients. After chemotherapy, stent removal was safely performed in each case because the tumor was substantially smaller.Dumon stents effectively secured the airway. These stents were easily removed after chemotherapy without severe complications.Temporary stenting is useful in patients with a giant anterior mediastinal tumor who require general anesthesia. When the diagnosis or treatment of a huge anterior mediastinal tumor requires general anesthesia, fatal respiratory failure may occur due to airway narrowing and muscle relaxation. We report two cases in which we safely secured the airway using an airway stent while performing a giant anterior mediastinal tumor biopsy under general anesthesia. These cases have been reported in line with the SCARE criteria .2Case 1: A 15-year-old boy presented to our hospital with fever and respiratory distress. On physical examination, his respiratory distress was only relieved by placement in the left lateral decubitus position. The patient’s chest X-rays showed enlarged mediastinal shadows and left lung atelectasis a. Chest Case 2: A 36-year-old man presented with no particular complaint, and he had no respiratory distress at rest on physical examination, but his abnormal findings were pointed out incidentally. The patient’s chest X-rays showed enlarged mediastinal shadows and no pleural fluid retention. His chest CT showed a giant tumor with a contrast effect in the anterior mediastinum, and, although tracheal and bronchial contractions were observed, complete occlusion had not occurred . We atte3Central airway narrowing causes severe dyspnea and may be fatal. However, there are no clear guidelines for the management of a narrow central airway, and only a few reviews on the topic are available . AzizkhaECMO is invasive, with the major complication being bleeding secondary to anticoagulation . ConsequTherefore, we propose the insertion of a temporary airway stent at the time of induction of general anesthesia that can then be removed when the airway is no longer compressed. Disadvantages of temporary stenting include the possibility of airway injury during stent insertion or removal and stenosis progression due to granulation in cases where the stent is retained for a long period . HoweverIt should be noted that temporary stenting cannot prevent the compression of large blood vessels. Takeda et al. reported the case of a patient with a large anterior mediastinal tumor who developed severe hypoxemia during general anesthesia secondary to total obstruction of the left main bronchus and right pulmonary artery . In such4Temporary stenting is useful in patients with a giant anterior mediastinal tumor who require general anesthesia.There is no source of funding for our research.Our case report is exempt from ethnical approval in our institution.Each patient and parents provided consent for the publication of his case, and it is stated in the paper.Masahiro Mitsuoka - Manuscript preparation and editingToshihiro Hashiguchi - Manuscript preparationShintaro Yokoyama - Manuscript preparationDaigo Murakami - Manuscript preparationKoichi Yoshiyama - Manuscript preparationTatsuya Nishi - Manuscript preparationMasaki Kashihara - Manuscript preparationHirofumi Ono - Manuscript preparationShinzo Takamori - Manuscript preparation and editingYoshito Akagi- Manuscript preparation and editingThis report is a case report and does not require the application of the Declaration of Helsinki 2013.Guarantor: Ryoichi Matsumoto M.D. Masahiro Mitsuoka M.D.Not commissioned, externally peer-reviewedThere is no conflict of interest.


Surgery for patients with multiple endocrine neoplasia type 1(MEN-1) related gastrinoma remains controversial and total pancreatectomy (TP) has rarely been performed. We reported a case of patient with MEN-1 related gastrinoma treated by TP.A 46-year-old female was admitted to our hospital due to abdominal distension and diarrhea for 2 years. The patient underwent pituitary tumor resection and kidney stone lithotripsy 10 years ago.Abdominal computed tomography showed single lesion in the duodenum and multiple lesions throughout the pancreas. The patient's gastrin level was significantly increased (1080 pg/ml). These findings in combination with the pituitary tumor history suggested the presence of gastrinoma associated with MEN-1 syndrome.An exploratory laparotomy was performed. Intraoperative ultrasound confirmed the numerous tumors diffusely distributed throughout the pancreas and the patient eventually underwent TP.Twelve months later, the patient was hospitalized again for anastomotic fistula and underwent a partial gastrectomy, small bowel resection and drainage of the abscess. One month later, she received gastrostomy and jejunostomy due to digestive tract fistula, and died a month later (14 months after TP).There still might be the possibility of recurrence even after radical surgical resection of gastrinomas, and we suggest the need to measure the basal acid output and maintain regular anti-acid therapy in the long-term follow-up of patients with MEN-1 related gastrinoma. They are characterized by gastric hypersecretion that results in peptic ulcers and diarrhea; this condition is known as Zollinger–Ellison syndrome (ZES).–4 Most gastrinomas are sporadic (75%–80%), whereas approximately 20% to 25% are associated with multiple endocrine neoplasia type 1(MEN-1). In patients with MEN-1, tumors are generally small, multiple and have a high tendency to metastasize; thus, achieving biochemical cure without radical surgical resection is impossible.,7 However, surgery for patients with MEN-1 remains controversial because of its potential short- and long-term complications,–7 and a total pancreatectomy (TP) has rarely been performed. Here, we reported a case of a patient with MEN-1 associated gastrinoma treated by TP.Gastrinoma is the second most common functional pancreatic neuroendocrine tumor (pNET), with a yearly incidence of approximately 0.5 to 21.5 cases per a million of people worldwide.2A 46-year-old female was admitted to our hospital complaining of abdominal distension and diarrhea for 2 years. Gastroscopy revealed duodenal ulcer, and she was treated with proton pump inhibitors (PPIs) for half a year, but symptoms persisted. The patient underwent pituitary tumor resection and kidney stone lithotripsy 10 years ago. The patient's gastrin level was significantly elevated . Parathyroid hormone, blood calcium, and serum tumor markers  were normal. Abdominal computed tomography (CT) showed one local thickening of descending duodenum wall and several lesions located in the head, body, and tail of pancreas, and the largest one, which measured 0.8 cm × 0.6 cm, was located in the pancreatic head , and the others were grade 1  according to the World Health Organization 2010 classification system. Immunohistochemical analysis results revealed that the tumor cells were positive for Syn, CgA, and gastrin . CT scan revealed encapsulated effusion and gases surrounding the gastrointestinal anastomosis Fig. , therebyInformed consent was obtained from the patient's son for this publication and any accompanying images.3 The incidence of MEN-1 is 0.25% and 16% to 38% in patients with gastrinomas. In patients with MEN-1 associated gastrinomas, the average onset is 5 to 10 years earlier than that of sporadic gastrinomas and generally before 50 years old.,10 Gastrinomas in patients with MEN-1 mostly occur in the duodenum (85%–100%) and less commonly in the pancreas (0%–15%); the tumors are often multiple and small (<0.5 cm) and are associated with lymph node metastases in 40% to 60% of the cases.,11 In our case, interestingly, tumors were mainly located in the pancreas.MEN-1 is a rare, autosomal dominant inherited syndrome caused by mutations in the MEN-1 tumor suppressor gene. Patients can be diagnosed with MEN-1 when 2 or more primary endocrine tumors, including pituitary tumors, pancreatic tumors, and parathyroid adenomas, associated with MEN-1 are present. The diagnostic evaluation of gastrinomas begins by measuring a fasting serum concentration of gastrin. If the fasting serum gastrin is more than10-fold normal (<100 pg/ml) and the gastric pH is < 2, a diagnosis of gastrinoma is established. Ultrasonography, CT, MRI, somatostatin receptor scintigraphy, and endoscopic ultrasonography are useful and important modalities for localization diagnosis and ruling out metastases.,7,12,13The most common presenting symptoms of gastrinomas include abdominal pain, diarrhea, and esophageal symptoms.,15 Others recommend surgical resection of tumors only if the tumor is larger than 2 to 3 cm, and enucleation at surgery remains the generally recommended surgical procedure.,17 However, larger tumors are often associated with increased metastatic risk and, consequently, reduced curability. Therefore, some surgeons support a more aggressive surgery, such as pancreas-preserving total duodenectomy, Whipple pancreaticoduodenectomy, or TP, to reduce the risk of distant metastases, achieve biochemical cure, and improve survival.–20Surgery for patients with MEN-1 associated gastrinomas remains controversial. Several authors conclude that the multicentricity of tumors mostly in the duodenum preclude surgical cure and suggest medical therapy, such as PPIs and/or somatostatin analogs.,21 of MEN-1 receiving TP as initial surgery because of the diffuse presence of macroscopic tumors within the pancreas; furthermore, 3 cases,22 had TP at reoperation, of which TP in one case was as a rescue after the dehiscence of pancreato-jejunal anastomosis. However, the long-term survival of the above cases had been seldom reported. In our case, the patient died 14 months later from serious infection and severe malnutrition caused by the disruption of gastrointestinal anastomosis. The reason why the anastomotic fistula occurred 12 months after TP was unclear. Hypersecretion of gastric acid persists in up to 62% of the patients with gastrinomas after surgical excision of tumors; hence, maintaining a postoperative anti-acid therapy is necessary. Ulcer perforation caused by the hypersecretion of gastric acid might be the cause of the rupture of gastrointestinal anastomosis.There is a general agreement that TP should be avoided, except in cases of multiple and diffuse macroscopic lesions. To date, TP has rarely been performed for patients with MEN-1. We searched literature and found only 3 cases4We reported a case of patient diagnosed with MEN-1 associated gastrinoma and died 14 months after TP. Hypersecretion of gastric acid may persist in patients after complete removal of tumors, and we suggest the need to measure the basal acid output and maintain regular anti-acid therapy in a long-term follow-up, considering the possibility of recurrence even after radical surgical resection.Supervision: Xu-Bao Liu, Wen Wu Shen.Writing – original draft: Shu Gong, Zhi Li.Writing – review & editing: Xin Wang, Wen Wu Shen.


Lymphomas are one of the most common malignant entries across all populations. Originating most commonly from the lymph nodes, extranodal lymphomas, including those originating from the connective tissue capsule of the internal organs, are rare entries. Herein we present a case report of a 78-year-old male patient presenting with a palpable mass in the region of the left kidney. Ultrasound and computer tomography revealed a mass engulfing the kidney. Nephrectomy was performed, with the histopathological investigation revealing a non-Hodgkin lymphoma originating from the renal capsule, with infiltration into the adjacent tissues. The patient was referred to a hematologist for treatment and one and a half years later, following two negative bone marrow biopsies, the patient is alive and disease-free. Lymphomas are consistently cited as amongst the top 10 most common malignancies, with increasing incidence worldwide . OriginaPrimary lymphoma of the connective tissue capsule of parenchymal organs is an extremely rare finding and can often be interpreted as a sign of infiltration or a soft tissue sarcoma .Herein we report the findings in a 78-year old male. The patient presented with a palpable mass in the left renal region, without any further complaints such as pain, hematuria, and weight loss. An ultrasound and computer tomography scan showed a large formation in the renal capsule Figure . ConcomiAn endoscopic nephrectomy approach was chosen. The procedure was carried out under general anesthesia. An additional renal artery and vein were located in the inferior pole and after their ligation and separation, the principal renal artery and vein were ligated and separated. An extended resection was performed with full ureter resection and partial resection of the urinary bladder. The kidney along with its capsule was then dissected and explanted through a subcostal incision.The materials were sent for histopathological evaluation. The total specimen measured 17/10 cm, of which the kidney specimen measured 12/7 cm and the adjacent pale and solid tumor tissue measured 10/1.5 cm (Figure The FFPE tissue sections stained with H&E showed nodular structures comprised of small to medium-sized atypical monomorphous lymphoid cells with formation of pseudofolicles. The tumor originated from the renal capsule and infiltrated the kidney, adjacent adrenal gland capsule, renal hilar vessels, and proximal part of the ureter, without infiltration into its distal part and the accessory renal vessels Figures , 4. The Despite the casuistical origin, based on the lack of other affected structures and both the H&E tumor sample and the reactions with the IHC panel, the diagnosis of small lymphocytic lymphoma was accepted.The postoperative period was uneventful. The patient was referred to a hematologist for treatment and subsequent reevaluation. Two additional bone marrow biopsies were performed, with no evidence for bone marrow invasion by the process. One and a half years postoperatively, the patient is alive and disease-free.Hematological malignancies require deep-rooted knowledge for their interpretation and a wide set of IHC markers. In the case of extranodal lymphomas, the interpretation is even more difficult, and the histology needs to be interpreted together with the radiological findings and the patient’s clinical data to differentiate from infiltration from a nodal lymphoma .In such cases, a bone marrow biopsy should also be performed to evaluate the progression of the disease and also rule out leukemia with infiltration into the parenchymal organs.Differential diagnosis with small round blue cell tumors, more often originating from the kidney and perirenal tissue should also be kept in mind, which further prioritizes the use of IHC ,6. TheseThe value of IHC in such cases is unquestioned as, despite the similarities in the histological profile, the IHC reactions are specific for the separate groups of tumors such as CD20 for B-cell lymphomas, OCT3/4 in germ cell tumors, and S100 in soft tissue sarcomas.The kidneys, however, are the most common site of extranodal lymphomas, although most commonly affected as a secondary site . As suchPrimary lymphoma of the renal capsule is a rare condition, requiring a wide set of IHC markers and interpretation together with the radiological finding, clinical data, and bone marrow biopsy to differentiate it from nodal lymphoma infiltration and small round blue cell neoplasms.


Placenta is an organ that is responsible for nourishing and protecting the fetus during pregnancy. Histologic examination of the placenta can yield significant information about pre-uterine and uterine conditions affecting fetal growth. Chorangiosis is defined as the presence of ≥10 terminal villi, each containing ≥10 capillaries per terminal villus in ≥10 low power (×10) fields in at least 3 or more random, non-infarcted cotyledons of the placenta. Chorangiosis is an adaptive response to in-utero hypoxia and its presence signifies better pregnancy outcomes. Abnormalities that lead to multiple cord vessels are rare with the majority of reported cases highlighting four vessels due to a persistent right umbilical vein. We report here a case of chorangiosis of placenta associated with a rare 5-vessel umbilical cord and omphalomesenteric duct remnant. To the best of our knowledge, this is the first case report to document such an association. PRECIS: We report here a case of chorangiosis of placenta associated with the rare 5-vessel umbilical cord and omphalomesenteric duct remnant..’ The term ‘chorangiosis’ was introduced by Altshuler in 1984 and is defined as the presence of ≥10 terminal villi, each containing ≥10 capillaries per terminal villus in ≥10 low power (10´) fields in at least 3 or more random, non-infarcted cotyledons of the placenta. Chorangiosis is known to occur as an adaptive response to chronic low-grade placental hypoxia. It has been found to be associated with various maternal, fetal and placental disorders. Rarely, its association has also been demonstrated with umbilical cord anomalies such as true and false knots, long cord, umbilical vein dilatation or thrombosis, nuchal cord, and single umbilical artery. Herein, we report a case of chorangiosis of placenta associated with the rare 5-vessel umbilical cord.The placenta is an organ that is responsible for nourishing and protecting the fetus during pregnancy. Histologic examination of placenta can yield significant information about pre-uterine and uterine conditions affecting fetal growth. One of the histo-morphologic features to be evaluated is the vascularity of chorionic villi. The number of vascular channels present in terminal villi ranges from 2 to 6 and if the number increases beyond this then it is termed as ‘villous hypervascularityA 27-year-old female, para-3-live-1, with gestational hypertension and oligohydramnios presented to the gynecologic emergency at 34 weeks’ gestation in labor. Emergency lower segment cesarean section was perfomed in view of fetal distress. The child was born with a birth weight of 1.6 kg and was stable. There were no congenital anomalies in the child. The placenta was sent for histopathologic examination. On gross examination, the placenta was complete and measured 12´11´3 cm with the attached umbilical cord measuring 18 cm in length. The umbilical cord contained 5 blood vessels . On micr. Its incidence increases with gestational age with more cases found in late preterm (32 to 37 weeks) and term (>37 weeks) pregnancies,2. Its presence has been correlated with fetal morbidity and mortality and congenital malformations as high as 42% and 39%, respectively.Chorangiosis is a very rare entity found in 5-6% of placentas. An alternative hypothesis highlighting the role of macrophage-derived tumor necrosis factor-a has also been suggested. Increased intramural pressure due to umbilical vein obstruction is also thought to play a role in the development of chorangiosis in cases associated with cord anomalies, such as long umbilical cord and thrombosis of vessels.The proposed pathogenetic mechanism of chorangiosis is that chronic hypoperfusion or tissue hypoxemia causes elaboration of vascular endothelial growth factor, platelet-derived growth factor, and transforming growth factor-b by mesenchymal and trophoblastic cells,4. In placental congestion, the vasculature is numerically normal. In tissue ischemia, there is shrinkage of the villi. Chorangioma is a well-circumscribed mass of solitary or multiple nodules. On microscopy, it is comprised of capillary-sized vascular channels with a mixture of endothelial cells, stromal cells, and surrounding trophoblasts. Chorangiomatosis is a heterogeneous, less well-defined lesion with intermediate features between chorangioma and chorangiosis. It has hyperplastic capillaries surrounding larger vessels in the central core of stem villi with increased numbers of loose, poorly cohesive lattices of perivascular bundles of reticulin fibers and circumferential layers of pericytes. These pericytes stain positively for SMA. Also, both chorangioma and chorangiomatosis are seen before 32 weeks of gestation and involve more proximal elements of villous structures, whereas chorangiosis is more common in late preterm and term pregnancy, and is a diffuse process involving the terminal villi.Chorangiosis is a histopathologic diagnosis. It must be differentiated from placental congestion, tissue ischemia, chorangioma and chorangiomatosis. Placental disorders such as placentomegaly, chronic villitis, acute chorioamnionitis, amnion nodosum, and placenta previa have also been reported in association with chorangiosis,3. However, contrary to Altshuler’s initial description, it is now suggested to be associated with much improved pregnancy outcomes. Recently in 2016, Stanek reported that chorangiosis is an adaptive and protective mechanism against in utero hypoxia, and abnormal pregnancy outcomes are not a consequence of chorangiosis per se. In 2017, Petersen et al. concluded that chorangiosis is a placental marker of antepartum chronic low-grade hypoxia. In the present case study, the patient had gestational hypertension, oligohydramnios, and delivered a preterm stable child. The indication for cesarean section was decreased fetal heart rate with fetal distress, which might have been be due to chronic hypoxia resulting from pre-eclampsia.Its etiology is poorly understood, but it has been found to be associated with various maternal and fetal disorders. However, occasional case reports mention five or more vessels in the cord in association with conjoined twins. The child in the present case had no congenital anomalies. Also, the literature regarding their possible mechanism of occurrence and significance is sparse.Also, in the present case, an association of chorangiosis with a multiple vessel umbilical cord, having 5 blood vessels with an omphalomesenteric duct remnant was identified. Abnormalities that lead to multiple vessels in the cord are rare with the majority of the reported cases highlighting four vessels due to a persistent right umbilical vein. Microscopically, they are lined by cuboidal to columnar epithelium with an intestinal phenotype and may have a surrounding smooth muscle layer.The omphalomesenteric (vitelline) duct connects the midgut lumen with the yolk sac in the developing fetus. It is often associated with remnants of vitelline vessels, seen in about 7% of umbilical cordsTo conclude, chorangiosis is an important histopathologic sign of fetal injury. It is an adaptive response to in-utero hypoxia and its presence signifies better pregnancy outcomes. To the best of our knowledge, this is the first case report to document the association of chorangiosis with a 5-vessel umbilical cord, whose presence does not always herald an adverse perinatal outcome, and an omphalomesenteric duct remnant.


Contrast-induced encephalopathy (CIE) is a well-known complication of iodinated contrast agents during angiography and vascular interventions. It can manifest as hemiparesis, cortical blindness, speech changes, Parkinsonism, confusion, seizure, and coma. Most of the reported CIE cases have been transient and reversible. Irreversible fatal CIE cases have been rarely reported. All the fatal CIE cases reported involved the use of ionic high osmolar contrast agents. Here, we document a heretofore unreported fatal CIE after digital subtraction angiography (DSA) using iopamidol, which is a type of non-ionic monomer low osmolar contrast agent.A 71-year-old woman was admitted to our Department of Neurology for tinnitus in the head. The cerebral magnetic resonance angiography (MRA) detected atherosclerotic cerebral arteries and bilateral stenosis of the middle cerebral arteries. The patient underwent DSA for further diagnostic work-up. The total amount of iopamidol used during the procedure was 110 ml. The patient experienced headache during the procedure, followed by dizziness with nausea and vomiting. Despite treatment with anti-oedema medications, her clinical status was gradually deteriorating and ended up with deep coma due to irreversible cerebral oedema which was confirmed by cerebral computed tomography (CT). Finally, the patient died 56 days after the procedure due to irreversible fatal cerebral oedema.This report documents that iopamidol-induced encephalopathy may not always have a benign outcome and can result in irreversible fatal cerebral oedema. Contrast-induced encephalopathy (CIE) is a known but rare complication of angiography and endovascular interventions. The presentations may include hemiparesis, cortical blindness, speech changes, Parkinsonism, confusion, seizure, and coma , 2. In mA 71-year-old woman with a history of hypertension, hyperlipemia, and angina was admitted to our Department of Neurology for tinnitus in the head. On physical examination, bilateral hearing impairment was found. The cerebral magnetic resonance imaging (MRI) detected signal changes consisted with multiple cerebral infarctions and bilateral demyelination in the centrum semiovale. And the cerebral MRA detected atherosclerotic cerebral arteries and bilateral stenosis of the middle cerebral arteries Fig. a, b, c. The prognosis of most CIE is generally reported to be good with a rapid recovery, and only rare cases with the persistent deficits have been reported . NotablyThe diagnosis of CIE is important, as its presentation may be similar to embolism, and haemorrhagic complications following angiography or endovascular interventions. Typical radiological findings include abnormal cortical contrast enhancement and cerebral oedema, subarachnoid contrast enhancement and striatal contrast enhancement , 11. CT The patient experienced headache 10 minutes after the aortic arch angiography during the DSA procedure, and suffered nausea, vomiting and dizziness after the procedure. The symptoms were continuous, the patient was comatose at 17 h with respiratory failure. Anisocoria with non-reactive pupils developed, the limb drop test was positive, and Babinski sign was negative. All these symptoms supported the diffuse lesion of the brain, there was no sign of focal brain lesion. The cerebral CT scans detected diffuse unrelieved cerebral oedema after the severe deterioration. Therefore, cerebral hernia was considered due to severe cerebral oedema. The sudden respiratory failure was due to cerebral oedema leading to cerebral hernia. Hence the anoxic brain injury was not considered in this case. And the history, symptoms and cerebral CT scans did not support the diagnoses of secondary viral encephalitis, secondary cerebral vein thrombosis and metabolic causes.The mechanism of CIE is controversial. The temporary disruption of the blood-brain barrier (BBB) after injection of the iodinated contrast agent is widely accepted , 11–15. Studies have indicated that opening of the BBB may be accompanied by brain oedema, resulting from the flux of proteins, electrolytes, and water across the abnormally permeable cerebral vessels into the extracellular space . An idioAll types of iodinated contrast agents can induce the development of neurotoxicity, but the occurrence of fatal cerebral oedema is very rare. Unfortunately, there is no currently available effective treatment for such a severe fatal CIE. In the case reported by L. Junck and W.H. Marshall , the posIn summary, although CIE has typically been associated with benign outcomes in previous studies, we present a case of fatal cerebral oedema after DSA using iopamidol. This case illustrates the potential to cause severe complications, even fatal cerebral oedema, with all types of iodinated contrast agents. The doctors performing angiography and interventions should be aware of this severe potentially harmful effect. The rare occurrence of severe contrast-induced complications renders their prevention very difficult. Further studies are needed to define the risk factors and the mechanism of the iodinated contrast agent neurotoxicity, which may help minimise the occurrence of severe complications.


Extra-osseous chondroma is a benign and rare tumor. It usually sits at the extremities, we report an exceptional case of a chondroma of the soft parts of the shoulder in a 28 year old woman who manifested by a painless swelling of the left shoulder. The histology confirmed the diagnosis on the excision piece. Clinical and radiological follow-up after a 24-month follow-up did not show a sign of recurrence. Chondroma is a frequent benign tumor generally located at the bone level. Its extra-osseous location is extremely rare , 2. The A 28 year old female patient sought medical advice due to a painful tumefaction of the left shoulder which appeared four years ago and slowly increased in volume. The medical examination revealed that the patient did not have an old trauma nor did she have any medical or surgical antecedents. The physical examination showed a visible tumefaction , on the Extra-osseous chondromas are relatively rare. They may occur at any age but are predominantly frequent between the third and seventh decades , 5, geneAt the MRI, peripheral contrast is traditionally observed in the extra-osseous chondroma, but adjacent soft tissues are normal. A homogeneous signal mainly hypertensive on the T2 sequences is observed in most tumors. It is therefore a non specific sign that is not particularly favorable for a benign cartilage mass. On the histological level, the macroscopic examination usually shows a lobulated well-encapsulated rubbery tumor, which is sometimes more friable with focal cystitis. The size is small and rarely superior to 3cm. While microscopic examination shows the presence of chondrocytes which are marked by the anti-protein antibody S100 , electroThe chondroma of the soft parts is a rare lesion; its localization at the level of the shoulder is exceptional. The diagnosis is made at the clinical and radiological examinations. A complete excision of the tumor constitutes the treatment of choice and recurrences are exceptional.The authors declare no competing interests.


A paraganglioma is a rare form of neuroendocrine tumor of neural crest cell origin. These tumors arise from autonomic ganglia, and are classified based on their origin in the autonomic nervous system, with sympathetic paragangliomas being more commonly located in the abdomen and parasympathetic paragangliomas more commonly found in the head and neck region. Paragangliomas have a characteristically slow growth rate, and while many will present due to symptoms of mass effect or from hyper functional catecholamine secretion, some tumors are diagnosed incidentally on imaging studies. In this report, we present the case of a 33-year-old man who presented to the emergency department with symptoms of infectious mononucleosis and recurrent tonsillitis, for which he was scheduled to have a tonsillectomy in the near future, but was incidentally found on a CT scan of the neck to have an asymptomatic carotid body paraganglioma. Due to the close anatomical relationship between the carotid artery and tonsillar bed, had this surgery occurred without first discovering the paraganglioma it may have placed the patient at increased risk for a disastrous intraoperative hemorrhage. This idea prompts otolaryngologists to consider how best to approach the diagnosis of paragangliomas in patients that have yet to become symptomatic. Paragangliomas are a rare type of highly vascular neuroendocrine tumor of neural crest cell origin that arise from autonomic ganglia, comprising about 1 in 100,000 of all tumors in the head and neck region. These tumors are commonly compared to pheochromocytomas, also known as “intra-adrenal paragangliomas”, due to their ability to secrete catecholamines, although recent literature suggests only 1-3% have this ability . These uCarotid body paragangliomas are typically slow growing in nature, with a delay between first symptoms and time of diagnosis of approximately 4-7 years. They typically present as a lateral neck mass, which is mobile laterally but not cranio-caudally, referred to as a positive Fontaine sign. More extensive paragangliomas can present as a pulsatile mass, may have cranial nerve involvement, and may even present with carotid sinus syndrome, which refers to loss of consciousness with reflexive bradycardia and hypertension. Despite all of this, carotid body paragangliomas usually present as incidental findings or are discovered inadvertently on radiographic imaging. Typically, these tumors can be identified by computed tomography (CT) of the neck with contrast or, more commonly, by magnetic resonance images (MRI) with gadolinium. In this report, we present the case of a 33-year-old man who presented to the emergency department with cervical lymphadenopathy and a sore throat, and was incidentally found on a neck CT scan to have an asymptomatic carotid body paraganglioma.Our patient was a 33-year-old male who presented with a five-day history of fever, generalized body aches, sore throat, odynophagia, nausea, vomiting, dizziness, and diffuse abdominal pain. Past medical history was significant for gastroesophageal reflux and recurrent episodes of tonsillitis, for which the patient was scheduled for a tonsillectomy.3. On physical exam, tonsils were significantly enlarged  and erythematous, and he was noted to have enlargement of his left peritonsillar area concerning for an abscess, while the remainder of the physical exam was unremarkable. A Monospot test obtained in the emergency department was positive, indicating a primary infection with infectious mononucleosis. Due to the patient’s history of recurrent tonsillitis, fever, and asymmetric tonsillar hypertrophy, a CT scan of the neck with IV contrast was also ordered. This resulted in an incidental finding of a large avidly enhancing mass within the left carotid sheath that extended from the level of the hyoid to the jugular foramen at the skull base, in addition to prominent pharyngeal and adenoidal tonsils, with bilaterally enlarged cervical chain and submental lymph nodes , Collet Sicard syndrome , and Villaret syndrome . Given the neurologic nature of a majority of these physical exam findings attributed to paragangliomas, it is imperative for the examiner to perform a thorough neurologic exam in conjunctive with the history and physical.Historically, carotid body paragangliomas have been treated via primary surgical resection, with possible preoperative embolization. Other literature suggests that primary radiation may be used for nonoperative candidates, advanced tumors, or if there is presence of residual disease. A study published by Hu and Persky in 2016 suggested that observation without treatment is a viable option for patients who are asymptomatic, and specifically for older patients with significant comorbidities . The stuIn our case of this 33-year-old male patient, urine and plasma metanephrines and catecholamines were ordered, but were found to all be within normal limits. His physical examination failed to reveal any neurologic deficits or other physical exam findings that may be contributed to the compression nature of most paragangliomas. He had no airway compressive symptoms or other mass effect symptoms, as well as no outwardly apparent lateral neck mass. However, had the patient not presented to the ED with symptoms of infectious mononucleosis and tonsillitis, this tumor, with its rich vascular supply, may have continued to grow and eventually cause symptoms of mass effect or may have even led to catastrophic vascular injuries during the patient’s scheduled tonsillectomy. The close anatomical relationship between the carotid artery and the tonsillar bed, most frequently cited as lying 2-3 cm deep to the superior pharyngeal constrictor, lends credence to the tenuous nature of his tonsillectomy, had it occurred.The presented case in this paper highlights the silent nature of most of these tumors, and sparks thought as to how best to approach diagnosis of paragangliomas in the head and neck region that have yet to produce any discernable physical exam findings. At very least, this is a case of divine providence, where an asymptomatic paraganglioma was incidentally discovered when a patient presented to the emergency department complaining of an entirely separate etiology.


Dysphagia is commonly seen after a cerebral vascular accident. It is rarely caused by lipomas of the retropharyngeal region which are rare benign mesenchymal neoplasms. We report a case of a 53-year-old man who presented with a history of ptyalism and dysphagia occurring after a brain stroke. Flexible nasal endoscopy revealed a pooling of saliva in both pyriform sinuses. Cervical and neurological examinations were unremarkable. Computed tomography (CT) scan suggested the diagnosis of retropharyngeal lipoma. The mass was resected by trans-cervical approach. The histological examination confirmed the diagnosis of a retropharyngeal lipoma. The postoperative course was unremarkable. Although lipomas in the retropharyngeal space are rare, clinicians should evoke this diagnosis when treating a patient presenting with dysphagia, even if there is a medical history of cerebral vascular accident. Dysphagia is a sensation of difficulty in transferring the bolus from mouth through the esophagus into the stomach. There are a wide range of underlying causes such as neurologic diseases like stroke, a Zenker's diverticula, esophageal dysmotility, inflammation and structural abnormalities such as malignancy or external compression , 2. RetrA 53-year-old man presented to our department with a 7-year-history of ptyalism. He also complained of progressive dysphagia for solids and liquids with intermittent choking episodes for 8 months. There were no other complaints, especially dyspnea, odynophagia, voice changes, weight loss or neurological symptoms . The patient has a medical history of hypertension, an acute coronary syndrome with persistent ST-segment elevation 12 years ago and a cerebral vascular accident 7 years ago with mild left sequelae hemiparesis. On examination, there was no cervical swelling. Flexible nasal endoscopy revealed a pooling of saliva in both pyriform sinuses. Oropharynx and endolarynx exams were unremarkable. On neurologic examination, bedside screening cognitive functions, speech, cranial nerve functions, palatal movements and gag reflex were normal. Routine biochemical and hematological examinations were unremarkable. Despite patient’s history and the fact that symptoms started immediately after the stroke, an organic cause of dysphagia was suspected and a cervical CT was indicated (because of the characteristics of the dysphagia). The CT revealed a low density, homogeneous lesion measuring 7,3 cm × 2,6 cm x 11,1 cm in the posterior pharyngeal wall extending from level C2 to level C7. The mass was well defined with a few thin regular septae and did not enhance after injection of contrast medium. The mass was displacing the airway and the left thyroid lobe anteriorly and displacing the carotids laterally. There was no invasion to the neighboring muscular structures Dysphagia is common in patients with neurological disorders. In this case, the dysphagia seems to be caused by lesions in the central or peripheral nervous system or disorders of muscle or the neuromuscular junction . A carefDysphagia seems to be a common complaint after stroke. The challenge is to distinguish between a mild post stroke dysphagia and other organic causes of dysphagia. Retropharyngeal lipomas are rarely reported as an etiology. They are usually asymptomatic. The main symptoms are dysphagia and dyspnea. The radiological features of a lipoma can be ascertained using either CT or MR imaging. The definitive treatment is surgical excision by transoral or external approach.The authors declare no competing interests.


Lipomatous hypertrophy is an uncommon benign lesion of the atrium, generally asymptomatic, characterized by unencapsulated accumulation of adipose tissue entrapping cardiomyocytes. This pathology generally remains unnoticed and often emerges as an occasional finding. Here, we report two cases from our hospital including a review of the available literature. Lipomatous hypertrophy is a benign cardiac mass characterized by an unencapsulated accumulation of mature adipose tissue within the interatrial septum, rarely in the atrium wall . As mostHere, we report two cases of lipomatous hypertrophy referred to our hospital, one after surgical removal and the other at autopsy.The first case was found incidentally on preoperative investigation of a 73-year-old female patient with progressive coronary heart disease. The lesion, completely asymptomatic, was detected by transthoracic and transesophageal echocardiography and initially appeared as an exophytic mass occupying the right atrial cavity, lacking the typical hourglass morphology and appearing suspicious for atrial myxoma. Despite the absence of symptoms related to the lesion, the surgeons decided to remove it anyway in order to promote blood overflow through the atrial cavity and prevent later obstruction. The patient was subsequently admitted to the Cardiac Surgery Department for planned coronary artery bypass surgery and mass resection. During surgery, the lesion turned out to be also intraparietal but was totally resected. At macroscopic examination the lesion was 3 cm in diameter, yellowish, and slightly increased in consistency without a true capsule. Although surgery was successful, the patient died because of her illness.The second case is a 73-year-old male patient with an incidental finding in autopsy of a lesion of 4 cm in diameter in the interatrial septum that appeared thickened. No clinical problems or suspicious symptoms had emerged from the clinical information gathered.μm-thick sections subsequently stained with haematoxylin-eosin. Histologically, both of the lesions demonstrated an unencapsulated accumulation of mature adipocytes with infiltrative growth pattern within hypertrophied cardiac myocytes. Lesion cells presented microvacuolated cytoplasm and centrally located nuclei, also exhibiting variation in shape and size, dispersed within the fat. Mitoses were absent (Both lesions, after fixation with 10% formalin solution, were sampled and embedded in paraffin to prepare 3-e absent . The patLipomatous hypertrophy represents a benign though rare condition that should always be considered in the differential diagnosis in case of an atrial mass detected during imaging, surgery, or necroscopy and definitively diagnosed by histological examination.


De Garengeot hernias, defined as a femoral hernia containing the appendix, are rare. It is even uncommon to have an incarcerated de Garengeot hernia with associated acute appendicitis. We report a case of a 76-year-old female presenting to the emergency department for a right lower quadrant abdominal mass for four days. Physical exam was consistent with an incarcerated hernia. A point-of-care ultrasound revealed a non-compressible, blind-ended loop of bowel within the hernia sac, concerning for acute appendicitis within the mass. Computed tomography of the abdomen and pelvis confirmed the diagnosis of acute appendicitis within a femoral hernia. Abdominal hernias and appendicitis are both common conditions evaluated in the emergency department (ED). However, encountering acute appendicitis within an incarcerated hernia is quite rare. Amyand hernias are inguinal hernias with the appendix contained within the hernia sac. De Garengeot hernias are femoral hernias with the appendix contained within the hernia sac. Both of these hernias can be associated with acute appendicitis. This case report highlights the diagnostic difficulties in identifying patients with appendicitis within a hernia and is one of the few reported cases of making this diagnosis with point-of-care ultrasound (POCUS).2A 76-year-old female with a past medical history of nephrolithiasis, thyroid disease, and osteopenia presented to the ED for right lower quadrant abdominal pain for the prior four days. She stated that she had experienced pain after lifting several flowerpots. On the day of presentation the patient noticed a mass in the right lower quadrant. She went to her primary care physician for evaluation; an attempt to reduce the hernia in the office was unsuccessful, so the patient was transferred to the ED for concern of an incarcerated hernia.3 (range 4.8–10.8 mm3), normal serum lactate of 0.57 millimoles per liter (mmol/L) (range 0.5–1.6 mmol/L), and a normal metabolic panel. A second attempt to reduce the mass after intravenous administration of hydromorphone was unsuccessful. Subsequent POCUS showed a blind-ended, non-compressible, dilated loop of bowel one centimeter in diameter within the right lower quadrant mass, concerning for acute appendicitis within the incarcerated hernia sac rnia sac , 2 and 3Given the concern for acute appendicitis within the hernia sac, no further attempts at reduction were made and surgery was consulted. A computed tomography (CT) of the abdomen and pelvis performed per surgery’s request confirmed the diagnosis of a right-sided femoral hernia containing an inflamed appendix, consistent with a de Garengeot hernia with acute appendicitis . The patThe presence of the appendix in a femoral hernia sac was first described in 1731 by the French surgeon de Garengeot, giving this type of hernia its eponym.8What do we already know about this clinical entity?De Garengeot hernias, femoral hernias containing the appendix, are rare and can be associated with acute appendicitis.What makes this presentation of disease reportable?The diagnosis was initially made with point-of-care ultrasound (POCUS). Diagnosis by POCUS is uncommon and has only been reported a few times in the literature.What is the major learning point?De Garengeot hernias can present indistinguishably from a femoral hernia. If the hernia is reducible, the diagnosis of appendicitis may be missed, leading to higher morbidity and mortality.How might this improve emergency medicine practice?This case demonstrates the utility of POCUS. Additionally, increased awareness of this disease may decrease the rate of delayed diagnosis.De Garengeot hernias are often difficult to diagnose and may clinically present indistinguishably from an irreducible femoral hernia.15Our case of a de Garengeot hernia containing an acutely inflamed appendix shows that this diagnosis can be made with ultrasound. While the sensitivity and specificity of ultrasound in making the diagnosis of appendicitis within a hernia is still unknown, providers may consider ultrasound and CT in their initial evaluations. Emergency physicians should consider both Amyand and de Garengeot hernias in the differential diagnosis for patients with inguinal or femoral hernias, as these diagnoses can be difficult to make. In the setting of appendicitis within a hernia, reduction of the hernia alone will not adequately treat the appendicitis, which can lead to significant complications. Additionally, the lack of symptoms of appendicitis can lead to a delayed diagnosis, resulting in a high frequency of perforated or gangrenous appendicitis, leading to increased morbidity and mortality.17


Olfactory aplasia is an uncommon cause of anosmia, and it should be suspected in young patients with lifelong decreased sense of smell. The aim of this article was to remind readers about this condition that need to be part of the differential diagnosis in similar clinical scenario, to avoid unnecessary investigation and overtreatment for these patients. A 10‐year‐old healthy girl presented with nasal congestion and a lifelong anosmia. She had adenotonsillectomy at the age of 5 years. Examination of the nose showed no structural deformities or obstructive lesions. Neurological examination and cognitive development assessment were normal for her age. Blood tests including immunoglobulin E (IgE) level and radioallergosorbent test (RAST) were normal. Magnetic resonance imaging (MRI) scan performed to rule out underlying anterior cranial fossa or intranasal pathologies (Figure 11.1Primary anosmia as a result of olfactory aplasia is uncommon pathology with the incidence of 700 per 1 000 000 births.Even though there is no curative treatment for anosmia caused by olfactory aplasia, proper counseling is essential.None declared.AM: reviewed the literature, designed the case report, prepared and the manuscript as first author. OA: performed, reviewed and prepared the MRI scan images. AJ: assessed the patient, edited, supervised and critically reviewed the manuscript.


Chondroma is a slowly growing, benign cartilaginous tumor which predominantly occurs in long bones of the hands and feet. Primary mediastinal chondroma is rare, especially with Horner’s syndrome.We reported the case of a 31-year-old woman with a posterior mediastinum mass associated with Horner’s syndrome. After complete dissection of the mass, a pathological diagnosis of the primary mediastinal chondroma was rendered. The patient has shown no local recurrence or distal disease in a 3.5-year follow-up period.The preoperative diagnosis of chondroma should combine various examinations for comprehensive evaluation. Complete surgical resection should be the first choice of the treatment due to the risk of malignancy. Chondroma is a slowly growing, benign cartilaginous tumor which predominantly occurs in long bones of the hands and feet. Primary mediastinal chondroma is rare. Besides, Horner’s syndrome which is characterized by ipsilateral ptosis, miosis, and anhydrosis has been seldom described in such tumors before. Here we report the case of a primary chondroma located in posterior mediastinum which is associated with Horner’s syndrome.A 31-year-old woman was admitted to our hospital with the chief complaints of anhydrosis on the left upper limb, ipsilateral face, and miosis. These symptoms developed without apparent causes and in the absence of other problems, such as ptosis, enophthalmus, fever, chest pain, breathlessness, cough, expectoration, nausea, or vomiting. Contrast-enhanced computed tomography of the chest revealed a 6.1 × 5.6 × 5.5-cm, well-circumscribed soft tissue mass in the left posterior mediastinum (Fig. A left posterolateral thoracotomy through the fifth intercostal space was performed. During the surgery, it was found that the mass which was approximately 6 × 5 × 5 cm in size arose from the cortex of the second rib and was hard in consistency. Ossification could also be seen within the tumor. We resected the tumor completely and removed partial sclerotin on the surface of the second rib. Histopathologic examination confirmed the diagnosis of chondroma Fig. . Her posChondroma is a benign bone tumor that originates from the cartilage tissue. It predominantly occurs in long bones of the hands and feet. It is rare to be found in thoracic cavity, including the lungs, bronchi, and mediastinum –3. Only The preoperative diagnosis of chondroma should combine various examinations for comprehensive evaluation. At the same time, we should differentiate it with lung hamartoma, tuberculosis, and other diseases. Complete surgical resection should be the first choice of the treatment due to the risk of malignancy . We usua


Myofibroblastoma is usually occurred in the breast and extra-mammary disease is rare.A 38-year-old man was admitted to our hospital for further examination of the left inguinal tumour, present and enlarging for 16 months. The tumor was 50 mm in diameter, well-circumscribed, firm, and painless. Ultrasonogaphy, computed tomography(CT) and magnetic resonance imaging (MRI) could not provide the definitive diagnosis. Surgical exploration confirmed a 50 mm tumour with a clear surface with a thin capsule. Complete excision was achieved. Histopathology confirmed the tumor had oval and spindle shaped fibroblastic cells with rich collagen deposition. It stained positive for ER, CD34, desmin and CD10 but negative for -smooth muscle actin and S-100. A mammary-type myofibroblastoma was diagnosed based on these results.An extra-mammary myofibroblastoma is very rare and first reported in 2001. Since then, over 160 cases have been reported. On immunohistochemistry, these lesions are characteristically positive for CD34 and desmin, with variable staining for α-smooth muscle actin. Once the diagnosis is made, regardless of size or location, this tumour behaves in a benign fashion after surgical excision reported so far.This case is rare, but the correct diagnosis and treatment is important for good prognosis. First described in 2001 [2A 38 year old male was admitted to our hospital for evaluation of a left inguinal swelling which had been present and enlarging for 16 months. The tumour was 50 mm in size, well circumscribed, firm, fully mobile and painless. No inguinal or other local lymphadenopathy was present. Laboratory tests were normal. Ultrsonograph and CT revealed a well defined tumour with no communication to the spermatic cord. Magnetic resonance imaging showed that the tumor was T1 low and T2 high indicating a low fat content a, b. The3Myofibroblastoma was first described in 1987 as a benign, soft tissue tumor of the breast . The mosMulti-modalities such as US, CT, and MRI cannot diagnose the condition and it is rarely possible to have a correct diagnosis before surgery. Needle biopsy or intraoperative frozen section diagnosis are possible and important methods to establish a diagnosis but nearly all cases make a final diagnosis following surgical excision . On hist4Extra-mammary-type myofibroblastoma is a rare, benign soft tissue neoplasm with no known malignant behavior and excellent prognosis following surgical excision. Being rare, the correct diagnosis can be difficult, and to achieve this, the accumulation of cases is needed.The authors declare there is no conflict of interest.There are no sponsors involved in the case report.This case report was exempt from ethical approval in our institution.We have parental consent on behalf of the patient for publication of the submitted article and images.Atushi Ishihara operated on the patient, and performed the background research, writing of the manuscript, and submission of the manuscript. He has no conflicts of interest. Takeo Yasuda operated on the patient, and performed the editing of the manuscript. He has no conflicts of interest. Yukari Sakae, Masayuki Sakae, Tooru Hamada, and Takashi Tsukazaki contributed to editing the manuscript. They have no conflicts of interest. Hideki Tshkazaki operated on the patient. He has no conflicts of interest. Masaru Furumoto contributed to make a correct diagnosis and editing the manuscript. He has no conflicts of interest. All authors have made a significant contribution and arrowed the final version of the manuscript for publication.Not applicable.Takeo Yasuda.Not commissioned, externally peer-review.