Chronic rhinosinusitis with nasal polyposis is a common chronic disease that often affects maxillary sinus. Endoscopic sinus surgery is the most common procedure for treating the majority of maxillary sinus lesions.To demonstrate the role of canine fossa puncture during endoscopic sinus surgery procedure in patients with severe maxillary sinus disease.We present 2 cases where canine fossa puncture has been performed as method to obtain a complete access to the maxillary antrum.According our experience, 2 cases on 296 endoscopic sinus surgery (0.6%) where antrostomy and used of angled microdebrider were not sufficient, canine fossa puncture has been performed as an alternative method to obtain a complete access to the maxillary antrum.Although the advent of endoscopic sinus surgery, our cases support the fact that actually canine fossa puncture is a minimally invasive technique useful in selected cases. Chronic rhinosinusitis (CRS) with nasal polyposis (NP) is a common chronic disease that seriously affects the quality of life.Although the majority of maxillary sinus lesions can be removed through the widened natural ostium performing partial uncinectomy and middle meatal antrostomy (MMA), some patients have extensive disease that is difficult to handle purely endoscopically.In fact endoscopic access by natural ostium only allow to clear the posterior lateral wall, the posterior region of the roof, and the posterior wall of the maxillary sinus but no anterior and inferior regions. Failure to remove massive polyposis and fungal debris from the maxillary sinus may result in an early postoperative recurrence of symptoms and disease for the patient.One solution is the traditional Caldwell Luc approach performed through the anterior wall of the maxillary sinus. This is, however, associated with significant morbidity such as facial numbness or paresthesia (9%) for damage of the infraorbital and anterior superior alveolar nerves, oroantral fistulas (1%), gingivolabial wound dehiscences (1.5%), and dacryocystitis (2.5%). This technique has been superseded by endoscopic medial maxillectomy useful to treat benign tumors, not inflammatory disease.Although a few studies have demonstrated the benefits of CFP in management of the severely diseased maxillary sinus, the efficacy and superiority of this method compared with conventional MMA require further investigation.The aim of this study is to review the literature about the indications of CFP in patients with severe maxillary sinus disease and compare this surgical procedure with maxillary sinus clearance through MMA.We reviewed all endoscopic sinus surgery (ESS) performed at our department in 2015. A total of 296 endoscopic sinus surgeries were performed during this period. Of these, combined approach endoscopic sinus surgery and canine fossa puncture (CFP) was performed in 2 (0.6%) cases when there was difficulty in visualization and clearance of disease.In particular, CFP consist in a trocar placed in the canine fossa. The landmarks in canine approach are: the mid pupillary line and horizontal line running along the lower border of nasal ala and lateral aspect of canine fossa high above the 3rd and 4th teeth (canine and premolar), infero lateral to infra orbital foramen. The trocar should be aimed toward the maxillo ethmoid angle to avoid pterygopalatine fossa and orbital lesions. In most patients the trocar was inserted using a gentle twisting motion. In some patients with thicker bone, gentle tapping with a hammer was required for the trocar to be inserted.A 20-year-old Caucasian female was admitted to our Department on July 2015. She was nonsmoker and denied alcohol consumption. She reported paracetamol and dried fruit allergy. Three years ago, underwent to functional endoscopic sinus surgery (FESS) for presence of left antrochoanal polyp. Since 3 months, she complained a left nasal obstruction without other symptoms. Therefore, she has been subjected to nasal endoscopy that evidenced a presence of left antrochoanal polyp  confirmeA 77-year-old Caucasian woman was admitted to our Department because of left purulent rhinorrhea and paresthesia in left maxilla region since 3 months. She was subjected to dental implant on left maxilla arch in March 2015. Her past medical history was remarkable; she had a positive remote history for chronic lymphoblastic leukemia B cell resolved, splenectomy performed for spontaneous splenic rupture, hysterectomy and atrial fibrillation. An anterior rhinoscopy displayed the presence of pus filling his whole nasal cavity, which was originating from the ostio-meatal complex. During oral evaluation an oro-antral fistula was detected at the site of previous dental extraction. CT scan without contrast enhancement was performed and showed complete opacification of the left maxillary sinus and an interruption of sinus floor corresponding to alveolar process with dental implant inside sinus .Figure 2In April 2015 patient was subjected to MMA in order to remove dental implants but the procedure could not be completed transnasally neither with the use of curved blade so a CFP was required in order to remove the foreign body. Nasal packing was removed 1 day postoperatively, and the patient was discharged. After surgery, we prescribed saline irrigation and paracetamol. Patient has been visited in our section at 10 days, then at 4 weeks and finally at 6 months. Meticulous endoscopic dressing and saline irrigation were performed until the cavity was healed. To date patient is free of disease.Nowadays middle meatal antrostomy (MMA) is considered the gold standard I the treatment of maxillary sinusitis. Anyway critical areas such as inferior, lateral, anterior wall, recessus zygomaticus and recessus alveolaris and recessus prelacrimalis of maxillary sinus are difficult to approach. For this reason medial maxillectomy or external approaches such as Caldwell Luc approach or CFP are required.p = 0.02).The efficacy of this maneuver on the outcome after FESS has been the subject of a small number of studies. Lee et al. have compared the results of performing a canine fossa puncture with clearance of polyps via a middle meatal antrostomy. No benefit of the canine fossa procedure over conventional middle meatal antrostomy was seen after 12 months follow up, however series are small in both groups (11 CFP vs. 13 MMA). The authors concluded that although canine fossa puncture is a useful method for removing severe mucosal disease that cannot be reached through the MMA, it does not guarantee a better subjective or objective surgical outcome in patients with nasal polyposis.Many authors studied the maxillary sinus area explored by endoscopy.3 and mean SA was 31.0 ± 2.3 cm2. The 15°, 40°, 70° and 120° microdebriders accessed an average of 10%, 25%, 41%, and 66%, respectively, of the SA, and of 2%, 9%, 17%, and 36%, respectively, of the volume. There was a trend toward improved accessibility of the superior half versus the inferior half of the maxillary sinus. When instruments of different degrees were combined to maximize accessibility, 81% of the SA of the sinus could be accessed. However authors did not quantify volume and area of maxillary sinus exposed.Beswick et al. quantified the maxillary sinus volume and mucosal surface area (SA) that is accessible endoscopically via a middle meatal antrostomy in eight cadaver maxillary sinuses configured with image guidance software. In particular the authors demonstrated that mean maxillary sinus volume was 16.5 ± 2.5 cm3 vs. 2.88 cm3, p = 0.015). Median blade utilization was significantly higher with the TN approach vs. CFT .Feldt et al. in a sample of cadavers showed that a significant greater amount of debris was left after the transnasal endoscopic technique (TN) approach compared with canine fossa trephination (CFT) , and postoperative CT evaluation. SNOT-20 and VAS scores improved significantly at 3, 6, and 12 months postprocedure in both groups. However, significant improvement of SNOT-20 at 12 months and VAS scores for purulent discharge, foul odor, and postnasal drip at 6 and 12 months were observed in the CFP group compared with the MMA group. Postoperative CT scan evidenced that the volume of mucosal thickening was significantly greater in the MMA group than in the CFP group. In addition, CFP was not effective in patients with bilateral CRS and diffuse NP but provided better management and subjective and objective surgical outcomes in patients with unilateral CRS accompanying NP. Among unilateral NP, there is anthrocoanal polyps (ACP).ACP is relatively unusual in the sinonasal tract. It occurs predominantly in children and young adults and originates from the maxillary antrum with extension into the nasopharynx or oropharynx. Simple excision of the polyp via limited surgical procedures such as simple polypectomy results in high recurrence rates. Complete removal of the polyp in the antrum, including its site of origin, is essential to minimize recurrence. However, a broad base such as a lateral, inferior, or anterior location of the polyp makes eradication difficult via a MMA. In this situation, some authors choose the traditional Caldwell-Luc operation, even in children.Important indications to CFP are chronic odontogenic sinusitis (COS). Approximately 5–15% of the population suffers from chronic rhinosinusitis, and in 10–12% of them, it is of dental origin.Venetis et al. presented 20 cases with odontogenic sinusitis, 5 (25%) in which a foreign body was removed from maxillary sinus by combined transnasal and canine fossa endoscopic approach. The surgical procedure was performed with conventional instrumentation through the widened antrorhinostomy or through a bony window at the anterior sinus wall. At the end of the procedure, the window was repositioned and stabilized with two to three absorbable sutures. In two cases, with sizeable foreign bodies, the preservation of the bony window was impossible, and a modified Caldwell–Luc operation was performed with preservation of the healthy sinus mucosa.In literature, different opinions about approach to fungal maxillar sinusitis are reported. We did not show any case of CFP in fungal disease because in most of the patients it can be removed through the MMA using various curved instruments and saline irrigation without great difficulty. Also, if fungal invasion into sinus tissue is confirmed by histological examination, a systemic antifungal treatment postoperatively is paramount to reduce disease and potential recurrences.Instead there are no indications to perform CFP and/or Caldwell-Luc approach in maxillar sinus malignant tumor. According to literature, endoscopic medial maxillectomy can be considered as first choice in difficult maxillary sinus tumor removal because an unnatural opening like CFA or Caldwell Luc in locally invasive disease with malignant potential as the tumor can extend through this opening in recurrent cases.Although the advent of ESS, our cases support the fact that actually canine fossa puncture is a minimally invasive technique useful in selected cases. In fact, only in 0.6% of cases we used this technique without postoperative complications.The authors declare no conflicts of interest.


Hip pain is frequently encountered in the athletic community. Femoro-acetabular impingement (FAI) is a common cause of hip pain in young adults. However, it is important to appreciate the uncommon diagnosis and the role of imaging for unexplained hip pain. The pathology behind a posterior hip pain is often misdiagnosed as the cause of hip pain is non-specific, extensive and elusive. We managed to detect the pathology through magnetic resonance arthrography (MRA) of hip with gadolinium enhancement after a series of inconclusive history, physical examination and imaging findings were completed. This particular case vignettes an overlooked osteoid osteoma that leads to the delay in diagnosis and increase morbidity. Though rare, they are the indicators of increased morbidity due to the misdiagnosis. An accurate history, clinical examination and adequate imaging are needed to diagnose osteoid osteoma.Osteoid osteoma is a rare small benign osteogenic tumour which is usually found in young patient1. It accounts for approximately 14% of all benign bone tumours where it mostly seen in a long bone particularly at the proximal femurWe report a case of a 20-year-old young, fit and active male, who is presented with a complaint of long-standing unexplained hip pain with meralgia paresthetica and was diagnosed with osteoid osteoma at the proximal shaft of right femur that only detected through magnetic resonance arthrography (MRA) of hip with gadolinium enhancement.A 20-year-old patient, actively involved in parkour presented with progressive dull right hip pain radiating to the anterolateral aspect of the leg caused by osteoid osteoma of proximal shaft of femur is described. He was managed as herniated disc for eight months by primary care before the accurate diagnosis was established in sports clinic. He had no history of trauma and constitutional symptoms. The pain worsened upon walking, standing, prolonged sitting and it was partially alleviated by analgesic. As the pain progressed, he had difficulty in walking, affected his daily activities and limited his participation in any sports activities. On examination, he was healthy and fit looking. He had normal posture and antalgic gait.He is 163cm height and weight 50kg. The vital signs were within normal limits. The chest was clear to auscultation bilaterally with no chest wall abnormalities. The abdomen was soft, non-tender, and non-distended. Inspection of the spine and lower extremities revealed no erythema, effusions, or signs of trauma. The only positive findings revealed a vague discomfort around right hip area and right quadriceps muscular atrophy with the circumference difference of 3cm compared to the left side. Sensation was impaired at L2, L3 and L4. Other examinations and special tests were unremarkable. At that time all the conventional radiographs were reported as normal. The working diagnoses also included femoro-acetabular impingement, acetabular tear, paralabral cyst, piriformis syndrome and herniated disc.An urgent MRA pelvic and hip with gadolinium contrast done showed a well-defined intracortical lesion at anterolateral aspect of proximal femur with minimal surrounding edema and no cortical break . In addi1. It accounts for approximately 14% of all benign bone tumours where it mostly seen in a long bone with at least 25% located at the proximal femur2. The typical clinical picture is that either the patient will experience nocturnal pain or may manifest various degrees of limping which is responsive to NSAIDS1. An early diagnosis is difficult to make due to perplexing and nebulous clinical and radiological findings. The lag in diagnosis has been reported up to 8.5 months3. Femoro-acetabular impingement and labral tear are the commoner diagnoses in young adults with hip pain, it accounts for 46% of hip pain presentations4. Repetitive micro-trauma is the main causative factor particularly when it involves jump-landing tasks which may consist of extreme range of motion. The manifestation can behave atypically like no night pain, less responsive to NSAIDS, can also be overlapping with referred pain from the lumbar spine and presence of lower limb neuropathy with an absent of radiolucent nidus surrounded by a variable area of reactive sclerosis. These can lead to a diagnostic challenge.Osteoid osteoma is a rare small benign osteogenic tumour which is usually found in young patients ranging from 5 to 20 years old4. With a greater ability to visualise soft tissue and cartilage, MRI has become a vital imaging for evaluation of hip disorder. However, in the case of osteoid osteoma, MRI alone only contributes about 3% in making a correct diagnosis4. This is because the presence of localised cortical thickening and marrow edema can lead to erroneous alternative diagnoses. Majority of studies used the CT scan which is thought to be more sensitive to identify the nidus and to think of the possibility of an osteoid osteoma. However, recent studies showed gadolinium contrast MR demonstrated better sensitivity than CT scan5.It is important to be familiar with the radiological findings in osteoid osteoma and its mimics. Classically, 42% of patients had radiolucent nidus and about 58% had osseous sclerosis and cortical thickeningAs increasing numbers of young, active patients are being evaluated for various causes of hip pain, clinicians should have a pensive index of suspicion for osteoid osteoma. Osteoid osteoma of the proximal shaft of femur exhibit progressive course and mimics a lumbar spinal root nerve compression which difficult to diagnose at early stage. Atraumatic young and active patient with history of chronic pain should be evaluated and be advised to undergo regular re-examination. Multiple CT scan should be considered in order to detect nidus. Thereby, it helps in early diagnosis and intervention. Therefore, it significantly prevents the delay in making an accurate diagnosis and treatment. Thus, it will improve the patient quality of life.


Primary Ewing’s sarcoma of sphenoid sinus, observed in children and adolescents, is an extremely rare malignancy. Such rarity makes the imaging features and treatment strategies for Ewing’s sarcoma of sphenoid sinus unclear. This study aimed to offer guidance for treating this very disease by describing a patient with a rare primary Ewing’s sarcoma of sphenoid sinus and reviewing the available data in the literature.A case of Ewing’s sarcoma in sphenoid sinus treated with multidisciplinary treatment approaches, including tumor resection, radiotherapy, chemotherapy, and antiangiogenic therapy, was presented in this study. Moreover, literature for Ewing’s sarcoma in the head was systematically searched, and two cases in the sphenoid sinus and five cases in the sphenoid bone were identified. Furthermore, the clinical features, imaging findings, pathological characteristics, treatment, and prognosis were summarized.Tumor resection combined with radiotherapy and chemotherapy may provide favorable results for patients with Ewing’s sarcoma of sphenoid sinus and bone. However, more reports are still necessary to further clarify optimal management. Ewing’s sarcoma is an aggressive bone tumor, and ranks second only to osteosarcoma as the most common malignancy in children and young adults . It predIn May 2021, a 26−year−old man underwent an otorhinolaryngological clinical examination due to a history of intermittent right blepharoptosis and facial swelling; he had had these symptoms for 9 months. He was detected to have a mildly tender firm swelling in the right temporal region, and the eye movement, visualization, mouth opening, and airway were within normal limits. The patient had a history of occasional smoking, but no trauma, infection, or previous medical history, as well as an unremarkable family history. The blood routine examination, usual biochemical tests, and tumor biomarkers were also within normal limits. The computed tomography (CT) scan showed an inhomogeneous mass in the right sphenoid sinus cavity, and steolytic bone destruction and defect in the parietal wall of sphenoid sinus Figure 22 on day 1), vincristine (2 mg on day 1), cyclophosphamide , and ifosfamide  plus etoposide (100 mg/m2 on days 1–5) every 3 weeks before proceeding with the radiotherapy. Unfortunately, the response evaluation criteria in solid tumors (RECIST) criteria confirmed the residuary tumor as a stable disease after two cycles of postoperative chemotherapy. Then, intensity-modulated radiotherapy [gross target volume (GTV) 5,600 centigray (cGy)/28 fractions, clinical target volume (CTV) 5,040 cGy/28 fractions, with details summarized in To reduce the radioactive exposure of the right eye, the patient was arranged to undergo chemotherapy with alternating cycles of doxorubicin  a biopsy should be obtained for histopathological diagnosis to confirm Ewing’s sarcoma after imaging examination; (ii) the use of preoperative chemotherapy may increase the rate of complete surgical resection; and (iii) these genetic changes (EWS and FLI1) can be detected with cytogenetics, fluorescence In conclusion, primary Ewing’s sarcoma rarely occurs in sphenoid bone and sinus. Multidisciplinary therapy consisting of an initial biopsy, complete surgical resection, aggressive combination chemotherapy, and localized radiotherapy should be acknowledged as the most beneficial treatment strategy for Ewing’s sarcoma of sphenoid bone and sinus and results in long-term survival.Written consent for publication of this case report and the accompanying images was obtained from the patient.KW and ZL designed and wrote the report; KW, JW, YZL, and YunL collected the clinical data of radiotherapy and chemotherapy; XZ collected the clinical surgery data; DW and HW performed pathological diagnosis and collected pathological pictures; and YanL provided the imaging report and collected imaging pictures. All authors contributed equally to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Renal neoplasms represent a diverse spectrum of tumors with varying degrees of solid and cystic components that often dictate the potential for malignancy. Mixed epithelial stromal tumors (MEST) of the kidney represent an uncommon and heterogenous subset of these tumors, for which there remains a lack of extant literature and a poor degree of relative understanding. Our case represents a typical presentation of this uncommon neoplasm that contains several important differences regarding immunohistochemical staining and familial interplay that contribute to the literature surrounding these tumors. Medical literature describes a variety of diverse renal tumors with variable patterns of aggressiveness and malignant potential . Mixed eA 59-year-old female with a history of surgically managed ovarian cysts presented with a several-month history of diffuse abdominal pain radiating to the left upper back and associated intermittent nausea. Further history elicited an absence of hematuria; however, an approximate 10-pound weight loss due to decreased oral intake was noted. The patient underwent imaging via computed tomography (CT) scanning with demonstrated findings of a large 16.5 cm (16.5 × 12.0 × 13.6 cm) well-circumscribed exophytic left renal mass. While predominantly cystic in composition, the mass contained multiple thickened internal septations and internal loculations along the medial and superior aspects. A small portion of the mass extended into the mid-renal sinus, while the lateral aspect abutted the abdominal wall along with a loop of the proximal descending colon without evidence of invasion. Faint internal enhancement and calcifications were seen, consistent with a Bosniak IV type cyst and of concern for cystic renal cell carcinoma (RCC)  mass with multiple cystic spaces of varying sizes divided by fibrous septa and lined by hobnail cells. The tumor contained yellow-brown serous fluid along with a yellow gelatinous material. Within the large mass was a smaller complex multiloculated cystic area 12.5 × 7.0 × 6.5 cm in size. The tumor demonstrated weak to strong nuclear expression for estrogen receptors (ER) and progesterone receptors (PR), respectively, indicative of an ovarian-type stroma with small groups of cells identified within. By immunohistochemical investigations, the stromal cells demonstrated the expression for inhibin, human melanoma black 45 (HMB45), melanoma-associated antigen recognized by T-cells (MART-1), and calretinin, supportive of steroidogenic origin. The tumor showed no features of malignancy, and the patient recovered without complication. Of interest to this case is the presentation of the patient’s sister with advanced RCC approximately six months following our MEST diagnosis.MEST of the kidney are distinctive benign lesions accounting for less than 1% of all diagnosed renal neoplasms and require differentiation from other cystic tumors ,7. Our cMEST are typically characterized as biphasic septated cystic growths containing diverse morphologies that range from predominantly cystic to mainly solid in nature ,6. The tOn immunohistochemical profiling, the mesenchymal component of MEST is typically negative for melanocytic markers while displaying smooth muscle differentiation and immune reactivity for ER and PR ,13. PosiWhile melanocytic markers are typically negative when staining for MEST, our case displayed atypical HMB45 positivity, indicating the importance of considering findings in the context of radiological and morphological interpretations. Comparatively, one study found a lack of inhibin expression among 53 cases of MEST, while another report indicated 42% positivity for this marker among 14 cases ,12,13. OMEST represent a rare benign tumor of the kidney with a strong female preponderance, likely resultant of hormonal hyperstimulation. These tumors require differentiation from other cystic renal neoplasms; however, this is difficult on current imaging techniques prompting urgent surgical management. While nephron-sparing surgery should be considered in feasible cases, these tumors are complex and still not widely understood. Our findings contribute to the growing literature surrounding MEST given the substantial size and aggressiveness of the reported tumor and the interesting possibility for familial interplay.


Fat necrosis of the breast is a benign non-suppurative inflammation of the adipose tissue and often mimics breast cancers, posing a diagnostic challenge for the clinician and radiologist. It has a myriad of appearances on different imaging techniques, ranging from the pathognomic oil cyst and benign dystrophic calcifications to indeterminate focal asymmetries, architectural distortions, and masses. A combination of different modalities can assist a radiologist in reaching a logical conclusion to avoid unnecessary interventions. The aim of this review article was to provide a comprehensive literature on the various imaging appearances of fat necrosis in the breast. Although a purely benign entity, the imaging appearances on mammography, contrast-enhanced mammography, ultrasound, and magnetic resonance imaging can be quite misleading, especially in post-therapy breasts. The purpose is to provide a comprehensive and all-inclusive review on fat necrosis with a proposed algorithm allowing a systematic approach to diagnosis. Fat necrosis of the breast is a benign non-suppurative inflammation of the adipose tissue . It ofteThe breast parenchyma, which is composed of adipose, epithelial, and stromal tissues, is enveloped by skin and subcutaneous tissue. Adipose tissue forms the majority of the bulk of the breast volume, and the amount of adipose tissue varies throughout the reproductive life of a woman. An injury to the adipose tissue results in fat necrosis.This review article aims to discuss and illustrate the spectrum of appearances of fat necrosis using different imaging techniques. In this article, we also review the literature on the clinical features and etiopathogenesis relevant to a radiologist. The purpose is to provide a comprehensive and all-inclusive review on fat necrosis with a proposed algorithm allowing a systematic approach to diagnosis.The most common stimulus for fat necrosis is hypoxia, leading to ischemia. The fragmentation of adipose cells following ischemic damage leads to the formation of intracellular vacuoles filled with necrotic lipid material. Fibroblasts, multinucleated giant cells, and lipid-laden or foamy histiocytes (“fat-filled macrophages” or “foam cells”) along with enucleated adipocytes begin to accumulate . Damage Irreversible cell injury is of two types: apoptosis and necrosis. In the breast, both these processes prevail. The intensity of initial insult determines which process will predominate which in turn determines the clinical presentation, the radiological appearance, and the histological finding . The greThe common etiological factors leading to breast fat necrosis include trauma , radiotherapy, systemic anticoagulation therapy like warfarin, infection, and idiopathic disease. The most common cause is accidental trauma accounting for 21%–70% of all cases of fat necrosis .vs. free fat flap), the surgeon’s experience, and the administration of adjuvant radiation. Nakada et al. reported a 39% incidence of fat necrosis following pedicled tissue flap and almost 100% following free dermal fat flaps. Furthermore, symptomatic fat necrosis also showed a lower incidence following pedicled tissue flaps (2.9%) as compared with the free flaps (25%) , mastectomy, reduction mammoplasty, implant removal, and breast reconstruction, increase the risk of fat necrosis in the breast. A recent study by Dolan et al., comparing the imaging and biopsy results after breast surgery, found that the rate of fat necrosis after oncoplastic BCS was 7% as confirmed by pathology . Fat necps (25%) –10. Fat ps (25%) .Alone or following BCS, radiotherapy is an independent risk factor for the development of fat necrosis secondary to inflammation . The obsFat necrosis is more often than not asymptomatic and diagnosed incidentally on imaging. The clinical findings do not normally vary according to the etiology of fat necrosis and are neither specific nor sensitive. Palpable lumps of fat necrosis may present as indolent nodular and mobile masses with smooth margins or as hard fixed irregular masses. Associated features like induration, ecchymosis, erythema, nipple retraction, skin retraction or dimpling, and lymphadenopathy may be present. More than 50% of symptomatic fat necrosis has clinical features of malignancy such as hard mass, nipple retraction, and skin tethering . LesionsThe imaging modalities for the diagnosis of fat necrosis in the breast include mammography (MMG), ultrasound (USG), and magnetic resonance imaging (MRI). The emerging newer technique of contrast-enhanced mammography (CEM) aids in the diagnosis of fat necrosis in disputed cases and, along with MRI, serves as a road map for targeted biopsies.Mammography, digital mammography (DM), or digital breast tomosynthesis (DBT) plays a pivotal role in the imaging of fat necrosis especially in clinically suspicious symptomatic women above the age of 40 years and in post-therapy cases. In fact, in a postoperative and post-therapy breast, a regular annual follow-up mammogram is the gold standard for imaging surveillance . It shouThe appearance of fat necrosis on mammogram is in concordance with the stage of evolution of fat necrosis and ranges from focal asymmetries, architectural distortions, mass-forming solid lesions, cystic lesions, oil cysts, and calcifications. Early lesions develop hemorrhagic foci or areas of indurated fat with trabecular edema and can appear as focal asymmetry on MMG . OccasioA loculated necrotic fat-containing cavity called an oil cyst appears as a radiolucent lesion on MMG, owing to the internal fat component, with a thin dense peripheral rim of fibrosis. Oil cysts are pathognomic of fat necrosis and are the second most prevalent finding on MMG after dystrophic calcifications, accounting for 27% of the cases . The fibAn intermediate to late presentation of fat necrosis on MMG is focal asymmetry or architectural distortion. DBT is most useful in such cases to decrease the confounding effect of overlapping breast tissue. The underlying pathophysiology is the presence of varying amounts of inflammatory changes and areas of fibrosis interspersed with radiolucent necrotic fat. These are usually not clinically palpable and, in the majority of cases, are diagnosed solely on imaging. A post-surgical scar may appear as an area of architectural distortion with overlying contour deformity and skin thickening or nipple retraction at the site of surgery, features that may also mimic recurrence .Calcification is one of the most common findings following lumpectomy and radiation and also the most important imaging biomarker for local recurrence . With a Calcifications representing recurrence commonly have an amorphous or fine pleomorphic morphology with segmental or regional distribution . CalcifiThe most common calcification in fat necrosis is dystrophic calcifications. These are larger than 1 mm, rough, and irregular and tend to coalesce to become larger. Calcifications within the irradiated breast are usually dystrophic with a typical benign appearance. They appear linear or round and coarse, within the irradiated field. The tubular appearance of these calcifications following brachytherapy is secondary to the fat necrosis developing along the implanted needle tract which on serial MMG shows classical interval coarsening  is one of the most important sequences for the diagnosis of fat necrosis. Demonstration of fat-containing lesions and tissue distortion in the operative bed (fat-engulfing scar tissue) on T1W sequence can significantly improve the diagnostic conviction even in the presence of suspicious enhancement or kinetics which can be misleading . Fat-sat disease . The kin disease .Post-treatment or post-traumatic breasts with early-onset hemorrhage at the local site show a well-defined or an ill-defined mass or a focal asymmetry with altered signal intensity on different sequences. The signal intensity varies based on the age of blood, typically hyperintense on T1W images and hypointense on T2W images. No enhancement or mild peripheral enhancement can be seen on the post-contrast sequence . One of Architectural distortions occurring at or near the lumpectomy site under ideal circumstances would show signal intensity similar to fat on all sequences with adjacent parenchymal enhancement , 49. It Certain patterns of enhancement are highly suspicious, like mass-like enhancement, nodular enhancement (more than 5 mm), and clumped or heterogeneous non-mass enhancement with segmental or regional distribution and suspicious kinetics , and should not be considered as benign fat necrosis.18F-FDG PET/CT is not a routine recommendation for the detection of breast abnormalities and is primarily done for staging and metastatic evaluation. It cannot be emphasized enough that PET/CT is neither indicated nor recommended for recurrent disease evaluation in post-therapy breasts.The imaging features of fat necrosis on positron emission tomography/computed tomography (PET/CT) are all incidentally detected. Fat necrosis shows no uptake on PET/CT; however, few studies have detected “false positive” cases demonstrating uptake on PET/CT , 54. TheCases that are clinically and radiologically equivocal require confirmation with tissue diagnosis. Minimally invasive methods for tissue sampling are fine needle aspiration cytology (FNAC), core needle biopsy, and vacuum-assisted biopsy (VAB). The sensitivity and specificity of FNAC are 87% and 99%, respectively; however, it bears limitations such as inadequate sampling and repeated needling . Core neA spiculated dense mass on mammogram and a hypoechoic mass with angular margins and a taller-than-wide appearance on ultrasound in a post-therapy breast are suspicious features and warrant a tissue diagnosis. Amorphous or fine pleomorphic microcalcifications also require a histological sampling, compared with dystrophic and rim calcifications which are classically benign.A summary of the different stages of fat necrosis is tabulated with its clinical and radiological features as well as its gross histopathological and microscopic features in Mammography has stood the test of time for imaging the breast in eligible women. It is the best and first investigation tool for most cases. The diagnostic accuracy of mammogram increases when combined with ultrasound . UltrasoThe following flowcharts aspire to serve as a road map as an approach to various possible imaging appearances of fat necrosis in the post-therapy setting or a clinical setting of high suspicion for fat necrosis such as with a history of trauma, as depicted in Fat necrosis in the breast, albeit a benign entity, is a cause of concern for the clinician and often a cause of anxiety for the patient, and owing to its myriad of appearances on various imaging modalities, fat necrosis may be a cause of diagnostic dilemma for the radiologist. A radiologist should be conversant with the many typical and atypical features of fat necrosis and bear knowledge of the different evolution patterns enabling early diagnosis to circumvent unnecessary intervention. The overlap in imaging features of fat necrosis with breast cancer in a few cases makes it extremely difficult to reach a confident diagnosis based on imaging alone and often warrants histological sampling. Once diagnosed, fat necrosis requires no further attention or intervention as it bears no risk of malignant transformation.With this comprehensive review article, one can attain information on the interplay of various imaging modalities such as MMG, USG, CEM, and MRI and their use in different permutations and combinations in a nutshell to aid in arriving at a logical conclusion for the diagnosis of fat necrosis. The one-of-a-kind tabulated information on the clinical–radiological–pathological correlation for different stages of fat necrosis makes it easy for a radiologist to better interpret the imaging findings based on the clinical presentation and expected cellular evolution. A visually stimulating flowchart for the approach to a post-therapy breast as well as calcifications allows one to become a clinical radiologist.JM is the lead author of this review and has written and given the maximum contribution to the manuscript. PH has been a guide and mentor and has reviewed the content in-depth. PP, AK, and SC have helped by providing the images for the representative cases and by providing their valuable inputs. KB and SK have helped with the image-guided interventions of the representative cases. MT is the corresponding author and a source of inspiration and guidance for writing the manuscript. All authors contributed to the article and approved the submitted version.


TGFBR3 or MGEA5 rearrangements. Rare sarcomas originating from HFLT/PHAT have been reported, typically resembling myxofibrosarcoma or myxoinflammatory fibroblastic sarcoma. We describe a novel SMARCA4-deficient undifferentiated sarcoma with rhabdoid features originating from hybrid HFLT/PHAT in the foot of a 54-year-old male. The tumor pursued a highly aggressive course with rapid regrowth after resection and multiple metastases resulting in patient’s death within 5 months, despite systemic chemotherapy. Immunohistochemistry revealed SMARCA4 loss in the undifferentiated sarcoma, but not in the HFLT/PHAT. Molecular testing confirmed TGFBR3/MGEA5 rearrangements. This report expands the phenotypes of sarcomas developing from pre-existing PHAT/HFLT.Pleomorphic hyalinizing angiectatic tumor (PHAT) of soft parts and hemosiderotic fibrolipomatous tumor (HFLT) are two rare low-grade locally recurring neoplasms with predilection for the foot/ankle. Recent studies support a close link between the two entities, and origin of PHAT from HFLT and occurrence of hybrid HFLT/PHAT have been documented. Both lesions often harbor  Pleomorphic hyalinizing angiectatic tumor (PHAT) is a rare locally recurring, non-metastasizing low-grade neoplasm with predilection for the foot/ankle, first described by Smith, Fisher and Weiss in 1996 . Most caTGFBR3 and/or MGEA5 genes in both tumor types [In 2004, Folpe and Weiss described 41 PHATs and recognized areas indistinguishable from HFLT at the periphery of many PHATs [or types . The teror types .Several HFLT/PHATs (either primary or recurrent) showing morphologic progression to high-grade spindle cell sarcoma have been reported –13. MostHerein we report an exceptional example of hybrid HFLT/PHAT showing progression to a rapidly lethal, SMARCA4-deficient sarcoma with epithelioid and rhabdoid features, a previously undescribed phenomenon.A 54-year-old man with a 19-year history of rheumatoid arthritis, treated with methotrexate and etanercept, presented with a rapidly enlarging nodule on the dorsum of his foot. This mass had been present for 5 years and was clinically thought to represent a rheumatoid nodule. A nonradical surgical resection was performed at another center, and the patient was then referred to our sarcoma center for further treatment. Although the initial CT scan performed immediately after surgery showed minimal gross residual disease, the mass rapidly regrew, necessitating foot amputation Fig. . Post-opThe tumor specimens were fixed in buffered formalin and embedded for routine histological examination. Immunohistochemistry (IHC) was performed on 3-µm sections using a fully automated system  and the following antibodies: keratin cocktail , desmin , alpha smooth muscle actin , gp100 protein , ERG , CD30 , WT1-c-terminus , S100 protein , synaptophysin , CD34 , S100 protein , SOX10 , MUC4 , anti-NUT , SMARCB1 (INI1) , SMARCA2 , SMARCA4 , ARID1A , and PBRM1 . Samples were used in accordance with ethical guidelines for the use of retrospective tissue samples provided by the local ethics committee of the Friedrich-Alexander University Erlangen-Nuremberg (ethics committee statements 24.01.2005 and 18.01.2012).TGFBR3 and MGEA5 rearrangements was performed using previous published protocols [The tumor sample was tested for gene fusions using the TruSight RNA Panel  and for pathogenic mutations using the TruSight Tumor 170 Panel (Illumina) as described previously . FISH terotocols .Grossly, the amputation specimen showed extensive, multinodular mass on the dorsum of the foot with ulceration Fig. . On cut Histologically, the majority of the lesion (> 80%) was composed of an extensively necrotic, high-grade undifferentiated malignancy composed of poorly cohesive, large epithelioid and rhabdoid cells, growing in solid sheets and poorly cohesive aggregates Fig. . The tumThe periphery of the mass was notable for a distinctly different-appearing second component, showing characteristic morphologic features of HFLT/PHAT, including abundant mature fat, fascicles of hemosiderin-laden spindled cells, ectatic, fibrin-filled blood vessels, and pleomorphic cells with nuclear pseudoinclusions Fig. . The undBecause of the striking rhabdoid features of the high-grade component, the tumor was tested for expression of various components of the SWI/SNF complex ; > 95% loss of SMARCA4 expression was present and was limited to the rhabdoid high-grade component, with retained expression of the other SWI/SNF subunits Fig. . Strong The RNA fusion panel revealed no detectable fusions. Assessment of the expression results of the genes included in the panel showed highly overexpressed FGF8 with 809 reads compared to an expected median read of 0.40 counts in other tumor entities (data not shown). Elevated read counts were also detected for TGFBR3 (6682 reads compared to median count of 169), and MGEA5 (5158 reads compared to median count of 1111).MGEA5 and TGFBR3 probes confirmed rearrangements of both gene loci. Notably, both cell types (the spindled cells of the HFLT/PHAT component and the large epithelioid cells) showed split signals. The TST170 DNA Panel revealed no pathogenetic mutations in any other tumor-related genes. However, SMARCA4 is not included in this panel.FISH analysis using Sarcomas arising from pre-existing HFLT/PHAT are exceptionally rare, with fewer than 10 reported cases –13. As nThe current case is morphologically quite distinct from previously reported cases, showing instead strikingly rhabdoid and epithelioid features, and displaying loss of SMARCA4 expression. Interestingly, this morphology is essentially identical to that seen in a variety of recently reported SMARCA4-deficient malignancies of diverse organs. Unlike SMARCB1 (INI1) loss, which is most often an “entity-defining” event in tumors such as epithelioid sarcoma and pediatric rhabdoid tumors, SMARCA4 loss occurs more often as a late genetic event driving dedifferentiation in carcinomas of various types , but alsTGFBR3 (chromosome 1p22) and/or MGEA5 (chromosome 10q24) loci [FBXW14 (10q24.2) have also been very recently reported [TGFBR3-MGEA5 fusion seems to act via enhancer-related mechanisms resulting in altered gene expression without forming a detectable chimeric fusion protein. This may help to explain why the present tumor was FISH-positive, but negative by targeted RNA sequencing. In some cases, overexpression of FGF8 may serve as a “surrogate,” implying the presence of underlying TGFBR3-MGEA5 fusion [As noted previously, HFLT and PHAT show many similar morphologic features and frequently demonstrate either t fusion or rearrangements of the 24) loci . Rearranreported . Notably5 fusion .TGFBR3/MGEA5 rearrangements). Although only limited conclusions can be drawn from a single case, the natural history of SMARCA4-deficient sarcoma arising in this unique setting appears to be identical to that of SMARCA4-deficient malignancies elsewhere, with significant potential for adverse patient outcome.In summary, we have reported a case of SMARCA4-deficient undifferentiated sarcoma with rhabdoid/epithelioid features, arising from a pre-existing HFLT/PHAT of the foot. The distinctive morphology of this case, as compared to previously reported cases, likely reflects differences in the secondary genetic event (superimposed on pre-existing


To the best of our knowledge, thus far there are no reported cases of melanotic neuroectodermal tumor of infancy (MNTI) with multiple complications. In this case report, we describe the clinical phenotype of MNTI in a 9-month-old female infant associated with tetralogy of Fallot (TOF), a congenital heart defect, and congenital hypothyroidism (CH). Our study showed that the growth of MNTI was delayed by a lower dosage of levothyroxine (L-T4) that was prescribed to treat CH because of the presence of TOF, a severe congenital heart disease. However, the standardized dosage of L-T4 improved thyroid function but stimulated the rapid growth of MNTI. Our report demonstrated that treatment with L-T4 affects the progression of MNTI. Our findings demonstrated the role of thyroid hormone in MNTI growth and progression. Furthermore, our study suggested that the treatment of co-morbidities in children with MNTI requires careful consideration of their effects on the growth and progression of MNTI. Melanotic neuroectodermal tumor of infancy (MNTI) is a rare, rapidly growing, benign, and pigmented tumor of neural crest origin that was first reported by Krombecher as congenital melanocarcinoma in 1918 . More thThis case described the clinical characteristics of a 9-month-old girl with a 6-month history of growing mass in the left frontal cortex with faster growth in the recent 3 months. She was diagnosed with TOF and CH after birth and underwent radical surgery at the age of 6 months. The patient was given a reduced L-T4 dose for CH treatment because of the underlying TOF. After surgery, the dosage was gradually increased.The tumor was present on the left forehead and showed basal fixation. It was hard, about 3 cm × 4 cm in size, and did not show any signs of neurologic involvement. The skull did not show asymmetry, cutaneous lesions, or inflammation. Neck mass was not observed. There were no symptoms of chronic hypoxia, such as paroxysmal cyanosis and clubbing fingers. The physical growth and development of the infant were normal and in range for her age group.The brain CT scan showed irregular bone structure with mixed density mass on the left side of the cranial plate in the forehead, slightly reduced brain mass density in the bilateral parietal lobes, and wider ventricles and extracerebral spaces as shown in The postoperative cardiac ultrasound  showed tThe thyroid function was normal at admission.After admission, the left frontal tumor was resected under general anesthesia. After satisfactory anesthesia, the skin in the surgical area was routinely disinfected. An incision was made through the skin tissue, capillary tendon membrane, and the periosteum at the top of the frontal curvature to expose the skull. The skull in the surgical area was abnormally elevated, dark red in color, and poorly defined in comparison with the surrounding normal skull. Second, the abnormal skull was bitten, with a loose texture and poor blood supply. The abnormal skull was removed by grinding and drilling, and the cap-like aponeurosis, subcutaneous tissue, and skin were sutured. The wound was pressure dressed. The operation went smoothly without much bleeding. The patient was discharged after suture removal.Under the postoperative pathological microscope , most ofImmunohistochemistry of the lesion showed cytokeratin (CK)-positive epithelial cells, synaptophysin (syn)-positive small blue cells, S-100-positive, HMB45-positive, CD99-negative, CD3-negative, NSE-positive, ERG-positive vascular endothelium, and 15% Ki67-positivity . Based oThe postoperative outcome of the patient was good and did not show any additional neurologic impairment. Chemotherapy and/or radiotherapy were not required. The timeline of the patient’s clinical journey is shown in MNTI is a rare tumor of neural crest origin that is associated with increased urinary excretion of vanilloid acid . The bipClinically, MNTI is described as single, painless, non-ulcerated, pigmented, and fast-growing neoplasms. In this case-report, a fast-growing mass appeared in the left frontal cranial plate, after the child underwent radical surgery for TOF, a congenital heart disease, at the age of 6 months. This was consistent with the morphological characteristics of MNTI. The pre-operative CT image showed irregular bone structure and irregular soft tissue mass on the left side of the cranial plate in the middle of the forehead, and non-uniform density and “needle-like” periosteal reaction in the parietal bone . MNTI neFLI1, ERG, ETV1, ETV4, and FEV) and the EWS gene called Ewing sarcoma breakpoint region 1 (EWSR1) on chromosome 22q12. The most commonly reported chromosomal translocation is t , which involves the EWS and FLI1 genes and is observed in 83% of cases with ESFTs. This occurs through an in-frame fusion of the EWS gene at 22q12 and the FLI1 gene at 11q24 resulting in the formation of the EWS-FLI1 fusion gene product  are characterized by chromosomal translocations involving one of the several genes of the ETS family   translocation that generates the Since epithelial cells in MNTI neoplasms produce melanin, they need to be differentiated from melanomas. Melanomas are generally heterotypic and can be screened using the S-100 protein. However, the S-100 protein cannot be used as a confirmatory indicator because of its low specificity. Melan A, HMB45, and tyrosinase show higher specificity and varying sensitivity in melanomas, whereas CK and neuroendocrine markers are negative. Furthermore, in the melanomas, the Ki-67 positivity index and cyclin D1 expression levels were high and did not decrease with lesion depth. Therefore, for comprehensive diagnosis of MNTI, two or three of the above-mentioned markers are combined with the S-100 protein index .A slow-growing painless tumor mass is characteristically observed in more than half of the patients with primary soft tissue CCS. In patients with CCS, immunohistochemistry analysis shows strong positivity for S-100, HMB45, melanA, and Vimentin. CCS is also associated with the t  translocation and lack of neuroblastoma-like cells .In this case, intraoperatively, the endplate of the milled bone flap showed a “pinprick-like” protrusion that was infiltrative and closely associated with the deep dura mater. This suggested that preoperative imaging was important for the diagnosis of MNTI to provide a reference for guiding the extent of surgical resection of the lesion and the surrounding tissues.in situ despite the choice to expand the surgical resection area, which increased the tissue trauma to the child. Therefore, although MNTI is a benign tumor, it is characterized by rapid growth and confers destructive effects on the adjacent tissues. The incomplete excision of the primary lesion because of anatomical constraints may lead to local recurrence. Therefore, early diagnosis and treatment are necessary. Moreover, the impact of other comorbidities or congenital developmental malformations needs to be observed during treatment and follow-up. The most effective treatment is complete resection of the lesion and the surrounding tissues that may be invaded by the tumor.Surgical excision of the lesion is the treatment of choice for patients with MNTI. The prognosis for MNTI is generally good with a postoperative recurrence rate of approximately 15–45% mostly due to incomplete resection of the primary lesion . In 3% oin situ recurrences and confirmed the prognosis of the immunohistochemical index.The aggressive course and poor prognosis of MNTI are based on the following prognostic indicators: nuclear schistosomes seen in more than 2 out of 10 high power fields (HPFs); greater than 25% Ki67 positive index; CD99 expression status; higher proportion of neuroblastoma-like cells compared to the epithelioid cells (Pax3 genes lead to a spotted (Splotch) mutant phenotype and Waardenburg type I syndrome, respectively; the pure Splotch embryos show severe neural crest cell (NCC) defects with complex phenotypes such as spina bifida, extracerebral malformations, and cardiac outflow tract abnormalities , and resistance against the thyroid stimulating hormone . Thyroidpulation . In thisOnce CH is diagnosed, treatment should be administered immediately. L-T4 is the first choice of treatment for CH. However, in patients with severe congenital heart disease, the initial dose of L-T4 should be reduced. In this case, TOF, severe congenital heart disease was diagnosed soon after birth in combination with CH. The MNTI tumor did not show any significant increase in size during reduced L-T4 therapy. However, the tumor size was significantly increased after cardiac surgery and standardized L-T4 treatment. This suggested that the reduction of L-T4 because of TOF affected the complete recovery from hypothyroidism but retarded the growth of the tumor. After congenital heart surgery, the standardized use of L-T4 improved the recovery of thyroid function but accelerated tumor growth. Age-related growth of the MNTI tumor cannot be ruled out in this case. However, this case also suggests that MNTI tumor growth may be associated with adequate treatment of CH. Future studies of MNTI cases at a later stage would shed more light on the potential dysmorphic syndromes or neurodevelopmental disorders associated with MNTI. Furthermore, advances in genetic and other biochemical tests would aid in early prenatal diagnosis and therapeutic management.Congenital heart disease and/or congenital hypothyroidism are common complaints in children. However, their association with congenital neoplastic disorders is not clear. Our study shows that the growth and development of MNTI neoplasms require comprehensive and constant monitoring. Moreover, therapeutic interventions to co-morbidities may result in the progression of MNTI tumor growth. Genetic factors are the major risk factors for NCPs. Furthermore, large phenotypic heterogeneity and etiological homogeneity of the NCPs can significantly challenge unraveling the underlying pathogenic mechanisms of NCC development. Therefore, precise elucidation of the pathogenic mutations in the NCPs will help the development of targeted therapeutic and preventive tools.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Medical Ethics Committee of Tianjin Children’s Hospital. It belongs to Tianjin Children’s Hospital. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)’ legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.H-CZ: methodology, formal analysis, investigation, and writing—original draft. J-YH: writing—original draft, resources, and visualization. L-SZ: resources, writing—review and editing, project administration, and funding acquisition. X-LH: conceptualization, data curation, writing—review and editing, and supervision. L-SZ and X-LH: responsible for the study described in this manuscript. All authors contributed to the article and approved the submitted version.


The dermal sinus tract (DST) is an infrequent form of spina bifida occulta that can be complicated by infections. This is a case report of a child with a rare association of DST complications, namely hydromyelia and intramedullary abscess. A 1-year-old male child was admitted to the hospital with a history of fever and progressive loss of lower-limb movements and the presence of an ostium in the midline of the lumbar region and cutaneous stigmas with no secretion discharge. Computed tomography and magnetic resonance imaging (MRI) of the thoracolumbar spine revealed an extensive intradural T12-S1 abscess and cystic dilatation of the central medullary canal (hydromyelia) from T2 to T12. The surgery was conducted with the drainage of the large abscess and also improving hydromyelia. After 30 days of rehabilitation with physical therapy, the child could walk despite right crural monoparesis (possible L4/L5 injury). This report described a case of DST that showed a rare association of two complications, i.e., intramedullary abscess and hydromyelia, due to a late diagnosis. Sequelae could have been prevented with early diagnosis. Dermal sinus tract (DST) is a rare form of spina bifida occulta that affects approximately one in every 2,500 live births . It resuThis is a case report of a child who had a rare combination of DST complications, namely hydromyelia and intramedullary abscess.Staphylococcus aureus and Escherichia coli were grown on culture. For treatment, intravenous therapy with ceftriaxone and vancomycin was chosen for a period of four weeks. On the second postoperative day, the child was able to move his lower limbs. After 30 days of rehabilitation with physical therapy, the child could walk despite right crural monoparesis (possible L4/L5 injury).A 1-year-old male infant was admitted to the emergency hospital with a fever (39°C) and difficulty moving his legs. His mother reported that the fever had started a week prior to hospitalization. Progressive loss of leg movements had begun three days before admission. On physical examination, the patient was crying and paraplegic (reduced tone and zero degree of muscle power) and an ostium was observed in the midline of the lumbar region Figure , along wHart described the first case of an intramedullary abscess in 1830 . Infecti“Syrinx” and “syringomyelia” are synonymous and are defined as a fluid-filled cavity located inside the spinal cord. When this cavity is located in the central canal it is called hydromyelia . SyringoS. aureus [The clinical picture is usually non-specific, with fever, meningism, neurological deficit, and bladder incontinence. There is also secretion flow through the ostium of the congenital dermal sinus associated with the infection. When a spinal cord abscess occurs, there are some differential diagnoses, such as transverse myelitis, Guillain-Barré syndrome, and neoplasms. Spinal cord abscess is the most serious complication, and the most frequent causal organism is . aureus ,5.MRI is the gold standard in neuroimaging investigations because it allows for the identification of DST and the extent of infection, whether epidural, subdural, or intramedullary . GuillaiCongenital dermal sinus treatment has a better prognosis in cases diagnosed as early as possible, allowing surgery to be performed while the tissue is not infected and lesions are minor, thereby preventing future infections. In cases of late diagnosis with abscess formation, surgical drainage and appropriate antibiotic therapy are recommended to avoid irreversible damage to the spinal cord due to vascular involvement and the effects of mechanical pressure. Unfortunately, delays in diagnosis and intervention complicate the surgical procedure, with a significant risk of neurological deficits. Thus, surgery involves the complete removal of DST, drainage of the abscess with the possible removal of its wall, resection of any associated inclusion tumors, and obtaining samples for microbiological and histopathological examinations . In the This report described a case of DST that showed a rare association of two complications, i.e. abscess and hydromyelia, due to late diagnosis. Despite the surgical procedure, sequelae still persisted.As in the reported case, DST can evolve with complications and early diagnosis starting with a good physical examination can avoid sequelae.


Endometrial stromal sarcomas are the second most common type of mesenchymal uterine tumors, and they represent 1% of all uterine malignancies. Metastasis of this tumor occurs in about one third of patients, usually to the pelvis and lower genital tract. Metastases to the diaphragm or liver are exceedingly rare, with only a few published cases in the literature. This case presents a 28-year-old woman with a subphrenic endometrial stromal sarcoma metastasis between the right diaphragm and segment IVa of the liver that was treated with surgical resection. Endometrial stomal sarcomas (ESSs) are a rare entity representing ~1% of all uterine malignancies, and they are the second most common mesenchymal uterine tumor after leiomyosarcomas . The patet al. suggest liver resection in resectable patients by extrapolating data obtained on liver metastasis from other sarcomas and uterine tumors [et al. discuss their 45-year-old patient who developed a recurrence of her low-grade ESS between the right diaphragm and liver, very similar to the case we present in this paper, treated with chemotherapy and surgical resection [Most published case reports are on pulmonary, cardiac and pelvic metastases of ESSs. Distant metastases of this tumor to the diaphragm or liver are extremely rare, as such the literature regarding their clinical management is scarce. Ramia e tumors . Maeda eesection . Here, wThe patient is a previously healthy woman who presented at the age of 21 with severe abnormal uterine bleeding. She was initially treated with uterine artery embolization, and then underwent surgical resection in the form of a radical hysterectomy, right salpingectomy, left salpingo-oophorectomy and bilateral pelvic lymph node dissection. Pathology confirmed a 9 cm low-grade endometrial stromal sarcoma with right pelvic lymph nodes positive for metastasis, consistent with stage IIIC disease. She was also treated with long-term megestrol acetate. She developed recurrence adjacent to the right ovary in 2018 (at the age of 24), which was treated with surgical resection, doxorubicin, olaratumab and pelvic radiation therapy. She did well until early 2022, at the age of 28, when a surveillance abdominal magnetic resonance imaging (MRI) scan showed a lobulated enhancing mass measuring 3.6 × 2.4 cm over segment IVa of the liver, with possible parenchymal invasion . The casAs such, the patient was brought to the operating room for a laparoscopic segment IVa liver resection. Upon insertion of the laparoscope, the mass appeared tethered to the right diaphragm and segment IVa of the liver, and not embedded in the liver parenchyma . A windoEndometrial stromal sarcomas are rare uterine malignancies that typically present perimenopausally. They are slow-growing tumors with the potential to metastasize years after the initial diagnosis, most commonly to the pelvis and lower genital tract. Distant metastases to the diaphragm or liver are exceedingly rare; as such, the literature on this topic is limited. Our case of this young 28-year-old woman with a subphrenic ESS metastasis tethered to the right diaphragm and segment IVa of the liver is unique and highlights the importance of multidisciplinary discussion. The patient was treated with surgical resection, in keeping with the NCCN clinical guidelines for metastatic uterine sarcoma.


The majority of patients with paratesticular rhabdomyosarcoma (RMS) present in the pediatric age group with a unilateral, painless, palpable scrotum mass. By contrast, cases of RMS presenting as painful edema are rare. We present a case of alveolar paratesticular RMS in a 30-year-old man who had been suffering from a painful swelling of the scrotum on the left side for two years and a preceding mass four months before visiting the clinic. Complete resection of the left epididymal mass was performed through a left inguinal incision. The histopathological and immunohistochemical examination of the mass revealed alveolar RMS of the paratesticular region. Urologists should be aware that paratesticular RMS may present in adults with atypical symptoms such as scrotal pain and edema, especially in those who do not respond to antibiotics. Hence, such patients should have an additional evaluation. Rhabdomyosarcoma (RMS) is a primitive pediatric malignant soft tissue sarcoma of the skeletal muscle phenotype that originates from a primitive mesenchymal cell. Most cases are diagnosed at pediatric age, and it is rare in adults ,2. RMS aA 30-year-old male patient presented with intermittent mild pain in the left scrotum for two years; approximately four months before presentation, he felt a non-painful mass that gradually increased in size. He was started on antibiotics (ciprofloxacin for four weeks and doxycycline for two weeks) for possible epididymo-orchitis. However, the patient did not experience any improvement in scrotal swelling and requested a scrotal ultrasound, which revealed an epididymal mass. The patient was then presented to the urology unit of the Royal Commission Medical Center Yanbu’s Department of Surgery for additional evaluation.On physical examination, the left hemiscrotum appeared normal skin color and had no signs of acute inflammation. A palpable, hard, and movable mass measuring approximately 4×4 cm was located in the left epididymis tail below and was attached to the left testis but not to the scrotal skin.Laboratory tests revealed that beta-human chorionic gonadotropin (ß-HCG), lactate dehydrogenase (LDH), and alfa-fetoprotein (AFP) were in the normal range. The semen concentration was 5 ml, 40 million cells/ml, active 60%, and non-motile 20%, otherwise unremarkable. On imaging, the testicular ultrasound revealed a left testis with numerous tiny parenchymal calcifications with normal vascularity. Further, it showed a bulky mass in the left epididymal tail with numerous calcific foci with significantly increased vascularity, mostly consistent with inflammation Figure . On magnMicroscopic examination revealed an unencapsulated, poorly circumscribed tumor formed by cell proliferation. The fibrous stroma had foci of abundant smooth muscle and elastic fibers, which had a desmoplastic appearance and that were infiltrated by inflammatory cells with prominent cytoplasm vacuolation. The first impression was an adenomatoid tumor of the epididymis and free margins from malignancy. As our hospital’s policy requires us to obtain a second opinion to confirm a diagnosis, a specimen was sent to an advanced oncology center. There, immunohistochemistry revealed that the tumor cells were positive for desmin, MyoD1, and myogenin. Cytogenetic testing fluorescence in situ hybridization (FISH) for the FKHR (FOXO1) mutation was positive, confirming the diagnosis of alveolar RMS. Hence, the patient was referred to a more advanced oncology center to complete his treatment.RMS is a type of malignant soft tissue tumor that develops from striated muscle cells or mesenchymal cells that have been differentiated from striated muscle cells. It is the most common soft tissue sarcoma in children, accounting for approximately 6.5% of malignancies under the age of 15; however, it is extremely rare in adults . RMS typParatesticular RMS typically manifests as a painless epididymal mass or as nonspecific symptoms such as decreased appetite, fatigue, inguinal lymphadenopathy, and weight loss. Pain can occur when paratesticular RMS compresses a nerve. However, pain is extremely rare, occurring in only 7% of patients ,11. WhenIt is not straightforward to clinically establish a diagnosis of RMS of the testis, epididymis, spermatic cord, or anywhere within the scrotum because it can mimic the symptoms of epididymitis or epididymo-orchitis, which can delay diagnosis . UltrasoWood and Dewbury  describeMRI scans can show a heterogeneously enhancing mass within the testis or a mass in the paratesticular region compressing the testis . RadioloThe treatment of paratesticular RMS includes multimodal therapy with systemic chemotherapy and surgery, radiation therapy, or both to maximize tumor control. Surgical intervention alone produces a 50% two-year relapse-free survival rate before effective chemotherapy . PatientAll patients with paratesticular RMS should be considered for adjuvant chemotherapy treatment. Available protocols include doxorubicin and ifosfamide as well as etoposide, vincristine, actinomycin-D, cyclophosphamide, and cisplatin. According to the European Society for Medical Oncology and Minimal Clinical Recommendations, doxorubicin is the first-line chemotherapy for soft tissue sarcoma, and there is no clear evidence that polychemotherapy is more successful than doxorubicin alone in terms of overall survival. However, a combination of doxorubicin and ifosfamide results in a higher response rate ,22, reacRegarding our patient, he had a complete resection of the left epididymal mass through a left inguinal incision in our hospital, and he was then referred to an advanced oncology center to complete his treatment when the ultimate diagnosis of left alveolar paratesticular RMS was confirmed. In terms of outcome, the localized disease has a better prognosis than metastases. A poor prognosis is frequently associated with age, particularly in patients aged under one year or over 10 years .In conclusion, this case highlights an important point: urologists should be aware that paratesticular RMS can present in adults with atypical manifestations that include scrotal pain and edema. Due to the highly aggressive character of paratesticular RMS, additional evaluations are necessary for patients with epidydmo-orchitis symptoms, particularly those who do not respond to antibiotic therapy.


Osteoid osteoma (OO) is a primary benign tumor that accounts for up to 3% of all bone tumors. The cervical spine is less affected by OOs, and very few cases of C2 OOs have been reported in the literature, both in adults and children. Surgery may be required in case of functional torticollis, stiffness, and reduced range of motion (ROM) due to cervical OOs refractory to medical therapy. Several posterior and anterior surgical techniques have been described to remove C2 OOs. In particular, anterior approaches to the cervical spine represent the most used surgical route for treating C2 OOs. We describe the first case of OO of the odontoid process removed through a transnasal endoscopic approach with the aid of neuronavigation in a 6-year-old child. No intraoperative complications occurred, and the post-operative course was uneventful. The patient had immediate relief of neck pain and remained pain-free throughout the follow-up period, with complete functional recovery of the neck range of motion (ROM). In this case, based on the favorable anatomy, the transnasal endoscopic approach represented a valuable strategy for the complete removal of an anterior C2 OO without the need for further vertebral fixation since the preservation of ligaments and paravertebral soft tissue. Osteoid osteoma (OO) is a primary benign tumor that accounts for up to 3% of all bone tumors ,2. It usAge at the diagnosis ranges between 5 and 25 years, with anecdotal cases reported during infancy ,5. DespiSeveral surgical approaches and techniques have been proposed to treat C2 OOs. Based upon tumor localization and relationships with neighboring structures, anterior and posterior approach have been used, with or without cervical fixation, to obtain complete OOs removal.As an addition to the spectrum of surgical routes, we describe the first case of C2 OO removed through a transnasal endoscopic approach in a child. The case is herein detailed, and the surgical technique is described, supported by a systematic review of literature about C2 OOs.A 6-year-old girl was referred to the outpatient clinic of our Institution complaining of persistent neck pain for 8 months, which worsened at night, and was unresponsive to acetaminophen. Three months after pain onset, the patient presented progressive functional limitation in lateral bending and rotation of the head. Neurological examination was otherwise unremarkable, and blood exams were normal at the time of the first visit. Contrast Magnetic Resonance Imaging (MRI) revealed a rounded formation of about 7–8 mm axial diameter located on the left portion of the odontoid process. The lesion appeared adherent to the base of the odontoid process and axis body, adjacent to the left C1-C2 joint, and was characterized by a calcific-like appearance. The surrounding prevertebral and paravertebral tissues, together with the adjacent trabecular bone, were edematous A,B.The patient underwent a cervical spine CT scan, which revealed a thin hypodense border between the outer lesion boundary and the C2 bone. The base of the odontoid process and part of the C2 body looked thickened as they had been imprinted by the lesion growth B,C.According to the imaging, a differential diagnosis including primary bone lesions such as osteochondroma, inflammatory arthritis with associated synovial calcifications, and osteoid osteoma was hypothesized. Autoimmune and inflammatory markers were negative, and rheumatologic evaluation was inconclusive. Due to worsening functional limitation, the patient initially undertook NSAID therapy and underwent physical therapy. A few months later, since the progressive worsening of all symptoms irrespective of conservative therapies, the patient and her parents were proposed to undergo surgical removal of the lesion. Considering the need for surgery, she was admitted to our Institution. On admission, the patient complained of cervical pain with marked neck stiffness, acquired left torticollis, and severely reduced ROM; no neurological impairments were noticed. The case was discussed by a multidisciplinary team of neurosurgeons and otolaryngologists, and the endoscopic transnasal route was selected as the most convenient surgical approach in view of the favorable trajectory towards the lesion and minimal tissue manipulation needed to reach and excise the lesion . The surgical procedure was performed through a 2-surgeon, 4-hand technique by otolaryngologists and neurosurgeons, with the patient under general anesthesia. The transnasal endoscopic approach was aided by intraoperative neuronavigation  a. The fiSince the intraoperative evidence of ligamentous integrity, vertebral fixation was deemed unnecessary. After the surgery, the patient was briefly admitted to the pediatric intensive care unit and then transferred to the ward. The post-operative course was uneventful, and the patient had immediate relief from neck pain. She fed orally from the second post-operative day and was mobilized with a Philadelphia collar on the same day. An early post-operative CT scan of the cervical spine confirmed the total gross removal of the lesion without signs of complications. Pathological examination of the lesion confirmed the diagnosis of OO.Thus, the patient was prescribed to wear a cervical collar for 1 month to facilitate the subsequent postural rehabilitation. During the follow-up period, the patient underwent endoscopic medication under sedation and local anesthesia on the second day, 2 weeks, and 1 month after surgery.The collar was dismissed 1 month after surgery. The patient was symptom-free 3 months after surgery. Post-operative cervical MRI performed 4 and 6 months after surgery showed regular bone healing without indirect signs of vertebral instability or lesion relapse A–F. At tTo assess the rarity and peculiarity of C2 OOs, a systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . This reLiterature search retrieved the following results: (osteoid osteoma) AND (axis), 19 results; (osteoid osteoma) AND (odontoid), 5 results; (osteoid osteoma) AND (C2), 13 results; (osteoid osteoma) AND (endoscopic) AND , 23 results. Reference lists of all publications were also screened (3 results). Records screened were 55. Only studies regarding OOs affecting C2 were included. , Table 1Vertebral OOs are rare tumors: vertebral bodies are affected in only 10% of OOs . ConsideAmong the included studies, 10 cases of OO involving the C2 body and odontoid process affecting pediatric patients were reported, accounting for 52.6% of all cases. Neck pain was the most frequent symptom, which was present in up to 94% of cases and was associated with neck stiffness and functional torticollis in 4 23.5%) and 5 (29.4%) cases, according to available data, respectively 3.5% and ,17,18,19Conservative treatment can be a valuable option in selected cases, both adults and children. In particular, anti-inflammatory treatment with acetaminophen or celecoxib 200mg/day has been proven effective in relieving pain and improving neck ROM for a time ranging between 6 months and 2 years ,7,15.However, despite the pain relief, only in one case a complete regression of OO after prolonged NSAIDs therapy was reported. Thus, surgical treatment is advised in case of symptomatic OOs refractory to conservative therapy, in case of reduction of pain relief time, and to avoid side effects of prolonged NSAIDs therapy ,21. The Intraoperative neuronavigation was useful to map the tumor boundaries at the OO-normal bone interface and to confirm the complete removal of the lesion. Until now, in only one other case of C2 OO addressed through the posterior cervical approach, the surgery was aided by neuronavigation . As regaBased on the patient’s young age and favorable anatomy, the transnasal corridor was considered the most favorable route for removing the lesion. In fact, the anatomy of this young patient, as seen on the sagittal cranial CT scan, allowed wide surgical exposure of the anterior aspect of cranio-vertebral and atlanto-axial junctions through the transnasal approach ,23 Figu. MoreoveIn the only similar case in which C2 OO was removed through a transoral endoscope-assisted approach, subsequent stabilization through C1-C2 posterior fixation was required to overcome the atlanto-axial instability given by the complete removal of the C1 anterior arch and the base of the odontoid . Cranio-OOs of the C2 body and odontoid process are very rare entities that may occur in both adults and children. Provided that the trajectory from the piriform aperture to the target is favorable, the transnasal endoscopic approach represents a valuable strategy for completely removing anterior C2 OOs. Neuronavigation was remarkably useful in locating some tumor boundaries and intraoperatively assessing the complete removal of the OO. Preservation of ligaments and paravertebral soft tissues was paramount to avoid the need for vertebral fixation.


Cervical lymphoceles are atypical lymphatic accumulations that develop within the subcutaneous tissue of the neck. While these accumulations have traditionally been removed via surgical excision, sclerotherapy has recently emerged as a reasonable option to prevent injury to surrounding vascular, neurologic, and pulmonary structures. The purpose of this case report is to describe the efficacy of ethanol sclerotherapy for a cervical lymphocele refractory to surgical embolization. We present the case of a 70-year-old male with a large cervical lymphocele that was initially treated with surgical embolization. The mass rapidly reaccumulated within two weeks and the patient subsequently underwent ethanol sclerotherapy with no evidence of re-accumulation after 18 months. This case highlights the utility of ethanol due to its better side-effect profile, widespread availability, and cheaper cost when compared to better-described agents. Cervical lymphoceles are lymphatic accumulations composed of dilated cystic spaces separated by a complex network of connective tissue stroma, lymphoid follicles, and infiltrates . Given tThe proposed mechanism for ethanol as a sclerosing agent is through dehydration and denaturation of proteins, leading to thrombus formation and ischemia of the blood vessels supplying the lymphocele . EthanolAt the initial presentation to an otolaryngology clinic, the patient was an early 70-year-old male with a three-year history of a stable left-sided neck mass. In-office ultrasound was performed at his initial presentation which demonstrated a 6 x 3.5 cm cystic mass in the left neck, thought to represent a lymphangioma or cystic schwannoma at that time. An MRI of the patient’s face, neck, and orbit (F/N/O) was ordered and completed one week later, demonstrating a 6.5 cm cystic mass that projected along the anterior aspect of the left neck and revealed serpiginous channels extending posteriorly into the mediastinum, suggestive of a lymphocele Figure . The patSclerotherapy is a less invasive alternative to surgical excision for the treatment of cervical lymphoceles and other benign neck masses. While most studies have explored the use of agents such as bleomycin and OK-432, research is limited on the use of ethanol, a widely available and relatively cheaper agent, for the treatment of cervical lymphoceles. In this case review, we described the use of ethanol for the treatment of a large cervical lymphocele, refractory to embolization performed by interventional radiology. The patient received two injections of 97% ethanol with a gradual, yet significant, reduction in the size of his cervical mass over the course of 18 months.In a retrospective review of 32 patients who underwent percutaneous ethanol sclerotherapy for postoperative lymphoceles, ethanol sclerotherapy permitted the resolution of lymphoceles in 94% of patients . No patiIn the case presented in this study, ethanol sclerotherapy resulted in a significant reduction in the size of a left inferior neck lymphocele after only two sclerotherapy sessions. The patient denied any complications immediately post-injection or in the months to follow. The patient experienced over an 80% reduction in the size of the mass after an initial attempt at embolization had resulted in recurrence. The patient was followed for over 18 months, comparable to the duration of monitoring described by prior studies investigating the use of ethanol sclerotherapy ,7.There are multiple advantages to using ethanol as an agent for sclerotherapy. First, ethanol is widely available and cost effective, which can facilitate the use of ethanol ablation in the outpatient setting. Additionally, ethanol may be more effective than better-studied agents such as OK-432 for the ablation of other head and neck masses such as branchial cleft cysts . In a reAlthough the patient experienced a significant reduction in the size of his cervical lymphocele after only two treatments of ethanol sclerotherapy, we are unable to generalize our results due to this being only one case. Additionally, ethanol sclerotherapy was performed after the initial treatment with embolization had failed. It is possible that the prior attempt at embolization may have facilitated subsequent attempts at ethanol ablation. Additionally, the amount of ethanol that was injected was based on the senior author's experience with sclerotherapy for other head and neck masses. Although the patient has significantly benefited from these procedures, future work should explore the volume of ethanol required to achieve optimal resolution of lymphoceles as well as the ideal number and duration between treatments without causing toxicity. Little work has been done to evaluate the threshold of ethanol toxicity in sclerotherapy. However, one study identified a dosage greater than 0.24 mL/kg to be predictive of systemic toxic effects . FurtherEthanol is a widely available and effective sclerosing agent in the management of lymphoceles. While its utility has previously been described in the management of lymphoceles throughout the body, its use for cervical lymphoceles remains unclear in the existing literature. The purpose of this case presentation is to demonstrate the success of ethanol sclerotherapy in the management of a cervical lymphocele refractory to surgical embolization. We also highlight the safety of using ethanol in scenarios where surgical excision may not be feasible, such as when the lymphoceles encroach on important vascular, neurologic, or pulmonary structures. Future randomized control trials are required to directly compare the success and recurrence rates of surgery, embolization, and sclerotherapy. Additionally, future work is required to elucidate the optimal volume of aspirate and concentrations of ethanol required to treat cervical lymphoceles.


Immunoglobulin light chain (AL) amyloidosis is a systemic disease in which different systems such as kidneys, heart, and lungs are affected by the deposition of amyloid, a form of fibrillary protein. Usually, it occurs in patients with pre-existing diagnoses of plasma cell dyscrasias and is rarely seen in the concurrence of marginal zone lymphoma (MZL). Earlier interventions with cyclophosphamide and dexamethasone in conjunction with newer therapies such as bortezomib, carfilzomib or lenalidomide, and pomalidomide are being used to treat patients with AL amyloidosis. In this report, we are presenting a unique case of a patient who was diagnosed with AL amyloidosis several years prior to presenting with a soft tissue mass, which was subsequently noted to be an amyloid mass within an MZL. Overall, the occurrence of AL amyloidosis and MZL is rare with less than 20 patients reported. The MZL developed prior to or simultaneously with AL amyloidosis in the reported cases. Therefore, to our knowledge, this is the first time systemic amyloidosis has preceded MZL. Amyloidosis is characterized by the abnormal tissue deposition of fibrillary protein aggregates, typically light chains in beta-pleated sheets ,2. AmyloAmyloid complicating MALT typically is localized , and systemic amyloidosis is unlikely -6. StuhlThe patient was a 54-year-old female with a past medical history of AL amyloidosis with kappa-restricted plasma cells initially diagnosed in 2011, 11 years prior to the current presentation, on the basis of a soft tissue biopsy. During the time of her diagnosis, 11 years prior, she had no evidence of cardiac involvement based on a cardiac MRI and her renal function was normal. She was advised to undergo autologous bone marrow transplantation, which she declined. She was lost to follow-up and did not receive medical care until November 2020, when she presented to an outside hospital with acute renal failure; her serum creatinine was 14 mg/dL (baseline: unknown). She was diagnosed with systemic amyloidosis with renal involvement and was started on hemodialysis. On December 2, 2020, she was started on chemotherapy with cyclophosphamide, DNA alkylating agent, bortezomib, which rapidly reduces serum-free light chains, and dexamethasone (CyBord). She was transferred from the outside hospital for management of septic arthritis and evaluation of a 17-cm mass in the left groin. Septic arthritis was treated with intravenous vancomycin on M/W/F, dosed per renal function. General surgery and plastic surgery were consulted for resection of the left groin mass. The soft tissue proved to contain amyloid, which was confirmed by Congo red and crystal violet stains. There was an infiltrate of small lymphocytes positive for CD20 and CD79a, consistent with MZL  associated with myeloma -12. WhilIn conclusion, we described a rare case with AL amyloidosis preceding MZL by several years. Moreover, MZL should be kept as a differential diagnosis for patients with AL amyloidosis and a new soft tissue mass to initiate suitable treatment in appropriate clinical settings.


Osteochondroma is a relatively common benign tumor of the bone, and compressive neuropathies due to osteochondroma are comparatively rare. Here, we present a rare case of osteochondroma of the fibular head that caused peroneal nerve palsy in an 8-year-old girl. Physical examination revealed 0/5 tibialis anterior, 1/5 extensor hallucis longus, and 1/5 peroneal brevis muscle power—according to the manual muscle testing grading system, as well as numbness on the lateral side of the right leg and the back of the foot. Radiological examination and ultrasound revealed a bone tumor in the head of the right fibula. Magnetic resonance imaging ruled out spinal nerve root compression. It was discovered that the bone tumor in the fibular head had compressed and displaced the common peroneal nerve. The patient underwent surgical decompression of the right peroneal nerve. A bone region measuring 22 × 14 × 8 mm was removed. Three months postoperatively, the preoperative neurological deficits were found to be nearly resolved. The patient presented with a foot drop for 1 year, but symptoms resolved 3 months after surgery. Conventional wisdom states that surgery should be performed within 3 months, but we recommend that surgery be performed as soon as diagnosis is made even in cases with a long history, as it may improve patient symptoms and outcomes. Osteochondroma is a relatively common benign tumor of the bone, accounting for 10–15% of all bone tumors . The preAn 8-year-old girl visited our hospital with complaints of difficulty in walking and gradual weakness of right foot dorsiflexion for 1 year. She reported no history of trauma or neurological disease.Neurological examination revealed 0/5 tibialis anterior, 1/5 extensor hallucis longus, and 1/5 peroneal brevis muscle power—according to the manual muscle testing grading system. And the patient had moderate sensory deficits in the anterolateral and dorsum of the foot and numbness of the lateral of the right leg and back of the foot. A Tinel-like sign was observed from the posterior part of the fibula head to the distal lower leg. X-ray and ultrasound detected an osteophyte protuberance in the fibular head . MagnetiThe patient underwent surgical decompression of the right CPN , which rThree months postoperatively, the preoperative neurological deficit was nearly resolved.The predisposition to CPN entrapment is thought to be due to anatomical causes . The nerCherrad et al. reported a case of peroneal nerve palsy caused by proximal fibular osteochondroma (PFO) and direct trauma of the left knee's lateral side that happened during a soccer match . There wCardelia et al. reported six patients diagnosed with PFO associated with peroneal nerve palsy . The patTherefore, while surgery should ideally be performed within three months of symptom onset, it should also be performed soon after diagnosis in cases with a long history for symptomatic improvement, and it is important to undergo rehabilitation immediately postoperatively. Shah et al. reported that postoperative physiotherapy can protect against muscle atrophy, prevent secondary muscle tightness, and preserve ankle mobility . We therWe diagnosed the patient based on the findings of clinical and imaging examinations. X-rays revealed the presence of osteochondroma in the fibular head. MRI can be useful for confirming edematous changes and inflammatory findings around the peroneal nerve. Ultrasounds may also prove useful for dynamic evaluation.


After being diagnosed with myasthenia gravis, a 55-year-old male was referred for treatment of an invasive thymoma. Preoperative imaging revealed a thymoma adjacent to the superior vena cava (SVC) with possible invasion of the left innominate vein. After multidisciplinary discussion, he underwent upfront en bloc resection of the tumor with SVC resection and reconstruction. He was discharged after an uncomplicated postoperative course with improvement of his symptoms. The association between myasthenia gravis (MG) and thymomas is well established, as mentclass2pt{minimA 55-year-old male initially presented to his primary care provider with diplopia and eyelid droop. He was diagnosed with MG via confirmation of positive acetylcholine receptor blocking antibodies. CT chest revealed a complex, multilobulated, 6 cm anterior mediastinal mass compressing the SVC and possibly involving the central aspect of the left innominate vein. A core Before resection, he underwent MG optimization with a 3-day treatment course with IVIG and was asymptomatic on the day of operation. After standard median sternotomy incision, the tumor was identified and noted to be firm, adherent to the sternal wall and right upper lobe of the lung. In addition, it wrapped 270° around the SVC and had invaded and obliterated the lumen of the left innominate vein. A Vein of Marshall, identified preoperatively on CT scan, was also identified at this time and appeared free from involvement and was providing outflow from the left upper extremity, thus this was left patent to allow for appropriate collateral circulation.The decision was made to place the patient on CPB when it was evident the tumor would not safely dissect off the SVC. Then, careful dissection was performed around the SVC and innominate vein. The SVC was resected proximally and distally to the tumor, as well as en bloc wedges resection of the right upper lobe of the lung . Frozen Postoperatively, the patient’s course was uncomplicated. Chest tubes were removed on postoperative day (POD) 2, epicardial pacing wires on POD 3 and he was discharged home on aspirin on POD 5. Final pathology confirmed Stage III thymoma, type B2 with one positive microscopic margin on the posterior SVC. Due to the R1 resection, the patient underwent adjuvant 60Gy radiation to the mediastinum and is recovering well. He currently remains with no evidence of disease recurrence.Once the diagnosis of MG has been established, it is common practice to obtain chest CT to screen for thymoma, given the increased incidence . When foIt is important to differentiate between invasive thymoma and thymic carcinoma, as the disease free and long-term survival are significantly different, and thus when feasible, biopsy is recommended . In caseIntraoperatively, this case also presented many challenges that are not typically encountered in thymoma resections. Given the adherence to the great vessels, dissection could not be performed safely without the use of CPB and cardioplegia. The lumen of the left innominate vein was completely obliterated; however, the patient remained asymptomatic preoperatively as he had venous return through collateral vessels, including a patent Vein of Marshall, which is typically seen in <3% of the population . FinallyThis case demonstrates that although upfront surgical resection for stage III thymomas may involve more invasive techniques, when performed at high volume centers with a multidisciplinary team, it can safely be performed with successful outcomes and can still be considered as an optimal first line treatment.None declared.None.