This report describes a clinical case of asymptomatic compound odontoma in the anterior left side of the maxilla associated with an impacted canine and supernumerary tooth with a gubernacular canal of a 47- year-old female with no relevant medical history. Cone-beam computed tomography (CBCT) was performed for precise three-dimensional localization of each structure and assessment of their spatial relationship with the associated structures before surgery. The treatment protocol involved surgical enucleation of the odontoma and open extraction of both impacted and supernumerary teeth. The patient had uneventful healing and proceeded with the prosthodontic treatment plan. The dentist should be aware of the probability of a close relationship between the development of odontoma and presence of the gubernacular tract, which could be used as a future radiographic diagnostic criterion of an odontoma. Also, we recommend that more studies be performed in this field to deeply analyze the imaging characteristics of GT and its spatial association with various pathological lesions in the future. Compound odontoma consists of a tumorlike malformation (hamartoma) with varying numbers of tooth-like elements (odontoids). The complex odontoma consists of a tumour-like malformation (hamartoma) in which the enamel and dentin, and sometimes cementum, are present3. Pathogenesis of odontoma is still unclear, although some etiologic factors have been suggested such as trauma during primary dentition, genetic factors, and chronic inflammation4. They are usually small, asymptomatic and discovered through radiographic examination when patients present with a missing permanent tooth6.Odontoma is defined as a benign odontogenic tumor containing enamel, dentin and cementum, and are classified by the World Health Organization into two main types: compound and complex7Odontomas may cause disturbances in the eruption of teeth such as impaction, delayed eruption, or retention of deciduous or permanent teeth, despite these critical disturbances only a few patients have been described8. Exceptionally, it can be associated with the supernumerary teeth or an odontoma1.An impacted tooth is one that fails to fully erupt into the dental arch within the usual range of expected time. The tooth becomes impacted because abnormal tooth orientation, adjacent teeth, dense overlying bone, excessive soft tissue, or a genetic abnormality prevents eruption11The gubernacular cord is a structure composed of conjunctive tissue that connects the tooth follicle to the overlying gingiva, this cord guides or directs the course of the tooth eruption. A canal is formed within the bone by the osteoblastic activity to contain the gubernacular cord which is named gubernacular canalWe present a case of an impacted upper canine with compound odontoma and a supernumerary tooth accompanied by gubernacular canal, where we utilized cone-beam computed tomography (CBCT) to locate each structure precisely prior to surgical treatment.A 47-year old female – of African origin - presented to the dental clinic to treat multiple carious teeth, and to replace multiple missing teeth. On Intraoral clinical examination, both the maxillary canines were missing as well as the third molars, and there was a bulge on the buccal cortex of the missing maxillary left canine, which was asymptomatic . The pat CBCT showed that tooth #23 was palatal impacted between teeth #21 and #22. There was a very small well defined rounded denticle like mass positioned distal to tooth #22 and coronal to the impacted supernumerary tooth (crown only), preventing its eruption. .The sagittal CBCT slice showed radiographic evidence of continuity of the follicular space of the supernumerary tooth along the bone up to its most inferior part at the alveolar ridge. This was determined to most likely be the gubernacular canal as it followed its possible eruption pathway through the bone. However, the denticle like structure was located inside this pathway and prevented the eruption of the supernumerary tooth. The most probable differential diagnosis would be a compound odontoma because of its denticle like density, organization, and coronal position.Intraoral surgery was planned under local anaesthesia, based on the clinical, radiographic findings and multidisciplinary consultation diagnosis of the radiopaque mass as a compound odontoma.Local infiltration of the area was performed, a full-thickness mucoperiosteal buccal flap was raised to expose both the mass and supernumerary tooth and soft tissue in between, a palatal flap was raised to expose the impacted canine. The cortical bone was removed utilizing rotary instruments accompanied by normal saline irrigation to minimize heat generation. The calcified mass was identified and ditched all around and then elevated with a Coupland elevator. The incompletely formed supernumerary tooth along with soft tissue attached to it was extracted using straight forceps, and for identification, the soft tissue was tagged with a black silk suture. By access from the palatal region, the impacted canine was sectioned horizontally and extracted , then thMacroscopically, the calcified mass measured 0.7 × 0.5 × 0.3 cm , while tHistopathologic examination of the excised mass showed a tooth-like structure with dentin, and some enamel matrix confirming the diagnosis of compound odontoma . Histolo14, as is the case in our findings.Odontoma is a benign tumour that is usually asymptomatic, diagnosed clinically through routine radiographic examinations, or when investigating other events such as the delayed eruption of permanent teeth, or ectopic position of teeth18 or/and cystic association19. Due to its rare recurrence, conservative surgical excision is the treatment of choice for odontomas20Odontomas are mostly located at the anterior maxilla and associated primarily with permanent teeth, although they can also be associated with deciduous teeth and also can be associated with some complications such as impacted teeth, as in the present case, maxillary sinus complications21. Occasionally, supernumerary teeth may be associated with some developmental syndromes like, cleidocranial dysostosis, Down’s syndrome, Apert syndrome and Gardener’s syndrome22Supernumerary teeth occur most frequently at the anterior midline, causing malposition of neighboring teeth or preventing their eruptionIn the present case, the supernumerary tooth was non-syndromic, incompletely formed, and it was extracted along with the impacted canine and odontoma.23. In the current case, we primarily detect the presence of impaction of a supernumerary tooth and odontoma through panoramic and periapical radiograph.Panoramic and periapical radiographs are conventional two-dimensional radiographic techniques which are widely available and are frequently used for multiple diagnostic purposes like detection of impaction, odontoma, bone loss and various intraosseous lesions. Nevertheless, these radiographs have various limitations in revealing the buccolingual relationship, and presence of superimposition, also having geometric inaccuracy24. In our case, we used CBCT for 3D localization of the odontoma, impacted canine and supernumerary tooth before surgical removal25.CBCT is an advanced 3D imaging modality that offers precise localization and detection of the spatial relationships of any dental structure with the surroundings, also it lessens the radiation dose in comparison with conventional CT and delivers high spatial resolution11. Oda M.et al.26 suggested that the presence of and contact with the gubernacular tract (GT) should be added as a characteristic CT finding of some types odontogenic masses including dentigerous cysts, calcifying odontogenic cysts (Gorlin Cyst), odontomas, Adenomatoid Odontogenic Tumor and perhaps others. Moreover, they concluded that dentists should pay more attention to the association between the GT and odontogenic masses27. Our case demonstrated an association between the GT and the odontoma where the odontoma was inside the GT of the supernumerary tooth with the same spatial relationship in agreement with Oda M.et al.26 which reports that the majority of odontoma cases (about 70%) detected with CBCT were inside the GT of the unerupted teeth  and the canal in tooth eruption is not clear, although it has been suggested that it may have a central role in inducing normal tooth eruption as it constitutes a pathway from the dental follicle to the gingiva for the eruption of permanent teethd teeth . Also, Oet al. 201128 stated that the Gubernacular cord may act as a source of epithelial remnants of the dental lamina which could be the basis of the development of some odontogenic tumors and/or cysts, Thus, the identification of imaging features of GT in CBCT may assist in the diagnosis of odontogenic cysts and tumors.Moreover, Ide Fet al.29 found that the continuity of the pathological lesion with the GT could be a characteristic differentiating imaging feature between some types of odontogenic and non-odontogenic tumors as this continuity was detected in CT of almost all of the odontogenic lesions (93.7%) in this study.Furthermore, odaet al. reported that the most communal attachment site of GC was to the occlusal side of the dental sac of the unerupted tooth (93.2%) and was classified as a usual attachment. These findings were in agreement with our case, where we also found the GT to be attached to the occlusal aspect of the dental sac of the supernumerary tooth27.This was in harmony with our study, where during surgery, it was apparent that the GT was contiguous with the supernumerary follicle, suggesting that the GT was guiding the eruption of the supernumerary tooth, but the development of the odontoma prevented its eruption. Gaêta-Araujo HThe dentist should be aware of the probability of a close relationship between the development of odontoma and presence of the gubernacular tract, which could be used as a future radiographic diagnostic criterion of an odontoma. Also, we recommend that more studies to be performed in this field to deeply analyze imaging characteristics of GT and its spatial association with various pathological lesions in the future.Written informed consent for publication of their clinical details and clinical images was obtained from the patient.All data underlying the results are available as part of the article and no additional source data are required. The revisions have addressed all posted queries, and the improved version is a good read.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Oral medicine and radiology.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. I thank the authors for their effort and for accepting suggestions to improve the article.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?PartlyIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?PartlyIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Oral Pathology, Histopathology, Oral MedicineI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. It is a clear, simple and interesting article, easily understood by the reader. The authors describe a rare case of an odontoma in the anterior left side of the maxilla associated with an impacted canine and supernumerary tooth with a governmental canal.a) The x-ray image is not clearly representative of a composite odontoma, it could also be a complex odontoma. Due to the aforementioned, I suggest that in the histopathological image 4a and 4b) the authors mark and mark each dental tissue that makes up the odontoma . In image 4c, the authors should put the following description: It is observed odontogenic epithelium arranged in islands and cords surrounded by mature connective tissue, suggesting the presence of epithelial lamina surrounded by collagenous. Please indicate the magnification of the image .1).b) The reviewer suggests (in the discussion section) to go deeper into the imaging of the gubernacular tract with CBCT and the presence of odontomas or odontogenic tumors, I suggest reading in this article: Chaudhry and Sobti (2020c) I believe that the conclusion paragraph that says "The dentist should also be aware of the probability of a close relationship between the development of odontoma and the presence of the governmental tract, which in future could be used as a radiographic diagnostic criterion of an odontoma" is very ambitious. I suggest that the authors clearly explain why they believe that it could become a radiographic criterion for an odontoma and/or not for another odontogenic tumor that has the presence of mineralized tissue.  There are some points that could improve the quality of the article:In the case report section, the authors describe the patient in the following way: "A 47-year old house wife - of African origin -" I think that this data is not important for the clinical case, I suggest describing only; "A 47-year old female ...". Minor points:Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?PartlyIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?PartlyIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Oral Pathology, Histopathology,Oral MedicineI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. a) The x-ray image is not clearly representative of a composite odontoma, it could also be a complex odontoma. Due to the aforementioned, I suggest that in the histopathological image 4a and 4b) the authors mark and mark each dental tissue that makes up the odontoma . In image 4c, the authors should put the following description: It is observed odontogenic epithelium arranged in islands and cords surrounded by mature connective tissue, suggesting the presence of epithelial lamina surrounded by collagenous. Please indicate the magnification of the image .Response a: thanks for your opinion, it was considered and added (changes were added to the newly submitted version of manuscript).b) The reviewer suggests (in the discussion section) to go deeper into the imaging of the gubernacular tract with CBCT and the presence of odontomas or odontogenic tumors, I suggest reading in this article: Chaudhry and Sobti (2021).Response b: Thanks for your recommendation and the suggested paper was very valuable.c) I believe that the conclusion paragraph that says "The dentist should also be aware of the probability of a close relationship between the development of odontoma and the presence of the governmental tract, which in future could be used as a radiographic diagnostic criterion of an odontoma" is very ambitious. I suggest that the authors clearly explain why they believe that it could become a radiographic criterion for an odontoma and/or not for another odontogenic tumor that has the presence of mineralized tissue. Response c: Thanks and a paragraph was added in the discussion to explain the role of GT in differentiating between odontogenic and non-odontogenic lesions based on previous studies.Minor points:In the case report section, the authors describe the patient in the following way: "A 47-year old housewife - of African origin -" I think that this data is not important for the clinical case, I suggest describing only; "A 47-year old female ...".Response for minor point: The recommendation was considered and changes were made, although it was a request by the editor. et al. fills this gap. Odontoma is a common clinical entity and is often spotted on dental radiographs taken to inspect missing permanent teeth. However, this report's merit lies in the CBCT demonstration of an odontoma within the 'gubernacular canal' (GC)-a finding less frequently spotted on radiographs. Although vital in tooth eruption, GC goes unnoticed in dental radiographs due to a lack of focus on this crucial anatomical landmark. As rightly suggested by few previous authors and the authors of this report, this typical association could aid the radiographic diagnosis of odontoma. Because odontomas are closely associated with GC, they cause delayed/failure of eruption of the underlying permanent tooth. Since many clinicians may still be unaware of some of these aspects, more technical reports are necessary for this direction. The current report by Lubna K. ElsayedHere are a few recommendations which could improve the manuscript:housewife – of African origin presented' can be modified as 'A 47-year old female – of African origin presented' The 'A 47-year old an otherwise healthy and non-syndromic patient,' can be added to the case history section. A brief discussion on the syndromes associated with odontomas and supernumerary teeth may be a valuable addition to this report. Supernumerary tooth and odontoma are also associated with syndromes. If the patient is non-syndromic, the phrase, 'early detection and management of odontomas can help correct any dental irregularity and avoid further complications" has been included. When odontomas are asymptomatic entities and discovered incidentally during radiographic surveys taken for evaluation of missing permanent teeth, how is early detection achievable? Consider adding some info regarding the same and mention which are the further complications. In the conclusion section, the sentence "Thus, Since the report mainly circles around GC, the conclusion paragraph could straightaway focus on the GC-odontoma connection. Consider avoiding conventional odontoma literature in conclusion. The below paragraph seems to be fitting:'The dentist should be aware of the probability of a close relationship between the development of odontoma and presence of the gubernacular tract, which could be used as a radiographic diagnostic criterion of an odontoma.' odontoma-GC literature and appropriate differential diagnosis.  The discussion section can also include a brief review of 'Association of the gubernacular canal, supernumerary tooth, and odontoma with an impacted canine on cone-beam computed tomography' seems fitting.  To avoid hype, the word 'unusual' can be removed from the title. The title Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Oral medicine and radiology.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Recommendation 1: The 'A 47-year old housewife – of African origin presented' can be modified as 'A 47-year old female – of African origin presented' Answer: Thanks for the recommendation and the change is accepted, although it was a request of the editor to mention “occupation”.Recommendation 2: Supernumerary tooth and odontoma are also associated with syndromes. If the patient is non-syndromic, the phrase, 'an otherwise healthy and non-syndromic patient,' can be added to the case history section. A brief discussion on the syndromes associated with odontomas and supernumerary teeth may be a valuable addition to this report.Answer: Thanks for your opinion, it was considered.Recommendation 3:  In the conclusion section, the sentence "Thus, early detection and management of odontomas can help correct any dental irregularity and avoid further complications" have been included. When odontomas are asymptomatic entities and discovered incidentally during radiographic surveys taken for evaluation of missing permanent teeth, how is early detection achievable? Consider adding some info regarding the same and mention which are the further complications.Answer: Thanks for the suggestion and further complications were added to the discussion sectionRecommendation 4: Since the report mainly circles around GC, the conclusion paragraph could straightaway focus on the GC-odontoma connection. Consider avoiding conventional odontoma literature in conclusion. Answer: Thanks for the valuable comment and the recommended phrase was added to the conclusion section.Recommendation 5:The discussion section can also include a brief review of odontoma-GC literature and appropriate differential diagnosis. Answer: Thanks for the comment and the suggestion was considered and added to the discussion section.Recommendation 6: To avoid hype, the word 'unusual' can be removed from the title. The title 'Association of the gubernacular canal, supernumerary tooth, and odontoma with an impacted canine on cone-beam computed tomography' seems fitting.  Answer: Thanks for the suggestion and it was considered. The introduction is well written. The methodology and approach to diagnosis was systematic and the discussion was fruitful. It would have been more fulfilling to provide more past literature about the case and to discuss how the gubernacular canal could affect differential diagnosis both radiographically and histologically. All in all I found it very interesting.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Oral and maxillofacial pathologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Thank you for your valuable comments and we appreciate your recommendations, and they were considered, a brief description about how the gubernacular canal could affect differential diagnosis both radiographically and histologically was added to the discussion section. Thank you for your valuable comments, and your recommendations were considered as we added more literature about similar cases and a discussion about how the gubernacular canal could affect differential diagnosis both radiographically and histologically was added in the discussion section.


To report surgical management of ocular complications occurred after dexamethasone (DEX) implant (Ozurdex®) injection.  Retrospective interventional case series.  Different surgical procedures including viscoexpression to manage the migration of the implant into the anterior chamber, “phaco-rolling” technique for the intralenticular injection, and vitrectomy with implant removal for an acute endophthalmitis were performed. Successful management of different complications after DEX implant by using individualized surgical approaches was observed.  Early and targeted surgical management is required in selected cases of ocular complications after DEX implant. The implant removal was needed to preserve ocular anatomy and function. The Ozurdex®  is a 700 mcg dexamethasone (DEX) biodegradable ocular implant, formulated in a solid polymer drug delivery system, designed to be injected into the vitreous using a 22-gauge applicator device. It is used to treat macular oedema (ME) related to diabetic retinopathy, noninfectious uveitis, and retinal vein occlusion . Major cThis retrospective interventional case series was conducted in the Eye Clinic of University of Bari, Bari, Italy. A total of 1066 cases underwent DEX implant between October 2015 and October 2018 were reviewed. Implant was performed to treat ME secondary to Irvine-Gass syndrome, central or branch retinal vein occlusion, noninfectious uveitis, and diabetic retinopathy. Mayor ocular complications occurred in only four eyes . We identified two patients who experienced the migration of the implant into the anterior chamber, one patient with intralenticular implant and one patient with acute endophthalmitis. Patient's age ranged from 60 to 81 years. All these patients underwent a comprehensive ophthalmic examination that included best-corrected visual acuity (BCVA) measurement, slit-lamp examination, intraocular pressure (IOP) measurement, spectral domain optical coherence tomography (SD-OCT), and fundus examination. Ocular ultrasonography was performed when ocular fundus cannot be examined by ophthalmoscopy. We reported targeted surgical management of three patients that experienced ocular complications after DEX implant. The study adhered to the Tenets of the Declaration of Helsinki.An 81-year-old Caucasian woman underwent a complicated cataract surgery with posterior capsule rupture and sulcus intraocular lens (IOL) implantation. Three months after surgery, a central retinal vein occlusion with ME occurred in the same eye and five consecutive intravitreal injection of anti-Vascular Endothelial Growth Factor (VEGF) were delivered monthly. Due to a poor therapeutic response, she was planned to perform an intravitreal DEX implant. Three weeks following the implant, she complained decreased vision. Visual acuity was limited to 20/200, and IOP was 25 mmHg. We found implant migration into the anterior chamber, and corneal oedema and Descemet's membrane folds were observed . After tA 67-year-old diabetic Caucasian man underwent DEX implant to treat diabetic ME, as the first treatment. At 1-week follow-up, we observed DEX rod impeded into the lens. BCVA was 20/200. IOP was 30 mmHg unresponsive to topical therapy. After the informed consent was obtained, phacoemulsification was performed. The nucleus and the implant were removed using a variation of “phaco-rolling” technique firstly described by Güell et al. . A tempoA 60-year-old male patient underwent combined phacoemulsification with in-the-bag hydrophilic acrylic IOL implantation followed by DEX implant for cataract and diabetic ME in the left eye. Five days after surgery, the patient complained pain, redness, and vision loss in the treated eye. Visual acuity was limited to light perception. Slit-lamp examination revealed ciliary injection and 2+ anterior chamber cells. The retinal reflex was poor. B-scan ultrasonography showed high iperecogenous echi with mobile membranes in the vitreous chamber . The diaIn a retrospective review of 924 DEX implantations performed, Kang et al. reported four cases of anterior chamber migration in the presence of a compromised posterior capsule,  as we obVarious procedures to remove the implant from anterior chamber such as the aspiration of the disintegrated implant, the use of forceps, viscoelastic material, or IOL injector when the implant is still stiff were reported –8. We pe


Desmoplastic fibroma of the bone (DFB) is a notably rare, lytic, locally aggressive but nonmetastatic, primary benign bone tumor in patients less than 30 years old. As the recommended primary treatment for DFB, wide resection is preferred to curettage from the perspective of recurrence but wide resection of DFB in the pelvis such as in the acetabulum could result in greater functional loss, suggesting the need for conservative treatments. However, there is no report on long-term follow-up following conservative treatment for DFB. The present case involved a 21-year-old woman with right hip pain. Radiological evaluation revealed a massive lesion throughout the right ilium and acetabulum with partial osteolysis, cortical destruction, marginal sclerosis, slight pseudotrabeculation, and bone expansion. Open biopsy from the ilium showed the proliferation of spindle cells in an abundant collagenous matrix without atypia and mitosis, suggesting a diagnosis of DFB. Conservative treatment was selected considering the risk of greater functional loss following wide ilium resection. An evaluation 10 years after follow-up showed a partially sclerotic lesion of the ilium and the absence of pain. The current case demonstrates that conservative therapy may be effective even in some cases of aggressive DFB. Desmoplastic fibroma of the bone (DFB) is a notably rare, lytic, locally aggressive but nonmetastatic primary bone tumor. This tumor currently accounts for 0.06% of all bone tumors and 0.3% of benign bone tumors . It occuA 21-year-old female patient presented to our orthopedic outpatient department with right hip pain. She had no history of preceding episodes of trauma or intense exercise. Her medical history was unremarkable. On physical examination, although the hip range of motion was normal, right hip pain occurred under loading. Blood laboratory findings were within normal limits. Radiography and computed tomography (CT) showed an osteolytic lesion of the right ilium and acetabulum with cortical destruction, marginal sclerosis, slight pseudotrabeculation, and bone expansion Figures . MagnetiDFB is a benign, locally invasive bone tumor, initially described by Jaffe in 1958 . The lonRadiographically, DFB has been described as an osteolytic lesion with cortical bone destruction, marginal sclerosis, and pseudotrabeculation. On MRI, the lesion shows low-signal intensity on T1-weighted images with signal enhancement after contrast administration . In the Histologically, DFB is composed of spindle cells with minimal cytological atypia and abundant collagen production, which is similar to a soft tissue desmoid tumor . ImmunohTreatment strategies for desmoplastic fibroma vary but may include curettage, wide resection with or without an allograft, cryosurgery, and amputation in recurrent cases. Böhm et al. analyzed 191 cases of DFB and reported that recurrence rates following curettage, excision, and wide resection were 55%, 72%, and 17%, respectively . ConsequThere are 107 published cases of DFB in the English literature . Of these, 9 report follow-up for over 10 years . Table. In conclusion, the present report described a 10-year follow-up for massive DFB of the ilium successfully treated without surgery.


Lipomas in fingers are rare and account for less than 1% of all cases. As a type of lipoma, the spindle cell lipoma is exceptional and it presents 1.5% of total adipocyte tumors. Moreover, its localization in the thumb is extremely rare. Only three cases have already been reported in adults; our case constitutes the fourth case, which is about a 61-year-old female who presented since 18 months a mass on the ulnar lateral aspect of the thumb. After clinical and radiological assessments, an entire excisional biopsy of the mass was performed. The histopathological analysis confirmed the spindle cell lipoma of the thumb. At the last follow-up of two years, the patient did well with no recurrence and no restricted motion of the thumb. So, although lipomas of the digit are rare, they should be considered a possible etiology of either painful or mechanic restricted motion of the digit. Lipomas account for approximately 16% of soft tissue mesenchymal tumors. However, they are rare in the hand and extremely rare in fingers that account for less than 1% of all cases . The indA 61-year-old female, maid, with no disease history, presented, since 18 months, a painless mass in the right thumb which increased slowly. The patient did not consult since it is not painful and does not bother her during physical activity. However, for the last two months, the mass started to bother her in her daily activities and it became a protruding mass; she consulted our orthopedic department. On admission, she was at good general health with no weight loss. At this visit, she reported a trauma history of the thumb two years ago. The clinical examination found a prominent mobile mass on the ulnar lateral aspect of the thumb with neither inflammatory changes nor a palpable pulse . PassiveThe lipomas of the digit are rare. Furthermore, as a type of lipomas, the spindle cell lipoma is a rare tumor that is reported for the first time by Enzinger and Harvey in 1975 . Its locHowever, patients are often uncomfortable with the limitation of mobility once they reach a significant size  as in ouAlthough lipomas of the digit are rare, they should always be kept in the list of the etiology of either painful or mechanic restricted motion of the digit. Besides, the spindle cell lipoma should be differentiated from the well-differentiated sclerosing liposarcoma and the spindle cell liposarcoma.


Microwave ablation (MWA) has become a popular therapeutic technique in hepatocellular carcinoma (HCC) alongside cryoablation, radiofrequency ablation, and liver resection/transplantation in patients with limited tumor burden. Generally well tolerated, and not as invasive as surgery, the technique results in low mortality and complication rates. We report the exceedingly rare complication of hepatic artery thrombosis with subsequent fatal ischemia of the left hepatic lobe in a 64-year-old female with cirrhosis and HCC who underwent MWA.  Microwave ablation (MWA) has become a popular therapeutic technique alongside cryoablation and radiofrequency ablation in patients with limited tumor burden hepatocellular carcinoma (HCC). The non-surgical technique benefits from good patient tolerability and low rates of serious complications. We describe the case of a 64-year-old female with compensated cirrhosis and HCC who, after receiving MWA to liver segment IV, experienced a very rare and fatal complication: left lobar hepatic ischemia secondary to hepatic artery thrombosis.A 64-year-old female presented to the hospital with the chief complaint of right upper quadrant pain, multiple episodes of non-bilious emesis, and anorexia since undergoing a computer tomography (CT)-guided microwave ablation of an HCC tumor in liver segment IV the day before. The patient’s past medical history was significant for untreated hepatitis C, compensated liver cirrhosis, and HCC stage IA diagnosed in 2017 with a single lesion measuring 1.5 x 2.0 cm in diameter. At the time of presentation, the patient was hypotensive to 81/52 mmHg and tachycardia to 118 beats per minute. Physical examination was significant for scleral icterus, abdominal distension, right upper quadrant tenderness and hypoactive bowel sounds. Laboratory studies demonstrated an aspartate aminotransferase of 2,467 U/L, an alanine aminotransferase of 688 U/L, an alkaline phosphatase of 355 U/L, a total bilirubin of 4.5 mg/dL, and an international normalized ratio of 1.1. CT angiogram of the abdomen revealed thrombosis of left branch of the hepatic artery with hepatic infarct This work has been presented as a poster at the Annual Scientific Meeting of the American College of Gastroenterology, Philadelphia, PA, October 7, 2018 (Aujla AK, Shah N, Sharma T, Swales C. P0647-Hepatic Artery Thrombosis: A Rare Complication of Microwave Ablation in Hepatocellular Carcinoma, Although MWA is generally regarded as a safe procedure, it is important to not only know and understand its common complications, but also the potentially life threatening hepatic segment dependent ones. While post procedural thrombosis of the portal vein and narrow lumen, low flow hepatic vessels has been well documented with MWA therapy, on very rare occasions, larger, high flow vessels such as the hepatic arteries may also become involved with catastrophic consequences.


Adrenocortical oncocytomas are rare and mostly nonfunctioning neoplasms. We report the case of a 27-year-old woman diagnosed with an ACTH-independent Cushing's syndrome due to left adrenal oncocytoma. She underwent laparoscopic adrenalectomy. Histopathological examination revealed an oncocytoma of uncertain malignant potential with a low Ki-67 proliferation index, inhibin A positivity, and chromogranin A negativity. Electron micrographs confirmed adrenal oncocytoma cells, characterized by the presence of a large amount of mitochondria. The postoperative course was uneventful, and the patient experienced a progressive regression of Cushing-related symptoms. Periodical follow-ups with MRI and cortisol dosage are required due to the neoplasm's uncertain malignant potential. Considerations on the diagnosis, pathology findings, clinical remarks, and interventions are made. Adrenocortical oncocytic neoplasms (ACONs) are an epithelial subtype of adrenal tumours, firstly reported by Kakimoto et al. in 1986 , 3. The μg/dL. Hormonal test results are summarized in Tables A 27-year-old Caucasian woman was referred to our Emergency Department due to the acute onset of severe hypertension 190/110). She reported one year of insomnia caused by recurring sleep hyperhidrosis. Apart from that, she had neither relevant medical history nor any previous surgical history. She was a regular cigarette smoker, with a body mass index of 21, who followed a vegan diet. Physical examination revealed a full-moon face, a mild buffalo hump, and a light hypotrophy of proximal limb muscles. In addition, dermatologic signs showed thin skin with the tendency to bruise, purple striae, thickened hair, and facial seborrheic dermatitis. There were no signs of virilisation nor did she report menstrual irregularities. Initially, hormonal studies showed a slightly elevated basal cortisol level ; however, D4-androstenedione, progesterone, aldosterone, testosterone, and adrenaline urinary catabolites levels were normal. After performing an overnight suppression test with 1 mg of dexamethasone, basal serum cortisol was increased to 19.90 90/110. SThe surgical specimen underwent histopathological examination: it consisted of adipose tissue containing a tan-brown neoplasm, with regular and smooth margins, of 2.7 × 2 cm in size, largely replacing the normal adrenal gland parenchyma . MicroscPostoperatively, the patient began glucocorticoid and mineralocorticoid replacement therapies with cortisone 21-acetate 18, 75 mg per day, which were gradually tapered. One month after surgery, the patient had already experienced a progressive regression of Cushing-related symptoms and a relative normalization of blood pressure levels, as confirmed by a blood pressure Holter. She was advised to undergo quarterly ACTH cortisol dosage and referred for follow-up to our oncological team.ACONs are a rare epithelial subtype of adrenal tumours firstly reported by Kakimoto in 1986 , 8.While renal oncocytomas have radiological features suggesting preoperative diagnosis, such as the central scarring, the same is not true for adrenal oncocytomas. Benign adrenal oncocytomas may be distinguished from lipid-rich adenomas on CT scan due to the fact that the latter show low attenuation on CT scan (<10 Hounsfield-HU), whereas the malignant oncocytic neoplasm can demonstrate features similar to adrenocortical carcinomas (ACCs), including larger size, internal necrosis, and lower percentage enhancement washout [An ultrasound-guided biopsy is safe but rarely performed as it is frequently inconclusive and is difficult to use for the discrimination between kidney-originated tumours and adrenal tumours , 12. IndIn the last edition of the WHO classification of endocrine neoplasms, the LWB-specific criteria was reported in order to classify ACONs as malignant when at least one major criterion was present, such as a high mitotic rate (>5 mitoses per 50 high-power fields), atypical mitoses, and venous invasion. ACONs of uncertain malignant potential are classified as such in the presence at least one of the minor criteria: large size (more than 10 cm), necrosis, and capsular and sinusoidal invasion , 13, 14.ACONs preferably arise from the left gland, with an M/F ratio of 1 : 2 and an average age of 44. The ACON reported retains an uncertain malignant potential since the capsule was focally infiltrated, but it was certainly a smaller lesion (2.7 × 2 cm) when compared to the average size of 10 cm for the commonly found borderline ACONs.Prognostic factors still need to be validated because of the low number of patients reported in literature. However, males appear to be more frequently associated with malignant ACONs, whereas younger patients are more commonly affected by smaller benign ACONs compared to borderline and malignant ones .Currently, ACONs of uncertain malignant potential appear to have an 88% probability of a 5-year survival rate, with only two recurrences reported in literature out of 57 cases. Although malignant potential is classified by the LWB criteria, there are still no formal guidelines regulating the follow-up. Surely, borderline and malignant ACONs should undergo periodic MRI/CT scan. Ipsilateral adrenalectomy is usually indicated for the uncertain nature of the mass and to resolve the concomitant symptomatology. Laparoscopy seems to achieve similar rates of R0 resection of open surgery for ENSAT I and II ACC and for masses smaller than 10 cm. Laparoscopic adrenalectomy is feasible, safe, and offers all the advantages of the minimally invasive surgical technique –19.Functioning and cortisol-secreting ACONs are very rare entities, but they can certainly be responsible of ACTH-independent Cushing's syndrome. Surgical excision is indicated, and the laparoscopic approach appears to be feasible and safe in most instances. Since borderline ACONs are of uncertain malignant potential, a proper follow-up is warranted.


A 15-year-old adolescent girl presented with well-tolerated large volume hematemesis. She had no significant illnesses in the past. On examination, she had pallor and splenomegaly . There was no jaundice. She underwent an ultrasound doppler that suggested extrahepatic portal vein obstruction. After stabilization, she underwent a gastroscopy, which showed large esophageal varices with a “white-nipple” sign indicative of recent bleeding. Endoscopic variceal ligation was performed. On further endoscopic evaluation, 3 small (∼3–5 mm) sessile polyps were seen in the second part of the duodenum Figure . Snare p1 PHPs have been mainly described in the stomach and less commonly elsewhere in the gastrointestinal tract. Duodenal involvement is uncommon, with a prevalence of 0.2%–0.8% in cirrhotic adults.2 To the best of our knowledge, there is only 1 previous report of PHPs in children.3 Devadson et al reported multiple duodenal PHPs (similar to our case) in 3 children with extrahepatic portal vein obstruction.PHPs have been described in individuals with portal hypertension, adding on to the list of other gastrointestinal abnormalities such as gastropathy, antral vascular ectasia, enteropathy, colopathy, and others that have been described earlier. They have been reported in 1%–2.5% of adults undergoing upper gastrointestinal endoscopy for portal hypertension.5 It has been postulated that polyps develop because of neovascularization secondary to high portal pressure. Factors such as long-term proton pump inhibitor use, Helicobacter pylori infection, presence of multiple congenital anomalies, and endoscopic treatment for portal hypertension at an early age have been implicated in its pathogenesis, none of which were present in our child.3There are no diagnostic criteria for PHPs, but the presence of proliferating capillaries in the lamina propria indicates their portal hypertensive nature. The clinical significance of these polyps is unclear. They are mostly asymptomatic and have been suggested to be responsible for gastrointestinal bleeding, although there is insufficient data to definitely implicate them.3 Whether they have a malignant potential is also unknown, but the fact that there is no increased risk of gastrointestinal cancers in patients with portal hypertension is reassuring and makes it unlikely. We believe that until we have more data about their relevance, simple watchful observation would suffice in such children. To conclude, we report an unusual gastrointestinal manifestation of portal hypertension in a child. Whether they are uncommon or have simply been underappreciated in children is a matter of speculation.It is not clear what happens during the follow-ups. In the report by Devadson et al, the findings persisted during the 6 years of follow-up.Author contributions: S. Naseerudin wrote the manuscript and approved the final manuscript. R. Bolia revised the manuscript for intellectual content, approved the final manuscript, and is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.


The critical biomechanical importance of talus and nonspecific clinical features of talus lesion warrants a meticulous diagnostic work-up for specific management, particularly when the talus lesion is associated with concomitant soft tissue and joint abnormalities. We present a rare case of osteoblastoma of talus with concomitant tenosynovitis of tibialis anterior, ankle joint effusion, varicose vein and moderate distal arterial stenosis. Bone tumors of the foot comprise of approximately 3% of all osseous tumors. Osseous tumors of talus have been reported to be between 8% to 23% of tumoors in the foot . The comA 45-year-old male patient presented to the orthopedics OPD with long standing painful swelling of the right ankle since 2 years. There was history of claudication in the right lower limb. There was no history of trauma or any other constitutional symptoms. The patient was a non-smoker and a teacher by profession. On clinical examination, there was diffused tenderness over right ankle and pain increased on passive dorsiflexion and plantar flexion of the foot. On visual analog scale, patient had a score of 8 on presentation. There was a bony hard swelling over the anterolateral aspect of ankle  with varicosities over the lateral aspect of leg. The patient had already taken multiple sclerosant injection for varicose veins. The hematological parameters were normal. Anteroposterior and lateral radiographs of the right ankle demonstrated an exophytic osseous lytic lesion with sclerotic margin and small foci of calcified matrix Figure .The zone of transition was normal Figure .Based on the radiographs, we had a differential diagnosis of osteoblastoma, chondroblastoma, and osteochondroma. To know the nature and extension of this lesion, an MRI was done which demonstrated tenosynovitis of tibialis anterior tendon, ankle joint effusion with an exophytic osseous lesion in talus and perilesional marrow edema Figures -3D. Further a Bone scan was planned which showed increased focal uptake in right talus. As patient also complained of claudication, a right lower limb arterial doppler was done, which demonstrated moderate stenotic changes in the distal anterior tibial artery and dorsalis pedis artery. To know the nature of tenosynovitis and ankle joint effusion, aspiration of ankle joint fluid was done which revealed serosanguinous fluid and was reported to be sterile. Synovial biopsy demonstrated only fibrocollagenous cells. A CT-guided biopsy of the talus mass confirmed the diagnosis of osteoblastoma Figure .Surgical removal of the tumor was performed in supine position with a pneumatic tourniquet over the ipsilateral thigh. After preparation, sterile painting and draping, anterolateral approach to talus was used. Thorough soft tissue dissection was done and talus was exposed. An anterolateral exophytic growth was seen over the head of talus which was soft to probe as compared with the normal bone. No cortical collapse or fracture was seen. Tumor excision was done using a power burr and osteotome. Thorough extended curettage of the remaining lesion was done using a burr and hydrogen peroxide to achieve negative tumor margins. The cavity was irrigated with normal saline and packed with ipsilateral iliac crest bone graft. Closure of the wound was done and compression bandage applied. Post operatively, ankle was immobilized using a below knee posterior splint with ankle in neutral position for 6 weeks. Post-operative radiograph showed removal of the tumor with bone graft in the cavity Figure .Osteoblastoma is a rare benign tumor which forms an osteoid matrix, and accounts for less than one percent of all bone tumors . It is pTalar osteoblastomas usually present with chronic ankle pain, which is a localized, dull aching, and usually not nocturnal. Due to absence of response to salicylates, talus osteoblastoma may be wrongly diagnosed as ankle sprain . BeytemuTemple et al. used plain radiographs, CT, MRI and a technitium bone scan to diagnose osteoblastoma . HoweverTreatment options for osteoblastoma talus include open intralesional curettage with or without bone grafting, arthroscopic removal of the lesion and percutaneous radiofrequency ablation . ItokazuIn our case, the patient had osteoblastoma of talus, the presentation of which was masked by pain due to tenosynovitis and varicose veins. Thus a multidisciplinary approach was required to hit the bull’s eye and appropriate treatment was started only after a thorough diagnostic workup.Osteoblastoma of the talus is a rare benign tumour occurring mainly in the second decade of life and presents with nonspecific clinical features around talus. It warrants a meticulous multidisciplinary diagnostic work-up for specific management, particularly when the talus lesion is associated with concomitant soft tissue and joint abnormalities.


Circumcision is one of the most common pediatric surgical procedures performed all over the world and especially in Arab and Islamic countries. Many complications have been documented following this maneuver. We report on a rare case of intraperitoneal bladder rupture in a 7-day-old baby who was circumcised on his second day using the guillotine method. He presented to us with gangrene of the tip of the penis and a failure to void urine associated with progressive abdominal distension. Ultrasound revealed severe ascites. Aspiration and analysis confirmed the fluid to be urine. Ascending cystourethrogram was performed revealing a perforation of the posterior bladder wall near the trigone. Exploration was performed and repair done. Postoperative course was uneventful. Male circumcision is one of the commonest surgical procedures practiced in children worldwide. According to several studies, almost a third of the world male population is circumcised.Our patient presented to our emergency department on the seventh day of life with severe abdominal distension and vomiting. A thorough history revealed that the baby was circumcised on the second day of life following an uncomplicated cesarian section delivery. The exact mode of circumcision was unknown to the parents. After this the baby was found to be fussy and constantly crying and was no longer tolerating his feeds. He then started to become lethargic and show progressive abdominal distension. The baby was transferred to a neonatal unit with a provisional diagnosis of neonatal sepsis. Three days later he was referred to our center to assess and manage his ongoing abdominal distension.3.General examination revealed an elevated temperature of 38°C, pulse of 155, and a blood pressure of 70/38. The abdomen was diffusely enlarged with prominent dilated veins, a large protuberant umbilical hernia, and mild erythema. There was no tenderness on palpation. It was dull all over on percussion with the evidence of a transmitted thrill. The baby was passing stool normally and there were no bilious aspirates when an nasogastric tube was placed. Careful examination of the site of circumcision revealed that the glans penis was ischemic with signs of inflammation at the shaft . LaboraThe baby was immediately admitted and resuscitation was performed. An abdominal X-ray failed to show any free air in the abdomen and a concomitant abdominal ultrasound showed marked free fluid with internal echoes and bilateral moderate hydronephrosis. A provisional diagnosis of intraperitoneal bladder rupture was made based on this data and a conservative approach was decided. An abdominal drain was placed in the operating room under general anesthesia yielding >500ccs of yellowish turbid fluid. A urinary catheter was placed to drain the bladder; however, catheterization was difficult due to involvement of the distal part of the penile urethra.The baby remained under conservation for 2 days after which a retrograde cystogram was performed through the catheter revealing leakage of contrast from the bladder near the trigone into the peritoneum . An opeTwo pathological perforations were appreciated near the trigone between the ureteric orifices. These were debrided and closed in two layers with 4/0 polygalactine suture. The bladder was then closed over a suprapubic self-retaining catheter. An abdominal toilet was done, a drain was placed, and the incision was closed. A clear line of demarcation was visible at the time of surgery between the gangrenous and healthy penile tissue as almost a week had passed since the initial injury. This prompted us to perform debridement of the dead tissue to avoid sending the patient for a second general anesthetic.The baby was transferred to the surgical neonatal intensive care unit where he remained on broad-spectrum antibiotics for 3 days. Oral feeds were commenced on day 2. On day 5 postoperatively, a contrast study was done through the suprapubic catheter revealing absence of any leakage. The suprapubic catheter was then clamped. When the baby was voiding normally the catheter was removed. The baby was discharged on the seventh postoperative day.Neonatal bladder rupture is a rare problem that has been reported secondary to several different pathologies. The most common of these is urinary tract obstruction due to a posterior urethral valve or anterior urethral valve.In our patient, the situation was a little different. The circumcision was performed by a traditional practitioner employing mostly a bone cutter. Our hypothesis is that the distal end of the glans had become caught in the device causing a crush injury to it and the most distal part of the urethra and this wasn't managed correctly unfortunately. This caused an acute urinary retention that was missed on initial examination and ultimately led to pressure build up and bladder rupture.Our initial management was conservative through catheterization of the bladder per urethra and drainage of the urinary ascites after proper patient resuscitation. The decision was made for exploration due to a worsening general condition and the retrograde cytogram that demonstrated an intraperitoneal leak. Both modalities of treatment have been proposed to manage intraperitoneal bladder rupture; however, the inclination is usually toward a formal surgical repair especially when there is a deterioration of the patient's general condition. Our management was in accordance with published guidelines from the consensus on genitourinary trauma which underlined that neonatal bladder trauma usually requires surgical management.Most authors report that an open approach but some have advocated for a laparoscopic approach to repair bladder ruptures.Long-term monitoring of patients where suturing in done near the trigone is vital as such patients are at a higher risk of long-term bladder dysfunction.Neonatal circumcision remains a controversial subject to this day. Many studies have been designed to assess the advantages and disadvantages of this practice. Recently the role of neonatal male circumcision in the reduction in the risk of UTIs has been emphasized.However, this statement isn't supported by many. The relationship between circumcision and the development of UTIs according to several authors is only established in those with a predisposition to the condition such as those boys with PUJ (pelviureteric junction) obstruction, high-grade vesicoureteral reflux, and hydronephrosis.It is our message that although circumcision is performed routinely in many cultures, it can still lead to catastrophic and life-threatening problems adding a considerable cost to the already taxed health services especially in low- and middle-income countries. It cannot be stressed enough that this should only be performed by a trained professional under safe, sterile circumstances and where a proper follow-up can be provided to detect and manage any complications as early as possible should they occur.


The incidence of the iatrogenic foreign body retained after surgery is extremely low. Iatrogenic foreign body retained is surrounded by normal tissue, which responds to foreign matter to form inflammatory pseudotumors. Surgical sponge or swap is the most common type of foreign body. There were no reports of medical sutures remaining as foreign bodies in the lung parenchyma to form inflammatory pseudotumors.A CT scan of a 50-year-old female showed an irregular soft tissue mass in the left upper lobe with rough edge and spiculation. After 20 months, the size increased from 2.8 × 1.9 cm to 3.2 × 2.2 cm. The patient underwent a ventricular septal repair surgery for congenital Fallot tetralogy 35 years ago and a left breast surgery for breast cancer. She had a family history of lung cancer. Evaluation of this mass highly suggested a lung malignant lesion. The patient underwent video-assisted thoracoscopic surgery (VATS) lobectomy and her pathology revealed an intrapulmonary inflammatory pseudotumor caused by a medical prolene suture. Based on her medical history and other reports of iatrogenic foreign bodies, we believe that this suture retained from the heart surgery 35 years ago entered the pulmonary artery, moved to the distal branch, and eventually formed an inflammatory pseudotumor in the lung parenchyma. Here we reported and analyze this rare case.We reported a rare case of inflammatory pseudotumor in the lung parenchyma caused by a medical suture, and determined it was a prolene suture retained in the body during a cardiac surgery 35 years ago. Diagnosis of this rare disease required sufficient imaging experience. Besides, appropriate surgical exploration can help with the diagnosis and treatment. The iatrogenic foreign body retained after surgery is a serious medical fault, and its incidence is extremely low under the current strict and standardized medical procedures. Iatrogenic foreign body retained is surrounded by normal tissue, which responds to foreign matter to form inflammatory pseudotumors. Surgical sponge or swap is the most common type of foreign body. There were no reports of medical sutures remaining as foreign bodies in the lung parenchyma to form inflammatory pseudotumors.A 50-year-old woman presented with a lesion in the left lung for 20 months on routine examination. Computed tomography (CT) at a local hospital showed that there was an irregular mass in the upper lobe of her left lung, about 2.8 × 1.9 cm in size, with a clear boundary, peripheral spiculation, and stretched adjacent pleura. The patient had no symptoms such as cough, sputum, dyspnea, fever, and hemoptysis. One month ago, she underwent surgery for the left breast cancer in the local hospital. A second chest CT showed no significant changes in the mass. Positron emission tomography-CT (PET-CT) revealed an irregular high-density mass in the left lung with increased fluorodeoxyglucose (FDG) uptake, no significant abnormal FDG metabolism in the rest of the body, multiple small lymph nodes in the left axilla, and slightly increased FDG uptake in some lymph nodes.For further treatment, the patient was admitted to our department. There was no obvious abnormality on physical examination. The chest CT showed an irregular soft tissue mass in the anterior segment of the upper lobe of the left lung, and the border was not clear. The cross-sectional area was about 3.2 × 2.2 cm, and the spiculation sign could be seen. The plain CT value was 30 HU. Calcification of the patch was obvious after enhanced scanning, and the CT value was 98 HU. The mediastinal structure was clear, and no obvious enlarged lymph nodes were seen Fig. . There wAccording to the patient’s medical history and imaging findings, this mass was highly suspected to be malignant. The patient underwent video-assisted thoracic surgery (VATS) instantly without preoperative CT-guided percutaneous needle lung biopsy. The intraoperative palpation of the lesion suggested that the lesion was too close to the hilum to receive limited resection. So we performed the lobectomy of left upper lobe directly. The procedure was successful and the mass was completely removed.The dissected mass was gray-yellow, and a blue medical suture was visible inside Fig. . The surThe patient recovered well and discharged on the 3rd day after operation. Follow-up after 3 months showed no special abnormalities.In this case, the surgical specimen showed a mass of medical sutures and inflammatory changes in the surrounding lung tissue. The pathological diagnosis was inflammatory pseudotumor caused by iatrogenic foreign body. It is recognized by surgeons that this suture is a blue prolene suture, 2–0 size, which is often used in cardiovascular surgery. According to the patient’s history of ventricular septal repair surgery, we fully believe that this iatrogenic foreign body is a medical suture left over from the cardiac surgery performed 35 years ago, and eventually formed an inflammatory pseudotumor in the lung parenchyma.It is very rare for medical sutures to remain in the lung parenchyma as iatrogenic foreign bodies. Cases of medical foreign bodies such as medical guidewires, catheter fragments, embolization coils, and venous filters remaining and moving in large blood vessels have been reported . TherefoA retrospective survey showed that of the 191,168 operations performed in Mayo Clinic, Rochester (MCR) from 2003 to 2006, 34 cases of retained iatrogenic foreign bodies occurred (0.178 / 1000). Items retained included 23sponges (68%), 7 miscellaneous items (20%), 3 needles (9%), and 1 instrument (3%) [According to a systematic literature review of 254 case studies, gossypiboma occurs mainly in the abdomen (56%), followed by pelvis (18%) and thorax (11%) [Iatrogenic inflammatory pseudotumors mainly manifest as solid tumors with smooth borders , 5. The We report a rare case of inflammatory pseudotumor in the lung parenchyma caused by a medical suture. Based on the patient’s medical history, imaging data, and specimen, we determined that this suture was a prolene suture left in the body during a cardiac surgery performed 35 years ago. Detailed history tracing and accumulation of imaging identification are helpful in the clinical diagnosis of an iatrogenic inflammatory pseudotumor. Once it occurs, appropriate surgical exploration can help with the diagnosis and treatment.


Cogan’s anterior internuclear ophthalmoplegia (INO) is characterized by INO with inability to converge and commonly thought to be due to rostral midbrain lesion. A lesion outside midbrain that causes unilateral Cogan’s anterior INO combined with upgaze palsy and ataxia are rarely described.A 67-year old male presented with left Cogan’s anterior internuclear ophthalmoplegia (INO), left appendicular ataxia and bilateral upgaze palsy. A Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) brain showed a left dorsal tegmental infarct at the level of pontomesencephalic junction.This case highlights the clinical importance of Cogan’s anterior INO in combination with upgaze palsy and ataxia, and report possible site of lesion in patients with such constellation. Clinicians should consider looking for cerebellar signs in cases of Cogan’s anterior INO, apart from just considering localizing the lesion at the midbrain. Internuclear ophthalmoplegia (INO) is a discrete localizing sign which narrows down the lesion involving medial longitudinal fasciculus (MLF) anywhere at the paramedian tegmentum from caudal pons to midbrain . The MLFINO combined with ataxia has rarely been described. Most literature reported that the lesions were located in the midbrain , 5, 6. TThis case demonstrates unilateral Cogan’s anterior INO with ipsilateral limb ataxia in which the lesion falls outside the midbrain, located in the pontomesencephalic junction. This case highlights the importance of considering pontomesencephalic junction as one of the possibilities in a case with such constellation.A 67-year-old gentleman with undiagnosed dyslipidemia and hypertension presented with difficulty in walking and painless diplopia for 1 week. He noticed the symptoms after waking up from sleep.He denied any head trauma, headache, nausea, or vomiting. There were no associated sensory, motor, speech, and vertigo symptoms. There was no family history of cerebral vascular accident or ischaemic heart disease. His ocular history was insignificant, with no previous ocular surgery. He had never undergone any medical check-up.The vital sign showed elevated blood pressure (175/89 mmHg) with normal random blood sugar (6.7 mmol/L). Visual acuity with a pinhole was 6/10 OD (right eye) and 6/15 OS (left eye). Both pupils were round and equal in size (3mm) with a sluggish direct light reflex. The swinging light test showed no relative afferent pupillary defect.On primary gaze, eyes were central on Hirschberg light reflex test. There was no ptosis, proptosis, or abnormal head posture. Assessment of extraocular muscle motility revealed a horizontal abducting nystagmus in the right eye in right gaze and left eye was unable to adduct beyond the midline on dextroversion. Besides that, there was a limitation in elevation in both eyes, with normal depression.Fig.  He experMoving on to neurological examination, the patient was alert and conscious with a full Glasgow Coma Scale. His speech was clear, coherent, and relevant. Besides the abnormal ocular motility, other cranial nerves were all intact. The sensory and motor function of all 4 limbs were full and of normal tone. Proprioception and plantar reflex were unremarkable. However, he had bilateral appendicular ataxia in both upper and lower limbs worse in the left side. He was frequently falling towards the left side on tandem gait assessment. The cerebellum was normal. Humphrey visual field showed no visual field abnormalities.A brain Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiogram (MRA) with gadolinium showed hyperintense lesion (lacunar infarct) over left dorsal pontomesencephalic junction associated with atherosclerotic disease with stenosis at P2 Segment of left posterior cerebral artery. Fasting serum lipid showed a total cholesterol level of 7.1 mmol/L with LDL of 5.2 mmol/L.After reviewing the investigation and correlating with the clinical signs, the patient was diagnosed infarct of the left dorsal tegmentum of pontomesencephalic junction. During the admission, his ataxia was improving and able to ambulate without any support upon discharge. He was given oral Simvastatin, antihypertensive agent and aspirin. Patient was advice to modify his lifestyle . He was given an appointment with neurology and ophthalmology clinic before discharged.After 1 month, his diplopia and ataxia had significant improved. The extraocular movements were almost full with minimal cerebellar sign seen..This patient presented with three main clinical signs which include unilateral Cogan’s anterior INO, upgaze palsy, and appendicular ataxia. A constellation of these 3 signs are rare and made clinicians localized the lesion at the level of the midbrain , 9, 10. However, the MRI brain of this patient showed there was dorsal tegmentum lesion at the pontomesencephalic junction instead of the paramedian midbrain. In order to understand this better, we will need to localize lesions for each of the 3 signs to pinpoint the exact location of the lesion.Cogan’s anterior INO is defined as INO superimposed with inability to converge . InitialLeft Cogan’s anterior INO plus appendicular ataxia are rare. This combination narrowed the location to the left dorsomedial tegmentum of pontomesencephalic junction, left paramedian tegmentum of the caudal midbrain, and left paramedian tegmentum of rostral midbrain. In this case, MLF origin from the right paramedian pontine reticular formation (PPRF) at the level of abducens nerve nuclei in the caudal pons . The MLFThe superior cerebellar peduncle  ascends to the caudal pons and decussates over the midline at the level of inferior colliculus before their entrance to the red nucleus, this decussation point is called as Wernekinck commissure , 19. WerCogan’s INO, upgaze palsy with ataxia can be due to lesion located at the 3 levels as mentioned above . Among patients with INO, 40 % of INO with ataxia patients unable to converge, compared to isolated INO only 10 % had convergence impairment . Cogan’sINO with vertical gaze palsy is rarely seen with lesions in the upper midbrain, and to our best knowledge, there are only 2 cases reported . In caseThis is a rare case report with a constellation of unilateral Cogan’s anterior INO, upgaze palsy with ataxia due to a dorsal tegmental lesion at pontomesencephalic junction. Clinicians should consider looking for cerebellar sign in cases of Cogan’s anterior INO, apart from just considering localizing the lesion over the midbrain.INO with vertical gaze palsy should alert clinicians to look for lesions near pontomesencephalic junction and cerebellar involvement. INO with ataxia is mostly due to vascular infarct.


Rhinosporidium seeberi. This highly recurrent polypoid lesion has a predilection for the nose and nasopharynx, although other organ systems may be affected. Involvement of the tracheobronchial tree is very rare, and poses a challenge for diagnosis and management. In this report, we present a 30‐year‐old man with a history of recurrent nasal polyp who presented with cough, shortness of breath, haemoptysis, and a radiological feature of right lung collapse on imaging. He was diagnosed with rhinosporidiosis based on histopathological examination of bronchoscopic biopsy specimen taken from the right principal bronchial mass. Shortly after hospitalization, he developed acute respiratory distress requiring emergency bronchoscopic intervention. A pinkish mulberry‐like tracheal and right bronchial mass was removed endoscopically with cauterization of the base of the lesion. On long‐term follow‐up, the patient was free of symptoms without recurrence of airway disease.Rhinosporidiosis is a chronic granulomatous infectious disease caused by Mesomycetozoea  Tracheobronchial rhinosporidiosis is a rare benign cause of endobronchial obstruction and poses challenge for diagnosis and management. We report a 30‐year‐old man who developed acute hypoxaemia by a rapidly growing rhinosporidial mass causing central airway obstruction. Emergency bronchoscopic intervention saved his life. Rhinosporidiosis is a chronic granulomatous infectious disease that manifests as a slow‐growing tumour‐like mass, commonly involving the nose and nasopharynx. The tracheobronchial tree is a very unusual site and poses challenge in management owing to recurrent nature of the disease. Here, we report the case of a patient with a previous history of recurrent nasal mass and multiple nasal surgeries, presented with right upper lobe collapse followed by sudden respiratory distress. Emergency bronchoscopic intervention was life‐saving.A 30‐year‐old male from a rural background presented to a primary care physician with persistent cough and occasional sputum for six months and was getting treatment accordingly without much improvement. Four months later, he noticed frequent scanty haemoptysis and exertional breathlessness. There was no fever, wheeze, chest pain, and anorexia or weight loss. He was seen by a pulmonologist, and a routine chest X‐ray showed right upper lobe collapse Fig. . Pulmona2) breathing room air measured 89%. A computed tomography scan of the chest showed a polypoid mass in the right principal bronchus, extending up to the main carina  was performed. A mulberry‐like mass was seen nearly occluding the lower tracheal lumen. The mass was removed as much as possible by grasping forceps  showed complete clearance of the tracheal lumen and a residual lesion in the proximal right principal bronchus and a mass hanging from the posterior nasopharyngeal wall Fig. . The resR. seeberi. Recent phylogenetic analysis suggests that it is a protistan organism in the newly described class Mesomycetozoea of animal–fungus boundary. Its natural host and reservoir are unknown [In 1892, Malbran, and later in 1896, Seeber described an apparent sporozoan parasite in nasal polyp in patients living in Buenos Aires, Argentina. In 1923, Ashworth described the life cycle of the organism, argued it as a fungus, and named it Rhinosporidium seeberi has an affinity for the mucus membrane of the nasal cavity and nasopharynx. Various other sites may be involved, including the conjunctiva, lacrimal sac, lips, uvula, palate, epiglottis, larynx, maxillary antrum, parotid duct and gland, urethra, penis, vagina, rectum, muscle, skin, and bone [and bone , 4. Invoand bone . An exteand bone , 16, 17 The exact mode of infection is still unknown, but transepithelial transmission has been proposed as a probable mode of infection in natural aquatic environment, and there is a strong relationship between bathing in pond water and getting the disease. In their study, Karthikeyan et al. observed that 59.38% of patients with rhinosporidiosis had a history of bathing in ponds . OrganisPatients may present with cough, wheeze, breathlessness, stridor, haemoptysis, or collapsed lung. If there is critical airway narrowing, there may be rapidly developing respiratory distress and even sudden death , 6. AcutVarious methods have been used in management, including flexible and rigid bronchoscopic snaring, argon plasma coagulation, laser, tracheotomy, tracheostomy, and surgical excision. As our patient developed critical airway obstruction and acute hypoxaemia, we performed emergency rigid bronchoscopy and gently extracted the lesion using forceps, ensuring good haemostasis, and following a certain interval, repeated the procedure and cauterized the base to prevent recurrence. Dapsone  was added to treat concomitant nasopharyngeal lesions and to prevent recurrence, which acts by arresting the maturation of sporangia and fibrosis of stroma . The chaThis challenging case rapidly developed critical central airway obstruction requiring immediate multidisciplinary planning to rescue the airway. Teamwork of interventional pulmonologists, thoracic surgeons, and anaesthesiologists led to a favourable outcome of the uncommon life‐threatening cause of airway obstruction.Appropriate written informed consent was obtained for publication of this case report and accompanying images.This case was presented at the 22nd Congress of the Asian Pacific Society of Respirology.


Ewing’s sarcoma usually presents in paediatric patients with its primary location being bone tissue. Nevertheless, we present such an adult case which arises from the small intestine. We registered thirty one cases of such origin published so far excluding ours.We report a case of 30 year old female who was admitted due to the persistent anaemia. Whole body computed tomography scan revealed abdominal mass in her left upper abdominal compartment. Surgery on the mass originating from jejunum was performed, although due to extremely complicated postoperative period and rapid dissemination no additional therapy had been performed. The tumour was positive for CD99, ERG, CD56, Synaptophysin, PanCK, Cam5.2.Extraosseus Ewing’s sarcoma is extremely rare entity, with poor prognosis. Ewing’s sarcoma was first identified by A.P. Stout in 1918 –4. It inUp to date only 31 cases of extraosseus Ewing’s sarcoma arising in a small intestine are reported in the literature  scan discovered 4.7 × 6.2 × 6.5 cm non-homogenic tumour with a cystic component in a left upper abdominal compartment. Tumour had a close contact with an inferior mesenteric vein (IMV) at the long segment, near the entrance to the superior mesenteric vein (SMV) (Type A/B) without overgrowing any another surrounding organ. Gastrointestinal stromal tumour (GIST) was suspected Figs.  and 2. PTreitz ligament), a part of uncinated process of the pancreas, IMV and inferior mesenteric artery (IMA) was found. Enlarged small intestine lymph nodes were also seen. Resection of 50 cm of small intestine with the tumour was performed. Two layer end-to-end entero-entero anastomosis was performed and enteral feeding tube was inserted below the anastomosis. Early postoperative course was uneventful. On postoperative day (POD) five the blood appeared through the drains – emergency surgery was initiated. Massive bleeding from superior mesenteric artery (SMA) was found and the arterial defect was sutured. The cyanotic small intestines were noticed and a partial occlusion of SMA was suspected. Aorto-mesenteric shunt using saphenous vein was performed and the small intestine regained its blood supply. Two days later anastomotic leak was suspected – bile from the drain was noticed. Anastomosis was resected and two layer side-to-side duodenojejunal anastomosis was performed. By then, the pathology report revealed a high grade G3 peripheral/primitive neuroectodermal tumour (PNET)/atypical Ewing sarcoma which expansion to the pancreas  break-apart FISH test and PCR test for EWSR1-ERG, EWSR1-ETV1, EWSR1-FLI1, EWSR1-FEV, EWSR1-ETV4 translocations were performed. Unfortunately, there was no evidence of EWRS1 gene rearrangements by both FISH and PCR EWSR1 methods. Despite this fact there was no evidence of any other tumour and final diagnosis was high grade G3 peripheral/primitive neuroectodermal tumour (PNET)/atypical Ewing’s sarcoma, possibly with a rare translocation.Eleven days after the third surgery bleeding recurred – bleeding from the aorto-mesenteric shunt was found. It was sutured along its wall and intraoperative ultrasound showed reduced diameter of the shunt, and recanalized SMA. During postoperative period due to progressing bile leakage, bile ducts were catheterized trans-hepatically. Nine days later intraabdominal bleeding recurred. Bleeding from the aorta at the shunt area was found and sutured. Small intestine on the other hand showed total necrosis with multiple perforations. The changes were incompatible with life. Nonetheless 48 h later, patient vital signs improved and the condition stabilized. Therefore, during the next surgery necrotised small intestine was removed while closing both ends of the intestines at the demarcation lines and gastrostomy was made for the drainage of the gastric content. During the next few weeks bleeding recurred and multiple (> 50) liver metastases were found. Bleeding was controlled but the patient died because of rapid dissemination of the disease.Intestinal Ewing’s sarcoma as many other tumours can manifest asymptomatic although there are cases in which it occurs as intussusception , perforaThorough examination should follow CT scan to exclude other acute diseases although there are no specific radiological signs of Ewing’s sarcoma . For thiTo provide proper diagnosis, pathological examination should be carried out. It‘s round cell morphology is similar to neuroblastoma, malignant lymphoma, rhabdomyosarcoma, GIST, and desmoplastic small round cell tumour . While EAll Ewing’s sarcoma treatment includes local surgical and/or radiotherapy treatment followed by multidrug systemic chemotherapy , 7. It uPrognosis of intestinal Ewing’s sarcoma is not known as there are not enough cases. It could be compared to other sites. Although some authors do not relate tumour size with worse outcomes  other fiTo conclude, extraosseus Ewing’s sarcoma is extremely rare entity, with most often poor prognosis.


Primary mediastinal B‐cell lymphoma (PMBCL) is a rare tumour with different characteristics from other type of lymphomas. Clinical manifestations may vary and cause delay in diagnosis and management. We present a 22‐year‐old patient with symptoms of shortness of breath, weight loss, and night sweats. Laboratory studies only showed a markedly high lactate dehydrogenase (LDH) level and thoracic computed tomography (CT)scan revealed a large mediastinal mass. Core biopsy‐guided CT scan was performed and the pathological and immunohistochemistry established a PMBCL diagnosis. We administered Rituximab Dose‐Adjusted Etoposide Prednisolone Vincristine Cyclophosphamide Doxorubicin (R‐DA‐EPOCH) chemotherapy regimen and the patient responded well to treatment. This is an example of rare case of mediastinal lymphoma with challenges to overcome to achieve diagnostic and therapeutic success. Failure to differentiate PMBCL with other systemic diffuse large B‐cell lymphoma (DLBCL) could skew treatment algorithm and prevent optimal response. Administration of proper systemic therapy, especially in young, low‐risk patients could yield excellent outcome. Primary mediastinal B‐cell lymphoma (PMBCL) is a rare tumour with different characteristics from other type of lymphomas. Clinical manifestations may vary and cause delay in diagnosis and management. We reported a patient with PMBCL diagnosis and good response to treatment. Mediastinal lymphoma accounts for more than half of mediastinal malignancies, making it the most common malignant tumour in this area . HoweverA 21‐year‐old male patient visited outpatient clinic Haematology‐Medical Oncology Department of Internal Medicine, Dr. Cipto Mangunkusumo General Hospital, with shortness of breath since three months before admission. He also experienced night sweats and weight loss of 5 kg. Laboratory studies only showed an elevated lactate dehydrogenase (LDH) level, 484 U/L (reference range: 125–220 U/L). Thoracic computed tomography (CT) scan revealed a large mediastinal mass –CT imaging was performed and showed a poorly demarcated hypermetabolic mass with a necrotic core located in the anterior mediastinum. The mass itself had displaced anterior mediastinal organs dorsally. The tumour also encased vascular structures, mainly brachiocephalic vein. Nodal involvement was found in multiple sites. Pericardial and bilateral pleural effusions were also present.We performed a CT‐guided core biopsy procedure on the mass. Histopathological study found the tumour to be a non‐Hodgkin lymphoma. Further immunohistochemistry staining showed positive markers on CD20 (diffuse), CD30, CD79a, and Ki‐67 (50%). On the basis of imaging and histopathological findings, we established the diagnosis of stage II bulky CD20 (+) primary mediastinal DLBCL. According to age‐adjusted International Prognostic Index (aaIPI), this patient is categorized into low‐intermediate risk category, with estimated complete response rate of 78%.We administered the Rituximab Dose‐Adjusted Etoposide Prednisolone Vincristine Cyclophosphamide Doxorubicin (R‐DA‐EPOCH) chemotherapy regimen every three weeks × six cycles. Even though the patient developed febrile neutropenia, nausea‐vomiting, alopecia, and peripheral neuropathy, the patient tolerated well to treatment and completely finished six cycles. After chemotherapy, improvement was recorded: clinical condition was improved and plain chest X‐ray radiography showed marked reduction in tumour size Fig. . FurtherWe reported a case of PMBCL in a young male patient, which in this case came to us with non‐specific symptoms such as shortness of breath, weight loss, and night sweat. The dyspnoeic appearance can be caused by combination of mass effect to adjacent structures (lung and vascular) and pleural or pericardial effusions . ClinicaIn cases of mediastinal lymphoma with multinodal involvement, it is very crucial to distinguish between primary mediastinal lymphomas with nodal extension and systemic lymphomas with mediastinal involvement. The incidence of primary mediastinal tumour is much less than secondary mediastinal involvement of systemic lymphoma . TreatmeIn the initial imaging, the tumour had a largest diameter of 15.38 cm. Published reports find that in most patients, tumour diameter is >10 cm. Furthermore, leakage in the pericardial and pleural membrane is also prevalent and was observed in our patient. Core biopsy of the mediastinal mass provides excellent foundation for treatment as broad differential diagnosis could cause similar manifestation, such as thymoma, metastatic carcinomas, germ cell tumours, and other lymphomas with mediastinal nodes . After hWe utilized PET with fluorodeoxyglucose for pre‐treatment evaluation and response monitoring due to its high sensitivity in lymphoma . The PETIn general, patients with PMBCL shows favourable outcome and low rate of relapse . In our There are several treatment regimens that has been used in clinical trials and daily practice. Combination of Rituximab with CHOP (R‐CHOP) chemotherapy is one of the common schedules in PMBCL with good prognosis features . PublishAppropriate written informed consent was obtained for publication of this case report and accompanying images.


Leiomyosarcomas (LMs) of the inferior vena cava (IVC) are very rare neoplasms seldom reported in the literature. The majority of patients does not present with specific abdominal pain and IVC LMs are used to become symptomatic with the increase of tumor volume. The role of chemotherapy or radiotherapy is not yet defined and surgical resection seems to be the only chance to improve survival rates.We present a case of a 58-year-old female with a recent diagnosis of IVC LM who underwent surgery with a partial resection of the anterior wall of the vein using a lateral and partial vein clamping. The primary repair of the defect could result in stricture of the vein, so a parietal peritoneum patch was used for the vein reconstruction. The postoperative course was uneventful.Actual evidence suggests that vascular sarcomas have limited responsiveness to cytotoxic chemotherapy and chemoradiotherapy, so surgery is the treatment of choice. Major surgery entailing multivisceral and complex vascular resection is usually necessary to achieve negative margins and accurate vascular reconstruction techniques are mandatory to avoid serious circulatory complications. Different kinds of graft  are available for the reconstruction, with intrinsic advantages and limitations. The use of peritoneal patches seems a valid and cheap option for vascular reconstruction and it is gaining great attention in recent years.This case demonstrates that peritoneal graft could be a safe option to manage IVC defects in expert hands. A brief review of literature is also included. Different kinds of graft  are available for the reconstruction, with intrinsic advantages and limitations. The use of peritoneal patches seems a valid and cheap option for vascular reconstruction and it is gaining great attention in recent years.The current case report follows the Surgical Case Report (SCARE) guidelines .2A 58-year-old female with a recent history of chronic abdominal pain was referred to our tertiary care center. An abdominal CT scan showed a mass of 3.5 cm between the inferior vena cava and the duodenum . Chest CAfter multidisciplinary evaluation, the patient was offered surgery. A midline incision was performed. After a medial rotation of the right-sided viscera (Cattell-Braasch maneuver) and a Kocher maneuver, we exposed the infrahepatic IVC and renal veins.Intraoperative exploration revealed that the mass originated from the anterior aspect of the lower segment of the IVC with no infiltration of adjacent structures except for the right gonadal vein.A lateral clamping of the IVC was applied and the tumor was resected. The right gonadal vein was intimately attached to the tumor and, consequently, it was divided. Caval defect was about 1 cm and the direct suture was considered at risk of stenosis. For caval reconstruction, a rectangular peritoneal patch with the same dimension of the defect was harvested from the right parietal peritoneum. With gentle manipulation, all the fat tissue was removed from the graft and the patch was sutured with two 5/0 prolene running sutures with the mesothelial aspect applied to the lumen of the vessel a. A hepaPostoperative course was uneventful and the patient was discharged in fifth postoperative day. No symptoms or complications were observed on the postoperative follow up.Surgical pathological examination demonstrated a grade III leiomyosarcoma of the inferior vena cava of 5 cm of maximum diameter according to the FNCLCC  system with a focally positive margin.No evidence of disease at the time of this report, 5 months after surgery.3Inferior vena cava LMs are seldom reported in literature and most of the papers are case reports or case series . The sciWithout surgical resection, the prognosis is poor with an overall survival of months ,5,6.On the contrary, a chance of a 5-years overall survival rate of about 55% has been reported when a R0 resection is performed. However, recurrence rate is very high and 5-years disease-free survival rate is reported to be less than 10%.En-bloc resection of adjacent organs may be necessary to achieve tumor-free margins. Despite the effect of en-bloc resection on long-term survival has not well defined, an analysis of the ACS-NSQIP  database reported that multi-organ resection for retroperitoneal sarcoma did not increase 30-day morbidity or mortality . FurtherIf surgery is performed, the IVC can be safely ligated only in rare cases of slow-growing sarcomas causing complete obstruction when collateral veins could develop and bypass IVC block. However, low extremity oedema is a frequent complication ,9.In most of the cases, IVC control can be achieved with a lateral incomplete caval clamping with modest interruption of vascular return.In case a complex and time-consuming vascular reconstruction is required, a venovenous bypass can be used to guarantee venous return to the heart particularly in older patient with compromised cardiac function .Only few cases in literature report the use of cardiopulmonary bypass with full circulatory arrest: the limited use of this procedure reflects the fact that IVC sarcoma extending to the right atrium are likely to be considered borderline resectable because of locally advanced disease.To avoid strictures of the vein, IVC primary repair without graft interposition is safe only when a small part of the vessel is involved by the tumor. A narrowing of less than 20% is considered acceptable .In case of larger defects a replacement graft is recommended. Graft reconstruction has demonstrated excellent patency rates (80–90% after 5 years) with minimal complications .Synthetics materials such as Dacron® or polytetrafluorethylene (PTFE) are safe and have been used with good results but both have inherent drawbacks such as the risk of thrombosis or infections requiring long term anticoagulation, antibiotic therapy and, sometimes, the need of graft removal .Allografts such as cadaveric vein may be the most appropriate graft in term of low rates of complications, but their use is limited by their unavailability and high costs ,13.Autologous grafts such as saphenous or jugular vein grafts require a preoperative planning with further evaluation such as an ecocolordoppler; moreover, additional incisions are required .Peritoneal patches are an efficient and safe option to repair venous defects and their use has been recently reported ,15. TheyMoreover, peritoneal patches are free and they can be used for temporary repair in selected cases when a better graft is available and being prepared.Thickness of the patch could be different based on to the site of harvesting to best fit the vessel needing a repair: thinner patches may be harvested from the falciform ligament while thicker patches may be retrieved from the lateral hypochondrium with or without a muscular or aponeurotic layer.Both allo- and autograft have demonstrated fewer thrombotic complications when compared to synthetic patches .In particular, a recent study analyzed the risk of thrombosis in peritoneal patch compared to other autologous graft: vein intima may be injured due to repermeabilization-dilatation increasing the risk of thrombosis whereas mesothelium is rarely injured during the harvesting with a lower incidence of thrombosis ,14.On the contrary, peritoneal patches are less useful in case of larger or circumferential defects in which a synthetic or cadaveric graft could be more appropriate.4In conclusion, IVC LMs are rare retroperitoneal neoplasm with a poor prognosis and surgical resection is the only chance to improve patient survival. Vein reconstruction is often required. Different materials have been used, both synthetic or homologous.Homologous grafts have less infectious and thrombotic complications and they can be at surgeon’s disposal also in emergency situations.Peritoneal patches have been recently reported as a valid option to repair IVC defects in expert hands. In particular, they are easily and rapidly available and their use seems safe.The authors declare that there is no conflict of interest.This report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.Ethical approval was not required and patient-identifying knowledge was not presented in the report.Written informed consent has been obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Matteo Risaliti and Laura Fortuna: Conceptualization, Writing - original draft.Ilenia Bartolini: Writing - Review, Editing and Supervision.Paolo Muiesan and Antonio Taddei: Review, Editing, Supervision, Performed surgery.Not applicable.All authors were involved in the preparation of this case report.Not commissioned, externally peer reviewed.