Rheumatoid Arthritis (RA) is a multisystem autoimmune condition characterised by destructive synovitis and varied extra-articular involvement. Rheumatoid nodules are the most common extra-articular manifestations of RA. They develop most commonly in the subcutaneous tissue at the elbow and in the finger joints and may occasionally affect internal organs elsewhere in the body. A 65-year-old woman with seropositive RA on treatment with methotrexate presented with an enlarging mass in the buccal cavity. Ultrasonography revealed a well-defined solid lesion in the subcutaneous plane of the right buccinator space. A clinical diagnosis of a benign salivary gland tumour was made and the patient underwent excision of the nodule and histopathological examination showed central areas of necrobiosis surrounded by palisades of histiocytes consistent with a rheumatoid nodule. The diagnosis of rheumatoid nodules in typical locations can be made easily clinically, supported by classic histopathology. In many cases, particularly in unusual locations, the diagnosis can be challenging, requiring extensive examination of the lesion. Although a rare manifestation, clinicians should consider the possibility of a rheumatoid nodule as a possible differential diagnosis of buccal masses in patients with a history of RA or connective tissue disease. Through this case report, we review the pathogenesis, histopathological features, as well as diagnosis and differential diagnosis of rheumatoid nodules while discussing the challenges in distinguishing them from their mimics. A high degree of suspicion will avoid unwarranted surgical intervention.

We report a rare case of nodular fasciitis in a 12 years old boy.

Abstract Prostate cancer (PCa) staging has advanced significantly with the emergence of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT). However, PSMA-labeled radiotracers uptake is not exclusive to PCa, leading to potential pitfalls. We report an unusual case of a 71-year-old man with high-risk PCa undergoing initial staging with PET/CT using 18F-labeled PSMA (18F-PSMA), which revealed an unexpected uptake in a pleural nodular lesion. Given the extreme rarity of PCa pleural metastases, an excisional biopsy of the lesion was performed. Histopathological analysis confirmed the diagnosis of a pleural lobular capillary hemangioma, a benign vascular tumor extremely rare in this location. This case represents the first documented instance of PSMA radiopharmaceutical uptake in a pleural hemangioma, expanding the spectrum of known PSMA PET/CT pitfalls. This finding underscores the importance of histopathological confirmation for atypical PSMA PET/CT findings in unusual locations, preventing incorrect staging and avoiding inappropriate therapeutic decisions.

Demonstration of MDM2 amplification is currently recommended to confirm the diagnosis of well-differentiated adipocytic tumors arising in the retroperitoneum, abdomen, and pelvis; recurrent "lipomas"; those with equivocal cytologic atypia; deep extremity tumors >10cm which lack cytologic atypia and occur in patients >50years old, and in special clinical circumstances (Clay et al., 2015 [Clay criteria]). In our practice, fluorescence in situ hybridization studies (FISH) for MDM2 were historically performed for all referred-in testing requests, for all well-differentiated fatty tumors >10cm, and to confirm the diagnosis of atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDL) in cases with definite atypia. As part of a test utilization review, after exclusion of dedifferentiated liposarcoma, we reviewed 1151 ostensibly fatty tumors on which FISH was successfully performed. After exclusion of 203 cases for which testing was inappropriate or indicated for other reasons, 233/948 (24.6%) fatty tumors met at least one Clay criterion, and 222 (23.4%) had definite nuclear atypia. Among tumors with definite atypia, 152 (68.5%) were ALT/WDL, and 48 (21.6%) were spindle cell/pleomorphic lipoma arising in unusual locations or atypical spindle cell/pleomorphic lipomatous tumors. Thirty (12.9%) cases meeting any Clay criteria were ALT/WDL, and 4/453 (0.9%) tumors not meeting Clay criteria or having atypia were ALT/WDL. The sensitivity of Clay criteria plus nuclear atypia for ALT/WDL was 97.8%, while specificity was 62.7%. We conclude that it is safe to defer MDM2 FISH in well-differentiated fatty tumors not meeting Clay criteria and lacking nuclear atypia.

Lead Management in Special Scenarios.

Atypical gunshot injuries: A review of case reports and case series.

Squamous Cell Carcinoma (SCC) of the foot represents a rare clinical entity, often presenting diagnostic challenges due to its resemblance to benign conditions such as chronic ulcers or calluses. In this report, a case of a 61-year-old male with no history of significant sun exposure or smoking, presenting with a non-healing ulcer over the heel of his left foot. Initially misinterpreted as a benign lesion, biopsy revealed SCC, prompting surgical excision (below-knee amputation) with clear margins. Histopathological examination confirmed the diagnosis, highlighting the importance of considering malignancy in non-resolving foot ulcers even in patients with atypical risk profiles. This case emphasises the necessity for early biopsy and intervention to optimise outcomes in uncommon presentations of SCC, particularly in unusual anatomical locations like the foot. Early recognition and management are crucial to prevent local tissue destruction and potential metastasis in such cases. Understanding and recognising these atypical presentations are crucial for early detection, prompt biopsy, and initiation of appropriate treatment, ultimately improving patient outcomes and reducing morbidity associated with advanced SCC of the foot.

Soft tissue sarcomas are a heterogeneous group of connective tissue neoplasms with a low incidence. Myxoid liposarcoma is a rare subtype with a preferential location in the extremities. The gold standard of treatment is wide resection with negative margins for neoplasia. However, unusual locations have different clinical behavior, and their management is limited by a low level of evidence. A 65-year-old man with a lipomatous tumor in the inguinal region who, after marginal resection, showed evidence of myxoid liposarcoma with margins involved by neoplasia. Imaging studies revealed tumor in the inguinal region with retroperitoneal extension. A radical orchiectomy with en bloc resection of the tumor was performed with no evidence of neoplasia in the resected specimen. Close follow-up without adjuvant therapy was decided by a multidisciplinary committee. The approach to a rare soft tissue sarcoma in an unusual region is a challenge in oncological treatment and in the absence of high-quality evidence, the consensus of a multidisciplinary team is necessary to determine the best therapeutic option.

We report an exceptional case of primary cutaneous actinomycosis of the hand revealed by microbiological culture and histopathological analysis. Actinomycosis is a chronic bacterial infection caused by Actinomyces spp., anaerobic Gram-positive filamentous bacteria that are commensals of the human mucosa. The cutaneous form is rare, especially on the hand. The diagnosis relies on prolonged anaerobic culture and histological confirmation. We describe the clinical, microbiological, and therapeutic features of this unusual localization and emphasize the importance of bacteriological analysis for diagnosis and management.

Aims: We aimed to report a rare case of a cervicothoracic mass revealing Non-Hodgkin's Lymphoma (NHL), highlighting its unusual localization. Non-Hodgkin's Lymphoma (NHL) is a rare condition, primarily affecting lymph nodes but can involve any organ. Extra-nodal NHL occurs in 25% of cases, with 60% located in the head and neck region. NHL in this area presents diverse clinical, morphological, and biological features, reflecting the complexity of histopathological classifications. Diagnosis relies on histology, which guides therapeutic management. This case report describes a cervicothoracic mass revealing laryngeal NHL. A 70-year-old man with a history of diabetes and hypertension, was admitted to the ENT department with a 10-month history of a painless left laterocervical swelling, dysphonia, and deteriorating general condition, without signs of tuberculosis, dyspnea, or initial dysphagia. ENT examination revealed a large, adherent, painless left laterocervical mass extending intrathoracically, associated with left upper limb lymphedema. Nasofibroscopy showed left laryngeal paralysis and deviation of the left hemi-laryngeal structures. Blood tests indicated bicytopenia. A CT scan identified a lesion in the left hemi-larynx with thyroid cartilage lysis and a cervical tumor extending into the cervico-thoracic area, displacing the trachea and esophagus. No lung nodules or mediastinal lymphadenopathy were observed. MRI confirmed a cervico-thoracic tumor with diffusion hypersignal, low ADC, and homogeneous enhancement, closely associated with the left thyroid lobe. Direct laryngoscopy and biopsy revealed diffuse large B-cell lymphoma (non-germinal type). Immunohistochemistry showed tumor cells positive for CD20, Bc16, and Mum1, negative for CD3, CD5, CD20, AE1/AE3, and Cyclin D1, with a high Ki67 proliferation index of 90%.

Abstract Osteoid osteoma (OO) is a benign bone tumour, usually affecting young people. In over 50% of cases, it is located in the diaphysis of the femur or tibia, with the proximal femur most frequently affected. Atypical locations of osteoid osteoma present a diagnostic challenge due to their unusual symptoms and may lead to misdiagnosis and delayed treatment. Osteoid osteomas are usually cortical lesions but can occur anywhere within the bone, including medullary, subperiosteal (most commonly in the talus), and intracapsular sites. Computed tomography-guided radiofrequency thermal ablation (CT-RFTA) is a minimally invasive treatment option for osteoid osteomas and has been proven effective and safe for the treatment of OOs in typical locations. The ablation process for lesions in these sites is considerably more straightforward than in atypical or complex locations. The authors report their experience with a series of particularly challenging osteoid osteoma ablation cases in unusual locations.

Abstract Background The somatic JAK2V617F mutation (JAK2) in myeloproliferative neoplasms (MPNs) has been associated with an increased risk of thrombosis. Data are limited on the relationship between JAK2 and unexplained thrombophilia. As such, thrombophilia screening rarely includes JAK2 as a screening test, usually reserved for patients with thrombotic events in specific or unusual locations (e.g., mesenteric venous thrombosis). This study aims to determine the prevalence of JAK2 in patients with unexplained thrombophilia and its potential association in patients with cytosis. Methods Patients who had previously undergone thrombophilia profile including molecular testing with DNA-stored at TriCore Reference Lab during the 2022 calendar year were identified (n=359). 124 patients were sequentially selected to undergo JAK2 testing. All 359 patients were screened to determine the presence of = 1 cytosis: white blood cell, red blood cell, or platelet count above the respective reference range’s upper limit of normal either within one month of thrombophilia screening OR evidence of persistent cytosis. 23 patients had cytosis (11 in the sequential cohort, 11 additional patients with DNA, 1 patient with insufficient DNA). 11 additional patients with cytosis were tested for JAK2. Quantitative RT-PCR results were assigned qualitative values using JAK2 DNA standard clinically validated thresholds: 0%-0.5% negative, 0.5%-1% indeterminate, and > 1% positive. Results Of the 135 samples tested for the JAK2, mean age was 46 (range of 1-86) years, and 103 (76.3%) were female. 1/135 (0.7%) samples was positive for JAK2. The single positive sample (32-year-old male) was within original sequential cohort without cytosis. A Fisher Exact Test shows that there is no correlation with cytosis and JAK2 status (p=1). Conclusion These findings discourage using JAK2 in a first-line thrombophilia genetic screening panel, even in patients with concurrent cytosis. Future directions involve testing additional specimens to increase the sample size of random and cytosis groups. Clinical correlation would also potentially identify a additional associations with which patients could be screened for this testing.

Pseudomyogenic hemangioendothelioma: A series of 13 patients, highlighting unusual cardiac locations, novel gene fusions, and malignant behavior.

Pediatric lipomas: Usual sights-unusual sites.

Hyperhomocysteinemia (HHcy), defined as having over 15 µmol/l of homocysteine in the blood, is a disease that is generally linked to either a metabolic defect or a dietary deficiency. Patients suffering from HHcy are known to have elevated risks of arterial cardiovascular events, neuropsychiatric illness, compromised bone health, and increased risk of vein thrombosis in unusual anatomical locations. We present the case of a 45-year-old woman diagnosed with HHcy, who presented with acute pain on the sole of her right foot. The patient had previously experienced recurrent superficial venous thrombosis in the plantar veins. The patient was referred for an ultrasound, which revealed plantar metatarsal vein thrombosis. With fewer than 50 reported cases of plantar vein thrombosis in the literature, none of which are currently linked to HHcy, this is a very rare form of thromboembolic event. This case underscores the importance of considering thromboembolic events in atypical locations, in patients with HHcy who present with pain, even if these patients lack other major risk factors. Our case contributes to the growing body of literature on venous thrombosis in patients with HHcy and emphasizes the need for heightened clinical awareness in such patients. We further highlight the need to be aware of their propensity to develop thrombosis in unusual anatomical locations.

Introduction:Giant cell tumor (GCT) in Orthopedics is a clinically challenging problem pertaining aggressive expansion and recurrence. While GCT’s typically occur at epiphyseal ends of long bones, unusual locations, such as tendon sheath, distal ulna, and proximal tibia have been reported, which impose different challenges for management.Case Series:In this case series, we present surgical methodology tailored for individual characteristics of GCTs, with emphasis on functional recovery. We demonstrate four cases involving different sites GCT – tendon sheath in hand, distal ulna, distal radius, and proximal tibia. Each case was managed using a site-specific surgical approach, ranging from en bloc resection with ulna transposition and arthrodesis to Illizarov assisted bone transport. Emphasis is laid on strategic surgical technique coupled with functional preservation and prevention of recurrence. All patients were successfully treated without recurrences at follow-up ranging 6 months to 2 years. Functional outcomes varied depending on the location and extent of surgical dissection, but improved overall, as evident by patients’ return to routine daily activities with significant relief from pain. This case series underscores importance of a tailored, site-specific approach for managing GCT.Conclusion:Strategic surgical intervention employed with limb-sparing technique using reconstructive surgery, highlights the potential for restoration of optimal function while minimizing the risk of recurrence. However, the diversity of GCT presentation necessitates vigilant surveillance and an individualized patient management plan.

In the emergency radiology setting, ectopic air can frequently be a cause for alarm, such as with pneumothorax, pneumomediastinum, and portal venous gas. Ectopic air can often serve as a harbinger of serious injury, which can prompt the radiologist to notify clinicians so patients can receive appropriate care. However, there are many benign conditions which may present radiographically with air in unusual locations. It is critical to be able to recognize these benign entities, as inaccurate identification could lead to unnecessary procedures or imaging. We present numerous benign conditions which can produce air in unusual locations that we have encountered in our practice. For each condition, we will describe its etiology and will also provide key imaging findings that help to distinguish it from pathology.

When Air is a Red Herring: Benign Appearances of Air in Unusual Locations

Objective: Violence against children and adolescents represents a major public health issue, with significant repercussions on physical, psychological, and social well-being. This study aims to analyze the patterns of bodily, oral, and maxillofacial injuries in victims of physical aggression, emphasizing the interdisciplinary approach among healthcare professionals in the identification, documentation, and intervention in such cases. Materials and Methods: A systematic literature review was conducted using databases such as PubMed, SciELO, and BVS BIREME. Articles published in the last ten years were selected, focusing on epidemiology, clinical manifestations, and the role of different healthcare areas in the diagnosis and management of injuries resulting from physical aggression. Specific injury patterns, forensic documentation, and multidisciplinary protocols for victim care were analyzed. Results: The findings indicate that the face is one of the most affected regions in physically assaulted children and adolescents, with mandibular fractures, soft tissue lacerations, and dental avulsions being the most prevalent injuries. The presence of multiple traumas in different healing stages and unusual injury locations raises suspicion of abuse. Hematomas, burns, and neurological damage, such as shaken baby syndrome, were also commonly reported. Additionally, the underreporting of cases remains a major challenge, often due to a lack of training among healthcare professionals. Conclusion: The identification of maxillofacial injuries as indicators of child abuse requires a multidisciplinary effort involving Dentistry, Medicine, Psychology, and Social Work. Proper training of healthcare professionals and the implementation of clear protocols for reporting and intervention are essential to improving victim protection and ensuring timely intervention. Strengthening intersectoral collaboration and awareness campaigns are crucial strategies to mitigate the impact of violence on this vulnerable population.

Glomangiopericytomas are rare spindle cell neoplasms that typically arise within the sinonasal tract and exhibit borderline to low malignant potential. While unusual, occurrences of this tumor in other regions of the head and neck have been reported, such as the deep neck spaces, larynx, tongue, and middle ear. A 44-year-old male presented with a one-year history of left infraorbital swelling, enlarging over two months and occasionally pulsating with discomfort. Cross-sectional imaging revealed a 1.5cm x 0.8cm x 1.7cm homogeneously-enhancing mass in the left medial infraorbital region eroding the adjacent maxillary sinus wall, suggestive of an infraorbital nerve schwannoma or hemangioma. The tumor was excised via a lateral rhinotomy approach with anterior maxillectomy. The final pathological diagnosis was a glomangiopericytoma. Although typically localized to the sinonasal tract, glomangiopericytomas may arise in unusual head and neck locations such as the infraorbital region. It is important to distinguish these tumors from related mesenchymal tumors such as solitary fibrous tumors and myopericytomas due to differences in their biology and malignant potential.