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Highlights • COVID-19 serological tests are not recommended for early diagnosis because they cause a lot of confusion. • Patients who require lung or chest surgery must undergo strict preoperative control and early detection of SARS-COV-2 infection. • The treatment of COVID-19 in the postoperative of patients undergoing pulmonary surgery should be based on respiratory rehabilitation and oxygen therapy. • The use of broad-spectrum antibiotics contributes to the treatment of secondary bacterial pneumonia. • In the preoperative period of patients requiring pulmonary surgery, the chest tomography should be considered with an antiquity of no more than 5 days., Objective To describe the form of severe clinical presentation of SARS-COV-2 infection in the early phase, also the timely treatment of COVID-19 pneumonia in postoperative pulmonary lobectomy. Method Case report where the data were extracted from the clinical history and is in accordance with the SCARE 2018 criteria. Description of the case A 36-year-old man, with no significant history, who presented fever and mucopurulent expectoration of 1 month of evolution, received antibiotics for 4 weeks without response to treatment. Chest tomography shows cystic image with heterogeneous content in the left lower lobe. We decided to opt for surgery, previously 1 PCR in RT and 7 serological tests for COVID-19 were performed, the result of which was non-reactive. In the postoperative period, the patient developed fever and dyspnea on mild exertion, so a new serological test for COVID-19 was performed: IgM/IgG reactive, in addition chest tomography showed both lungs with “cracy paving” pattern. Discussion The serological tests did not contribute to a timely diagnosis of COVID-19 and generated confusion. We used oxygen therapy, broad spectrum antibiotics since the diagnosis of COVID-19. Likewise, respiratory physiotherapy was intensified even after discharge. Conclusion The early diagnosis and use of antibiotics at doses of sepsis, associated with corticosteroid pulses and respiratory physiotherapy improve COVID-19 pneumonia in postoperative lung surgery.

Highlights • It is considered that adenocarcinoma has the stepwise continuum of progression. • It is rare for adenocarcinomas with lepidic growth lacking invasion to be >3.0 cm. • We report a rare case of 6 cm diameter adenocarcinoma without an invasive component. • The tumour harboured uncommon EGFR mutation detected on next-generation sequencing. • Next-generation sequencing could be useful for detecting uncommon genes of tumour., Background According to the WHO classification, adenocarcinoma in situ (AIS) is a localised small (≤3 cm) adenocarcinoma whose growth is restricted to neoplastic cells along pre-existing alveolar structures, lacking stromal, lymphovascular, or pleural invasion. There is no evidence to define AIS as having a tumour size of ≤3 cm. It is extremely rare for adenocarcinomas with pure lepidic growth lacking invasion to be >3.0 cm. The biological characteristics of these large AISs should be revealed. Presentation of case The patient was an 82-year-old asymptomatic woman. Chest computed tomography showed a 6-cm-diameter pure ground-glass opacity in the left lower lung. The patient underwent lobectomy. On histologic examination, the tumour was restricted to neoplastic cells along pre-existing alveolar structures, lacking stromal, vascular, alveolar space, and pleural invasion. Papillary patterns were absent. Initially, the histopathological diagnosis was AIS, but the total tumour diameter exceeded 3 cm. The final pathological diagnosis was lepidic adenocarcinoma lacking an invasive component and harbouring an EGFR exon 20 insertion V774_C775insHV mutation using next-generation sequencing (NGS). Conclusion We report a rare case of lepidic adenocarcinoma with a total tumour diameter of 6 cm and without an invasive component. Although EGFR mutations are oncogenic driver mutations, AISs have fewer EGFR mutations than invasive adenocarcinomas do. An adenocarcinoma that progresses to AIS, not stepwise progression, might have uncommon mutations and might be another type of adenocarcinoma. NGS could be useful for detecting uncommon genes that reveal the biological characteristics of AIS, and may contribute to the validation of next TNM classification.

Highlights • This is a borderline tumor with indolent biological behavior. • There are still multiple poorly understood factors that can dictate its malignant transformation and prognosis. • Here, a rare tumor whose age and survival are tangent the literature reports describe. • There is a need for a long and rigorous segment to identify possible long-term metastases., Introduction Frantz’s Tumor or Solid Pseudopapillary Neoplasm (SPN) is rare with a solid-cystic pattern, and most common in young women. Presentation of case This study based on guidelines for case reports (SCARE) reports a case of SPN in a teenager aged 13 years at the diagnosis time, attended at a teaching public hospital in Brazil, which evolved into liver metastases. Clinical, laboratory, therapeutic and imaging data were collected from the physical chart and analyzed in light of current publications on the topic. The first consultation occurred in January 2012, where weight loss, fever, vomiting, left-sided hypochondrium and epigastric pain were reported. Imaging exams evidenced an expansive heterogeneous process in the pancreatic tail; however, laboratory exams and tumor markers did not present alteration in relation to reference values. In March of 2012, she underwent caudal body pancreatectomy, splenectomy, segmental colectomy and colo-coloanastomosis as a function of the intraoperative findings. After 63 months, right-sided hepatectomy was performed to resect metastases. Currently, she is undergoing outpatient monitoring, without complaint or alterations in imaging and laboratory exams, totaling 100 months of global survival. Discussion This is an interesting case report of a rare tumor, in so far as without any adjuvant chemotherapies, an 8-year long survival time could be achieved in this particular type of tumor despite initially large tumor expansion and later liver metastases. Conclusion Additional epidemiological studies, molecular and clinical trials are required to increase knowledge on SPN.

Highlights • H3K27M-mutant diffuse midline gliomas are incurable, WHO grade IV tumors. • These gliomas predominantly present in children, and rarely in adults. • The diverse features of these gliomas in adults remain incompletely characterized. • Early biopsy and detailed molecular characterization are critical., Introduction H3K27M-mutant diffuse midline glioma is a recently classified unique entity predominantly affecting pediatric patients and rarely adults. The clinicopathologic features in adults remain poorly characterized. Presentation of case A 36-year-old man presented with subacute progressive cognitive and visual deterioration, and hydrocephalus requiring ventricular shunting. MRI revealed a diffusely infiltrating lesion with a gliomatosis cerebri growth pattern, multiple foci of contrast enhancement, and diffuse leptomeningeal involvement. Suboccipital craniotomy with exploration of the posterior fossa revealed a subtle capsular lesion infiltrating into the choroid plexus. Although histologically low-grade, the tumor was found to have an H3K27 M mutation establishing the diagnosis. Discussion In spite of diverse clinicopathologic characteristics, H3K27M-mutant diffuse midline gliomas are incurable, WHO grade IV lesions with poor prognosis. We discuss our case in the context of a review of published reports of H3K27-mutant diffuse midline gliomas in adults. Findings late in the disease course may mimic inflammatory or infectious pathologies radiographically, and low-grade infiltrative neoplasms histologically. Conclusion The diverse clinical, radiographic and molecular features of H3K27M-mutant diffuse midline gliomas in adults remain to be completely characterized. A high index of suspicion is required to avoid missing the diagnosis. Early biopsy and detailed molecular characterization are critical for accurate diagnosis and patient counseling.

Highlights • Bronchial carcinoid tumor is exceedingly rare. • Diagnosis of bronchial carcinoid is often delayed or even missed. • Surgical excision is the main stay of treatment for bronchial carcinoid tumour. • Typical carcinoid tumour has excellent prognosis., Introduction Bronchial carcinoid tumors are rare, slow growing, malignant neuroendocrine tumors and account for less than 2% of all lung tumors. Early diagnosis is extremely important as the main stay of treatment is surgical excision. Presentation of case We present a rare case of bronchial typical carcinoid tumor in a 22-year-old female who presented with a complaint of intermittent productive cough with bloody sputum of 3 weeks’ duration associated with wheezing, low grade intermittent fever and loss of appetite. She was being treated as bronchial asthma for 10 years prior to her current presentation. Right lung bi-lobectomy with regional lymph node resection was done and she was discharged home in good condition. Discussion Majority of typical carcinoids are located in the central airways leading to bronchial obstruction with recurrent pneumonia, chest pain, wheezing and hemoptysis. Due to such nonspecific presentation most patients are misdiagnosed or diagnosed late. Both typical and atypical Carcinoids have similar radiologic features and definitive diagnosis relies on bronchoscopic tissue biopsy. Although hilar and mediastinal lymph nodes are the most common metastatic sites for typical carcinoids most lymphadenopathies are caused by a reactive inflammatory reaction. Conclusion Bronchial carcinoids are rare, malignant neuroendocrine tumors with complete surgical resection being the only curative management. Thus patients with recurrent respiratory symptoms despite optimum medical treatment should be thoroughly investigated for accurate and early diagnosis The outcome of typical carcinoids with lymph node metastasis is excellent with complete resection but close follow up is mandatory when dealing with larger tumors.

Highlights • Management of the pressure injuries (PIs) consisted of sequentially performed actions: wound debridement, cleansing, dressing and wound coverage. • Wound coverage should be done once the local infection is treated, the debridement is done and the budding is obtained. • Several processes can be performed for wound coverage: second intention healing, direct wound closure, skin grafting and fasciocutaneous flap or myocutaneous flap. • The main operative steps concerning V–Y flap surgery are: flap drawing, flap edge incision, dissection follow by the lifting and transposition of the flap on the recipient area, completed by fixation of the flap in the recipient area and closure of the donor area under suction drains., Background The occurrence of pressure injuries (PIs) in an inpatient is a serious medical condition that requires a rigorous clinical evaluation. Management of these lesions should be comprehensive, including general measures and local care. Wound care occupies a large part of the treatment. For large skin loss, the treatment requires plastic surgery techniques for reconstruction. Myocutaneous advancement flaps are a good therapeutic option due to the provision of vascularized tissue within the skin defect. To ensure the success of the surgery, a good surgical technique preceeded by careful preparation of the patient in conjunction with the anesthesia team is imperative. Case presentation We report the case of a 60-year-old bed ridden man for more than two months following an ischemic stroke with left spastic hemiplegia and loss of sensitivity. He was transferred to our surgical unit for the management of a chronic stage 4 PIs in the sacral area complicated with cellulitis, subcutaneous abscess and severe sepsis. Initial management consisted of resuscitation measures combining fluid therapy, antibiotic therapy, analgesics, blood transfusion, nutritional support, physioteherapy, wound care as well as preventive measures and psychological support. Once the granulation tissues were fully developed, the patient underwent reconstruction surgery with a V–Y myocutaneous advancement flap. The graft was successful with complete wound healing thereafter. Conclusion PIs are a multifactorial, complex and disabling pathology that requires multidisciplinary care. Surgeons, anesthetists, nutritionists, physiotherapists, nurses must act in agreement in order to provide optimal treatment. Prevention is the rule.

Highlights • Lung large-cell neuroendocrine carcinoma (LCNEC) is an aggressive and a rare type of lung cancer. • The prognosis of LCNEC with distant metastasis is extremely poor. • Surgical resection for liver metastasis of LCNEC may improve prognosis., Introduction Lung large-cell neuroendocrine carcinoma (LCNEC) is an aggressive and a rare type of lung cancer, and the prognosis of LCNEC with distant metastasis is extremely poor, with a five-year survival rate of 0%. Here, we report a case of laparoscopic hepatectomy for liver metastasis of lung LCNEC. Presentation of case A 63-year-old man received a routine physical examination, and abnormal chest radiographic findings were observed; chest computed tomography (CT) in our hospital revealed that the patient had left pneumothorax and a lesion measuring 18 mm in the inferior lingular segment of the lung. The patient underwent thoracoscopic lobectomy, and the final pathological diagnosis was lung LCNEC. Four years after surgery, abdominal CT revealed a mass measuring 27 mm in the liver. The patient underwent laparoscopic partial hepatectomy, and postoperative pathological examination showed liver metastasis of LCNEC. There was no sign of recurrence 6 months after hepatectomy. Discussion LCNEC with distant metastasis has a poor response to systemic chemotherapy, and the median survival time of patients with distant metastasis is estimated to be approximately 6 months, with a five-year survival rate of 0%. Although the common site of metastasis from LCNEC is the liver, there are no previous reports of hepatectomy for liver metastasis of LCNEC. Conclusion We report a case of laparoscopic hepatectomy for liver metastasis of lung LCNEC. It is suggested that surgical resection for solitary distant metastasis of LCNEC may improve prognosis.

Highlights • Resection of large Pheochromocytoma with invasion or metastasis is now considered indicated. • Pheochromocytoma surgery combined organ resection is generally challenging for surgeons and anesthesiologists because the procedure is complex and life threatening cardiovascular complications may occur during it. • A combination of early ligation of feeding arteries via a retroperitoneal laparoscopic approach followed by open surgery is a useful procedure for managing advanced pheochromocytoma., Introduction Pheochromocytoma surgery is generally challenging for surgeons and anesthesiologists for cardiovascular complications. Presentation of case A 54-year-old Japanese man was found to have a large right pheochromocytoma infiltrating the posterior part of his liver and vena cava and multiple lung metastases. After retroperitoneal laparoscopic dissection of the dorsal side of the tumor and ligation of the feeding vessels, total resection of the primary tumor, extended posterior sectional hepatectomy, and partial vena cava resection were performed by open surgery via a thoracoabdominal approach. Abundant congestive bleeding with instability of vital signs occurred during transection. It could be finally controlled by dissect the remnant feeding artery in the inmost space. Prior control of arterial in-flow enabled successful completion of the planned surgical procedure. The patient has now survived for 27 months since resection of the primary lesion. Conclusion Ligation of the feeding arteries to this hypervascular catecholamine-releasing tumor via a retroperitoneal laparoscopic approach prior to performing combined organ resection facilitated successful excision of this large malignant pheochromocytoma.

Highlights • Peliosis lienalis is a rare pathological entity which may be associated with chronic myelomonocytic leukemia. • Increasing splenomegaly in patients with hematological malignancies should rise suspicion of impending splenic rupture. • Peliosis lienalis may be suspected with new inhomogeneous splenic parenchyma on sonography., Introduction Atraumatic splenic rupture is a rare but life-threatening condition which may be associated with hematological malignancies. Presentation of case We present the case of a 63-year-old male patient with a history of chronic myelomonocytic leukemia and sarcoidosis under therapy with prednisone, who suffered an atraumatic splenic rupture with hemodynamic instability. He was managed with proximal splenic artery embolization and secondary open splenectomy. On pathology the diagnosis of peliosis lienalis was established. Discussion Peliosis is a rare pathological entity, which presents with multiple blood-filled cavities within parenchymatous organs and is of unknown etiology and pathogenesis. In retrospect a rapid increase in splenomegaly and inhomogeneous parenchyma of the spleen on sonography was realized. Conclusion Sonographic changes in size and parenchyma of the spleen in patients with hematological malignancies might help suspecting peliosis lienalis with impending splenic rupture and could alter clinical management towards a prophylactic splenectomy.

Introduction and importance Cemento ossifying fibroma (COF) is an encapsulated lesion that is often found in the mandible of middle-aged females. Cystic degeneration may be associated to several osseous lesion. This particular presentation is not well documented in the jaws. Case presentation Patient presented was referred to oral surgery department for abnormal radiolucency in the right mandible on panoramic X-ray. The patient did not have any specific medical history and reported painful areas in right mandibular region. During diagnosis assessment, ameloblastoma was first considered due to the presence of cystic lesion clusters. But the mixed image in previous X-ray pointed to a fibro-osseous with a change in pathogenesis pathway. Diagnosis buildup was based on previous radiographs, incisional biopsy was proposed to identify the histopathological feature of the lesion before proceeding to further investigation (CBCT) or treatments (decompression or enucleation). COF of the jaws associated to non-specific cystic changes was the histopathological diagnosis. Delay in treatment showed an unexpected outcome with good clinical and bone healing. Clinical discussion and conclusion This case shows the importance of previous radiographs, when available, in diagnosis buildup. The fibro-osseous lesion with cystic change may show a good biological response with conservative management. A clinical and radiological surveillance after a conservative treatment may be a better option in treatment of these lesions., Highlights • Non-epithelial lined cysts occasionally occur along with various bone lesions. These cysts vary from aneurysmal bone cyst (ABC), simple bone cyst (SBC) and non-specific cystic degeneration. • Evaluation of previous X-rays may be of a great importance in objectifying modification of pathogenesis pathway in osseous lesions. • Minimal surgical intervention with monitoring may be a great treatment choice in management of non-epithelial lined cysts associated to cemento-ossifying fibroma.

Introduction and importance Conjoined twin is a rare congenital anomaly characterized by a fusion of certain anatomical structures. Coronavirus-19 (COVID-19) is a new emerging infectious respiratory disease affecting worldwide and potentially leads to acute respiratory distress (ARDS) in children. COVID-19 has reconstructed the healthcare system, including surgical care and decision-making. Case presentation Herein we describe a surgical separation of 2.5 months old omphalopagus conjoined twins, with one of them (Baby A) presenting COVID-19-associated respiratory distress, as well as the challenges faced during the preparation and the execution of the complex surgical procedure. Clinical discussion Baby A underwent antiviral therapy, oxygen supplementation, and ventilation in the ICU, while baby B remained stable and confirmed negative for SARS-CoV-2. The separation surgery was conducted after baby A had become clinically stable. Defect closure and reconstruction were accomplished. At one week follow-up, Baby A died of lung infection, while baby B remained well after one year. Conclusion The complexity of surgical separation requires careful planning by a multidisciplinary team. Surgical separation of conjoined twins during the pandemic era has not been reported much in the literature, more reports are required to provide further insight., Highlights • Omphalopagus conjoined twins separation surgery is an intricate procedure that requires a multidisciplinary team • The separation surgery of conjoined twins during the COVID-19 pandemic necessitate a unique surgical preparation and disciplined health protocols. • The ideal timing of separation surgery of conjoined twins in the COVID-19 pandemic era remains controversial, factors that may play a role in the decision making include the age, weight, general clinical condition, and the complexity of fusion identified

Highlights • A thymoma mainly occurs in the anterior mediastinum, while few are seen in the middle mediastinum. • This is the first case of a mediastinum thymoma induced severe tracheal compression in literature. • In our review of middle mediastinum thymoma cases, none were Masaoka stage III or IV, while the majority (9/13, 69.2%) were WHO type A or AB. • A thymoma should always be considered in differential diagnosis of neoplasm, even when occurring in the middle mediastinum., Background A thymoma, an epithelial neoplasm of the thymus, mainly occurs in the anterior mediastinum, while few are seen in the middle mediastinum. Case presentation An 83-year-old male was referred for an incidental mass in the middle mediastinum. He had severe dementia and denied symptoms. Our follow-up computed tomography (CT) examinations had revealed the progress of tracheal compression along with tumor enlargement for 2 years. At 85 years old, we performed a thymomectomy via a median sternotomy to avoid complete trachea obstruction. The pathological diagnosis was WHO type A thymoma, Masaoka stage II. One year after surgery, the patient was free of disease. Discussion Thymomas occurring in the middle mediastinum are rare. In our review of 13 such cases, none were Masaoka stage III or IV, while the majority (9/13, 69.2%) were WHO type A or AB. Conclusion We encountered a thymoma in the middle mediastinum that showed enlargement over a 2-year period, inducing severe tracheal compression. Thymomas can occur widely in pharyngeal pouch-derived locations and should be considered in differential diagnosis of a middle mediastinum tumor.

Highlights • Based on the patients with better performance status, partial gastrectomy combining metastasectomy of liver is potentially useful in contributing to decrease tumor loading and cytokines secretion of tumor, which may result in immunosuppression. • PVC has the potential to be a well-tolerated and excellent option in GCLM patients who have no extrahepatic metastases. • Patients who without extrahepatic metastases, sensitive and well-tolerate to chemotherapy, having better performance status may get good prognosis., Introduction The liver is one of the most common sites of hematogenous metastases of gastric cancer. The 5-year overall survival rate of synchronous liver metastases from gastric cancer was less than 27%. We report a rare case of patient with synchronous liver metastases from gastric cancer who experienced stable disease for 7 years and 3 months following multidisciplinary modalities. The presentation of a case A 33-year-old woman was admitted to our institute because of abdominal pain lasting for a day. Haemoglobin level was 68 g/L. Computed tomography (CT) scan revealed hemoperitoneum, multiple round lesions within liver parenchyma. The pathological diagnosis was gastric cancer with liver metastases. Following multidisciplinary treatment, she experienced stable disease for7 years and 3 months. Currently, the patient remains alive with no recurrence. Conclusion We report a rare case of patient with synchronous liver metastases from gastric cancer who experienced stable disease for 7 years and 3 months following multidisciplinary modalities. Future trials are required to prospectively investigate the established regimen of multidisciplinary treatment.

Highlights • Hemangiopericytoma can present with abdominal metastases manifested by abdominal pain and subacute obstruction. • Laparoscopic resection is a feasible treatment strategy for intraperitoneal metastases from hemangiopericytoma., Introduction Hemangiopericytoma (HPC) is a rare mesenchymal tumor derived from capillary and postcapillary pericytes that often has an indolent course and occasionally presents with abdominal metastasis. Presentation of case Twenty-three years after the initial resection of an intracranial HPC located in the right frontoparietal region and left lateral ventricle, a 63-year-old man experienced dull abdominal pain and early satiety and had a palpable epigastric mass. Computed tomography indicated a suspected metastasis of HPC to the left upper abdomen. On laparoscopic exploration, the tumor was found in the falciform ligament and was excised laparoscopically per request of the patient. He had a fast recovery and experienced good relief of his pain and satiety. The patient had 2 additional metastases at his 12-month follow-up, both in the right retroperitoneum, and he again underwent laparoscopic resection. At his next annual follow-up, new metastases were identified in his liver, small-bowel mesentery, and peritoneal surface, prompting a trial of systemic chemotherapy. Because of progress of a left lower abdominal preperitoneal metastasis on follow-up at 3 years, the patient underwent a further successful laparoscopic exploration. Postoperatively, systemic chemotherapy was maintained. Discussion We report the recurrent laparoscopic resection of peritoneal metastases of primary intracranial HPC with good symptom control and fast recovery. Both the patient and the referring physician requested a minimally invasive surgical approach. Conclusion Laparoscopic resection is a feasible treatment strategy for intraperitoneal metastases and is effective in symptom palliation.

Highlights • Pancreatic undifferentiated carcinomas with OGCs are very rare neoplasms that may have an atypical clinical presentation. • Less than a hundred cases have been described until today. • Early diagnosis and aggressive surgical treatment is the only way to prolong survival., Introduction Undifferentiated head of pancreas carcinoma with osteoclast-like giant cells (UC-OGC) is a rare neoplasm, with less than a hundred cases reported. We present such a case, in which the UC-OGC presented atypically as a cystic lesion following acute pancreatitis and led to late diagnosis. Presentation of case A 75-year-old female patient, who had suffered acute pancreatitis three years ago, was referred with a diagnosis of osteoclast-like giant cell (OGC) tumor of the head of pancreas. She had suffered acute pancreatitis three years ago. Two years ago she developed abdominal pain, steatorrhea and weight loss. Abdominal computed tomography imaging showed a cystic mass in the head of the pancreas (maximum diameter 4 cm). The initial diagnosis was pancreatic pseudocyst; however as the mass gradually increased in size and the patient continued to be symptomatic, a CT-guided biopsy was performed. Histological examination revealed an OGC pancreatic tumor. In laparotomy a large (9 cm) encapsulated heterogeneous mass was found with partial involvement of the common hepatic artery. Pancreaticoduodenectomy was performed and the involved part of the common hepatic artery was replaced with a homologous graft from the major saphenous vein. Post-operative course was uneventful. Histology revealed an undifferentiated pancreatic adenocarcinoma with OGCs. She survived 10 months after the operation. Discussion Pancreatic undifferentiated carcinomas with OGCs are very rare neoplasms and can present with an atypical clinical picture. Conclusions A symptomatic cystic lesion of the pancreas, which is growing in size, should be investigated promptly in order to exclude the presence of malignancy.

Introduction Central odontogenic fibroma (COF) is a rare, benign, slow-growing intraosseous odontogenic tumor, and accounts for 0.1% of all odontogenic tumors. It is often confused with other entities, such as keratocysts, ameloblastomas, and odontogenic myxomas. Complete enucleation followed by curettage is the treatment of choice for COF to ensure the lowest possible chance of recurrence. Case presentation We report the case of a young Caucasian woman with COF that went undiagnosed for several years despite repeated radiologic examinations. Finally, a massive tumor was surgically removed and the wound was curetted. The specimen was histologically confirmed to be a COF. The patient remains under regular follow-up, and thus far there have been no clinical or radiologic signs of recurrence. Discussion This rare case of COF, which was documented over a period of 20 years, has helped us to describe the features of this tumor. It also confirms that adequate surgical treatment can lead to impressive bone regeneration in healthy individuals, as evident from the radiologic findings acquired before, during, and after enucleation of the COF in our patient. Our findings also confirm the view that COF has a favorable prognosis regardless of its final size. Conclusion Early diagnosis is key to successful treatment of COF. The slow but steady increase in the size of a COF with no accompanying symptoms has not been reported previously. To our knowledge, this is the only documented case of a COF that has been under continuous radiologic observation for over 20 years.