An 85 year old male presented to his General Practitioner with a vague history of a lump on his back that was mobile and non tender. He had a previous history of advanced prostate cancer and radiotherapy treatment.We present an unexpected diagnosis of malignant fibrous histiocytoma of a subcutaneous lesion removed from the patient’s back.Excisions of subcutaneous lesions along with cutaneous lesions form the majority of cases on a usual minor operations list. All lesions are sent for histopathological analysis and most are confirmed benign sebaceous cysts or lipomas. However the entity of malignant fibrous histiocytoma, now referred to as undifferentiated pleomorphic sarcoma (UPS) should be kept in mind.Patients will usually present late with advanced local disease or metastasis, usually to lungs and lymph nodes. Treatment is surgical with wide local excision and neoadjuvant/adjuvant radiotherapy has been advocated as well.Undifferentiated pleomorphic sarcoma should be a differential in subcutaneous lesions in older adults with a previous history of malignancy, radiation therapy and a mass in the subcutaneous tissue of the back. It is n2An 85 year old male was referred by his General Practitioner with a mobile, non tender lump on his back for excision under our surgical service. He had not had a similar lesion on any other part of his body before. Medical history included active prostate cancer, mixed hyperlipidaemia, hypertension, NSTEMI, TIA, paroxysmal atrial fibrillation and gastritis/duodenitis. Current medication included Aspirin, Omnic, Rosuvastatin, Furosemide, Folic acid, Omeprazole, Lexapro and Ensure Plus. He had been on Casodex (antiandrogen) and received radiotherapy treatment for prostate cancer. On physical examination the lump was mobile and non tender; no lymphadenopathy appreciated. On operation the lesion was discovered to be deep, extending down to the fascia involving muscle and extensively vascular. Two pieces measuring 45 mm × 35 mm × 22 mm and 35 mm × 15 mm × 15 mm was removed in entirety with clinically adequate margins having its malignant potential recognised. The histology showed it to be a malignant fibrous histiocytoma (undifferentiated sarcoma), pleomorphic type, Grade 3 , Fig. 2.Follow up was 2 weeks post procedure in OPD with wound healing well. He had a CT TAP which showed no supraclavicular or axillary lymph adenopathy and sclerotic lesions in the skeleton consistent with metastases of his prostate cancer. Previous CT brain and CXR was clear. Referral to an Oncologist was made and treatment was radiotherapy. On the next Surgical OPD appointment at 4 months the wound had healed well with new growths at the limits of the excision , Fig. 4.3Malignant fibrous histiocytoma, now referred to as undifferentiated pleomorphic sarcoma, is the most common soft tissue sarcoma of late adult life . UPS canSymptoms are usually a painless, enlarging palpable mass , like thRisk factors can include radiation treatment for another malignancy like Hodgkin’s lymphoma , post brWorld Health Organisation Classification of Tumors of Soft Tissue and Bone facilitates that [B- Raf, a proto oncogene that is mutated in many human cancers. Another commonly mutated gene is p16. These mutations, if present, are not limited to malignant fibrous histiocytoma and this type of testing is not routinely done at our laboratory facility.The diagnosis at histology involves microscopy, molecular studies and immunohistochemistry techniques. It is necessary for pathologists to have a consensus in classifying, grading and staging neoplasms and the tes that . Our pattes that . BRAF isdiagnose UPS; a biopsy is needed which is usually excisional if tumors are less than 3 cm. Our patient had the entire lesion removed in two parts which measured 4.5 cm × 3.5 cm×2.2cm and 3.5 cm × 1.5 cm×1.5 cm with clinically adequate margins; the amount of involvement was only determined at surgery hence decision to resect as entirely as possible. Post procedure CT TAP was thus not useful in evaluating the lesion; however confirmed no supraclavicular or axillary lymphadenopathy and sclerotic bony lesions consistent with concomitant prostatic metastases demonstrated. Specialists of choice are Orthopaedic or general surgical oncologists and they may choose additional imaging modalities like bone scans or Positron Emission Tomography (PET) scans.Imaging has a role with radiographs of the extremity  and chest  being the first investigation done. Magnetic resonance imaging (MRI) is the most useful test as it gives valuable information about the size, location and proximity to neurovascular structures . ComputeStaging can be done once biopsy and imaging is completed by using the American Joint Committee on Cancer Staging Manual, 8th edition  (AJCCM).Prognosis varies and factors include size, grade, location and inflammatory component. Unfortunately most cases are found late at Stage 3 and 4, possibly with metastases. They are aggressive and recur locally , which oThe main treatment of UPS remains complete surgical excision, with margins of at least 2 cm with a role for neoadjuvant/adjuvant radiotherapy and doxorubicin based chemotherapy ,10.4Undifferentiated pleomorphic sarcoma should be a differential of a deeper lying subcutaneous lesion. It frequently presents in an advanced stage in older patients. Past history of radiation therapy is a risk factor. Local, wide resection is advocated with a role for neoadjuvant or adjuvant radiation or chemotherapy. It is very important to grade the tumor and patients should receive a full work up for staging.No conflict of interest.Funding by authors.This is a case report submission and ethical approval is not required at our Institution for case reports.Consent has been obtained for the publication of this manuscript and images and is available to the Editor-in-chief of this Journal upon request.KS contributed in conceptualization, obtaining data (including consent and images), writing the original draft, editing the final copy and funding.NM obtained data (including consent and images), contribution to writing and reviewing manuscript and funding.JPMcG contributed to writing and review of final copy and funding.Not applicable for a case report.KS.Not commissioned, externally peer-reviewed.


Our patient is a 58-year-old female who presented to our emergency room with left upper quadrant abdominal pain the day after outpatient screening colonoscopy. A computed tomography (CT) scan of the abdomen and pelvis revealed a grade III spleen injury. She was admitted to our intensive care unit, and a gradual decline in her hematocrit was noticed. The patient did well and was discharged from hospital the day after splenic artery embolization. Colonoscopy is the most common procedure for the diagnosis and treatment of lower gastrointestinal diseases, with fifteen million colonoscopies performed in the United States in 2012 . The diaA 58-year-old female presented to our emergency room with worsening left upper quadrant abdominal pain radiating to her left shoulder the day after outpatient colonoscopy. A CT scan of the abdomen and pelvis revealed a grade III splenic injury with no obvious active extravasation Figure .She was admitted to our intensive care unit and her initial hemoglobin (9 grams per deciliter) dropped gradually to 7.4 grams per deciliter over 24 hours. Angiography revealed a subcapsular blush Figure . The patThe number of colonoscopies performed across the United States is increasing, and the potential complication of splenic injury should be on the examining physicians' differential . SeventySplenic injury after colonoscopy is a rare complication and requires a high index of diagnostic suspicion when a patient presents with abdominal pain after colonoscopy associated with hemodynamic instability. While splenic injury after trauma can be managed conservatively in the majority of cases, this does not appear to be the case with a colonoscopy-induced injury. Angioembolization of the splenic artery appears to be very promising for the management of splenic ruptures.


Gliomatosis cerebri (GC) has classically been considered a rare malignancy with a poor prognosis and is developmentally unique from solid tumors. More recently, GC has become better understood as a phenotype along the spectrum of gliomas and, most importantly, not mutually exclusive from the more common presentation of a tumor mass. The following case report illustrates not only the implications of the ontogeny of gliomas in clinical practice but also the successes that can accompany the early recognition of such a disease. Here, we report the presentation of a solid temporal lobe glioma, which, on presentation, was disseminating along well-defined mesolimbic white matter tracts. Once properly diagnosed and managed, the patient remarkably proceeded to achieve an impressive outcome given the extent of her pathology. Gliomatosis cerebri (GC) is a rare and rapidly infiltrating brain tumor of the glial family of brain tumors for which prognosis is rather dismal. Typically, within one year of the symptomatic onset of GC, patient survivability ranges between 25% and 50% . Since tWe report a 24-year-old, right-handed woman presenting upon referral from emergency medicine (EM) for the evaluation of a possible recurrence of temporal lobe astrocytoma (TLA). The patient initially presented at the age of 21 with an eight-month history of partial-complex seizures. MRI revealed a non-enhancing fluid attenuation inversion recovery imaging (FLAIR) predominant lesion in the right temporal lobe subtly extending into the right orbital frontal cortex and insula Figure . AnterioaCO2) of 12.7 mmHg, arterial partial pressure of oxygen (PaO2) of 138.9 mm Hg, concentration of bicarbonate (HCO3) of 13.8 mEq/L, a base deficit of -3 mEq/L, and hemoglobin oxygen saturation (SaO2) of 99.7%.The patient delayed planned involved-field radiotherapy and did not follow up with us for an additional four months, at which time she was admitted for dehydration and found to have severe metabolic alkalosis with an arterial blood gas pH of 7.65, arterial partial pressure of carbon dioxide  involving the medial basal structures of both frontal lobes, right insula, midbrain, pons, right middle cerebellar peduncle, and medulla Figures -1G. The She made a remarkable recovery after the conclusion of radiotherapy and continued her treatment with temozolomide Figure . She wasGliomatosis cerebri is a rare neoplasm characterized by diffuse invasion along white matter tracts and blood vessels. Median survival is approximately 12-14 months. Classically, GC has been defined as involving at least two lobes of the brain and has been thought to be distinct from focal, solid glial tumors . More reIn retrospect, initial imaging in our patient fit criteria for both a solid tumor and gliomatosis cerebri. Her imaging studies clearly showed a solid temporal lobe tumor in addition to an invasive component extending not only along the insula but also into the right frontal lobe via the diagonal band of Broca. While it could be argued at the time of surgery that this represented peri-tumoral edema, the continued progression of this lesion along defined mesolimbic pathways should have signaled the presence of GC and led to aggressive treatment. Instead, the patient went without further treatment for roughly 45 months. At the time of admission, she had diffuse bilateral involvement, including the brainstem, leading to interference with well-described respiratory brainstem centers manifesting as CNH. Her CNH did not resolve until after the completion of radiotherapy and the radiographic improvement of her brainstem disease -10. AggrThis case, in particular, illustrates the importance of appreciating the nuances of solid and non-solid appearing invasive tumors with respect to the earliest diagnosis of GC, the potential for GC to present with CNH, and the ability of aggressive multidisciplinary critical care and oncological therapy to successfully treat this condition. This case is extremely rare due to the age presentation and the aggressive proliferation of an ultimately lethal pathology that took on many proliferative avenues into vital brain centers for which radiation therapy and chemotherapy did not vastly change prognostic outcomes. In addition, this case highlights the crucial component of time in the proper management of all aggressive neoplasms, including GC.


Osteoma cutis can occur as a primary or secondary cutaneous lesion. Isolated lesions of perforating osteoma cutis are uncommon and can present with varying clinical features. Adverse events that can occur following placement of a tattoo include benign and malignant neoplasms, dermatoses, infections, and miscellaneous complications. We present a case of a man who developed perforating osteoma cutis within a tattoo and propose that osteoma cutis be included among the list of adverse events that can occur in individuals who obtain a tattoo. The acquisition of tattoos has increased in worldwide prevalence over the recent decades; the associated complications from tattoos have also risen in parallel. Typically, such complications may include allergic reactions, infections, and benign and malignant tumors . OsteomaA 42-year-old Hispanic man with a history of tattoos covering 80% of his body surface area and regularly shaven legs presented for evaluation of an asymptomatic solitary leg lesion within a tattoo. Further history revealed that his leg tattoos were done in his early twenties with a touch-up three years prior. Subsequently, he developed a papule that was progressively increasing in size within the area that received additional tattoo pigment during the touch-up.Cutaneous examination revealed a 5 x 5 mm dermal papule within the green tattoo pigmented area on the left pretibial leg Figure . There wMicroscopic examination showed bone  in the upper dermis that was perforating through the overlying epidermis. The site of perforation demonstrated a keratin-plugged crater and extension of the adjacent hyperplastic epidermis into the dermis. A proliferation of small endothelial-lined vessels and a predominantly lymphocytic inflammatory infiltrate was located in the dermis beneath the site of perforation and surrounding the bone. Also present in the dermis, adjacent to the bone, was pigment from his green tattoo which appears as small black particles Figure .He had no recurrence at six-month follow-up.Osteoma cutis can be either a primary or secondary condition. It is primary in approximately 15% of patients and secondary in about 85% of patients ,5-6. SecThe pathogenesis of osteoma cutis remains to be definitively established. In primary osteoma cutis, intramembranous ossification in the dermis may result in formation of bone . One thePerforating osteoma cutis is rare. Perforating dermatoses have been observed in patients with collagenosis, elastosis, folliculitis, granuloma annulare, Kyrle disease, and renal disease . IncludiSolitary lesions of perforating osteoma cutis have been observed in three men and one woman -4. TheirThe lesions ranged in size from 5 x 5 mm (our patient) to 1.5 x 0.5 cm. Two of the lesions were erythematous nodules and two were flesh-colored, including our patient. One lesion was an indurated nodule with central crusting , while aMicroscopically, perforation of bone through the epidermis was described for each lesion. An epidermal central channel, filled with the perforating bone, was noted; an associated inflammatory infiltrate was also present in the adjacent dermis. Bony nodules were present in the dermis and, in some lesions, calcium deposits were also apparent.The clinical differential diagnosis was described for three of the patients. The woman, who underwent mammography of her breast lesion, was diagnosed with a phlebolith. The pathologic differential diagnosis of the older man’s lesion, from most to least likely, included keratoacanthoma, squamous cell carcinoma, pilomatricoma, and pilomatrical carcinoma. The clinical differential diagnosis for our patient’s leg lesion included an ingrown hair, a foreign body reaction to keratin, a dermatofibroma, and a seborrheic keratosis.Treatment of the solitary perforating osteoma cutis lesion was surgical removal. One man’s lesion was diagnosed with punch biopsy followed by excision of the residual osteoma cutis . AnotherOne patient’s perforating osteoma cutis was considered to be primary . The othTattoos inks usually consist of a complex mix of organic and/or inorganic pigments dissolved in water. Issues of potential concern regarding tattoo inks include the presence of potentially toxic polycyclic aromatic hydrocarbons, organic colorants that have never been tested for use in contact with the human body, heavy metallic salts as contaminants, and the inclusion of nanoparticles -11. The Acute aseptic inflammatory reactions of variable intensity with erythema, induration, and an edematous “peau d’orange” dilatation of hair follicles often develop immediately during the tattooing session -14. HoweHypersensitivity reactions can occur in response to various substances in tattoo ink or in response to any topical agent applied during the healing phase  in sensitized individuals. These are classified histologically, and typically include eczematous, lymphohistiocytic, lichenoid, granulomatous, sarcoidosis-like, and pseudolymphomatous reactions . DelayedLichen planus, psoriasis, or vitiligo can also develop within a tattoo. Patients with chronic skin disorders that are known to koebnerize have a potential risk of localization of their skin disease on a tattoo. Risk factors include active disease as well as predisposing genetic features ,12. OtheCutaneous infections, including cellulitis, ecthyma, erysipelas, folliculitis, furunculosis, and impetigo, may occur after tattooing. There are several potential causes of the infection: the ink itself, inadequate disinfection of the skin area to be tattooed with superinfection due to scratching and subsequent inoculation of microorganisms, lack of hygiene control measures in the tattooing process, and insufficient personal hygiene . Viral dCutaneous malignancies appearing within tattoos include basal cell carcinoma, dermatofibrosarcoma protuberans, keratoacanthoma, melanoma, and squamous cell carcinoma. However, their discovery within tattoos may be a coincidental finding ,18. SurvMiscellaneous adverse events that have been observed within tattoos include foreign body granuloma and pseudoepitheliomatous hyperplasia. To this list, we also add osteoma cutis. Indeed, to the best of our knowledge, osteoma cutis secondary to tattooing has not been previously described.Isolated lesions of perforating osteoma cutis have rarely been described and can occur as either a primary or secondary condition. Multiple types of adverse events may occur in patients with tattoos; however, to the best of our knowledge, osteoma cutis developing in a tattoo has not been previously described. Therefore, we add osteoma cutis to the list of potential complications that can occur following the placement of a tattoo.


Cancer surgery has as its goal complete clearance and absolute containment of the malignant disease as it is being resected. Any aspect of the procedure which allows the escapes of malignant cells may result in disease recurrence.The patient presented to an emergency room with left-sided abdominal pain. Pelvic sonogram suggested the diagnosis of a ruptured left ovarian cyst. A uterine biopsy showed high grade serous carcinoma. Definitive treatment of the primary ovarian cancer wasen bloc laparoscopic resection of her uterus, Fallopian tube and ovaries.CT showed port site recurrence in both right and left upper abdominal trochar sites. The right-sided port site recurrence was through the fascia just lateral to the right rectus muscle and was small. A much larger port site metastases was present at the right trochar site that was through the left rectus muscle.The incidence of midline and lateral port site recurrence after laparoscopy for diagnosis or resection of ovarian cancer has not been determined. Limitation of trochar sites to the midline may reduce the extent of abdominal wall disease spread. Although cancer resection has as its goal complete curative resection of the malignancy, only a proportion of patients are cured. There may be situations where the surgical procedure with intention to completely resect and absolutely contain the disease results in dissemination of cancer cells. One surgical procedure reported to be oncologically flawed is morcellation of uterine leiomyosarcoma . Unfortu2www.researchregistry.com website with UIN 4797.Data on this patient was prospectively recorded and then retrospectively reviewed at an academic institution. This research work has been reported in line with the SCARE criteria . This st3In June 2012, a 62 year old woman complained of left-sided abdominal pain. In an emergency room a diagnosis of ruptured ovarian cyst was made. Her gynecologist performed a uterine biopsy which showed high grade serous carcinoma. Stage of disease was International Federation of Gynecologic Oncology (FIGO) IIc with positive peritoneal cytology.In August 2012, laparoscopic total hysterectomy with removal of adnexal structures, omentectomy, and para-aortic lymph node biopsy was performed. The upper abdomen was visually free of disease. Disease was confined to the pelvis. Postoperatively, modified FIGO stage was IC3 because of ovarian capsule rupture prior to surgery and positive peritoneal cytology. Postoperatively, she received intravenous paclitaxel and carboplatin for 6 cycles.In February 2015, colonoscopy was performed because of rectal bleeding. Biopsy of a lesion on the right side of the colon showed serous carcinoma.In April 2015, CT showed approximately 4 sites of disease progression. Cytoreductive surgery was performed for 11 h. It included peritoneal stripping of the undersurface of the right and left hemidiaphragms, completion greater omentectomy, small bowel resection, extended right colon resection, and pelvic peritonectomy. Intraoperatively, the patient received hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin and doxorubicin plus systemic ifosfamide and 2-mercaptoethane sulfonate Na (MESNA). HIPEC was performed before closing the partial resection of the right hemidiaphragm, before the ileocolic and small bowel anastomoses and before abdominal closure . The HIPIn January 2019, the CA-125 began to increase rapidly to 222 . A CT showed a left-sided full thickness abdominal mass located directly beneath the left upper abdomen laparoscopy port site . The masIn April 2019, the masses within the left rectus muscle progressed and required hospitalization for control of pain. An expanding left para-aortic mass was also present. Plans to resect the trochar site disease were delayed in order to begin additional systemic treatments.4There is no doubt that laparoscopic staging of ovarian cancer is being more frequently used . Also inIn this case report we have characterized port site metastases as an unintended consequence of laparoscopy to resect ovarian cancer. However, port site metastases are not restricted to ovarian cancer minimally invasive surgery. With uterine leiomyosarcoma, laparoscopic resection and then morcellation or slicing resulted in sarcomatosis in a majority of patients . These cThe location of the laparoscopic port site may be important in the progression that is observed. In our patient there was a 9 cm diameter mass in the left-sided port that seemed to pass through the middle of the left rectus muscle. On the right side the disease progression was lateral to the right rectus muscle and through the aponeuorosis. Yan and Sugarbaker observed that port site recurrence in the rectus muscle was likely to spread along muscle fascicles. Definitive resection required complete or near complete removal of that rectus muscle . That oc2 insufflation. Slight in and out or side to side movement of the trochar sheath may help deposit cancer cells on the lower aspect of the trochar tunnel. Postoperatively, ascites fluid may drain from the peritoneal cavity out through the port site and thereby seed the traumatized tissues. It has been well established that traumatized tissues are a site for high metastatic efficiency [The mechanism whereby port site metastases occur has never been clearly explained. Free cancer cells within the peritoneal space are necessary. A tunnel through the abdominal wall that allows access to abdominal wall tissue surfaces is necessary. Small amounts of peritoneal fluid containing cancer cells may be forced along the trochar site by intraabdominal pressure from COficiency . Sugarbaficiency . The larIn conclusion, laparoscopic resection of an ovarian cancer resulted in disease implantation within the abdominal wall. Extensive abdominal and pelvic treatments which involves cytoreductive surgery and perioperative chemotherapy adequately treated the intraabdominal component of the disease so that isolated port site metastases required resection. Surgical technology to prevent port site metastases have not been as yet described. However, limiting the ports to the midline may limit the disease progression within the abdominal wall and allow a less extensive surgical procedure if resection is required.Foundation for Applied Research in Gastrointestinal Oncology.Data management and secretarial support provided by Local IRB-approval for this case report was not required:does not meet the DHHS definition of research (45 CFR 46.102(d)(pre-2018)/45 CFR 46.102(l)(1/19/2017)) or the FDA definition of clinical investigation (21 CFR 46.102(c)) and therefore are not subject to IRB review requirements and do not require IRB approval.MedStar Health Institutional Review Board has determined that a case report of less than three  patientsThis case report is of 1 patient.Written and signed consent was obtained from the patient.Paul H. Sugarbaker, MD: study concept or design, data collection, data analysis or interpretation, writing the paper.This study was registered as a case report on the www.researchregistry.com website with UIN 4797.Paul H. Sugarbaker, MD.Not commissioned, externally peer-reviewed.Paul H. Sugarbaker has no conflicts of interest to declare.


Duplicate gallbladder is a congenital anomaly with various anatomical presentations that can pose difficult diagnostic dilemmas. This case presents the consequence of recurrent cholecystitis after prior cholecystectomy due to delay in diagnosis of a duplicate gallbladder and insufficient treatment at first presentation. It also provides the opportunity to discuss the anatomical variations of duplicate gallbladders and their clinical implications.We report on a 46-year-old woman who presented with symptoms of cholecystitis despite a history of cholecystectomy. Magnetic resonance cholangiopancreatography (MRCP) as well as review of intraoperative cholangiogram from the index surgery identified a cystic structure continuous with the biliary tree. Laparoscopic cholecystectomy was performed and histology confirmed a duplicate gallbladder. The patient did well post-operatively without any complications.Harlaftis’s classification of duplicate gallbladder categorizes anatomical variations based on embryological origin. Though rarity contributes to missed diagnosis, modern imaging techniques that delineate the biliary tree can identify these abnormalities. Recognizing these variations can identify risk for recurrent disease preoperatively and thereby guide surgical decision-making.Duplicate gallbladder poses a risk for the unique presentation of recurrent cholecystitis despite cholecystectomy. Advanced imaging techniques that demonstrate biliary anatomy can identify duplicate gallbladder perioperatively. For those presenting with disease in any one gallbladder, resection of both is ideal to prevent recurrence of disease. Here we2A 45-year-old woman referred to our tertiary referral center presented with a 1 month history of right upper quadrant pain exacerbated by meals with associated nausea and occasional abdominal distention. She had a surgical history of laparoscopic cholecystectomy 3 years prior and a Roux-en-Y gastric bypass with subsequent re-exploration due to internal hernia, both 1 year prior. She reported her symptoms resembled the pain she felt prior to her cholecystectomy.Abdominal examination demonstrated tenderness to palpation in the right upper and lower quadrants; no organomegaly or hernia defects were detected. Liver function tests identified marginally elevated AST (35 u/L) and alkaline phosphatase (154 u/L). CT scan done by her surgeon for evaluation showed a fluid collection in the gallbladder fossa of unclear etiology. Due to the persistent symptoms, she was referred for a second opinion to our tertiary care center.The differential diagnosis at that time included a remnant infundibulum from subtotal cholecystectomy, a pseudocyst of the common bile duct, a choledochal cyst, a recurrent internal hernia with postoperative changes on imaging, and a duplicate gallbladder. Review of her prior records showed that there was no aberrant anatomy noted during her initial operation, and that a cholangiogram was completed with no clear abnormalities identified by the surgeon at the time . PatholoShe was taken to the operating room and successfully underwent laparoscopic cholecystectomy. On dissection of the prior gallbladder fossa, clips from the prior cholecystectomy were identified along with the anomalous biliary structure inferior and lateral to the noted clips , which a3Duplicate gallbladders can be challenging to diagnose since they are rare congenital anomalies and because of a wide variation of presentations secondary to the multitude of embryologic etiologies. The variations were first classified by how the gallbladders drained into the common bile duct. Vesica fellea divisa denoted duplicate gallbladders sharing a common cystic duct while vesica fellea duplex described gallbladders draining through separate cystic ducts .The modern classification by Harlaftis takes embryological origin into consideration. Type 1 duplicate gallbladders arise from the same primordium but split later in development. These Type 1 gallbladders can often be identified by a common cystic duct that drains both gallbladders. The septate gallbladder is a single cystic structure separated into two by an involuting wall, though both gallbladders are joined at the base where they drain into a single cystic duct. In V-shaped variants the two gallbladders each have cystic ducts, which drain at a shared point along the common bile duct. In Y-shaped variants each gallbladder drains into its own cystic ducts, but these cystic ducts join to form a common cystic duct that drains into the common bile duct .In Type 2 variants, a distinctly separate primordia gives rise to the duplicate gallbladder which has its own second cystic duct and is often positioned more distantly than the Type 1 variants. This accessory gallbladder group is further subcategorized by the accessory gallbladder’s position in the biliary tree; ductular types drain into the common bile duct whereas trabecular types drain into either the right or left hepatic ducts . In our Appropriate diagnosis is important to avoid recurrence of disease, repeat procedures, and especially surgical complications secondary to distorted biliary anatomy . UltrasoPerioperative imaging options include abdominal CT scans, hepatobiliary iminodiacetic scanning, endoscopic retrograde cholangiopancreatography, transcutaneous cholangiography, or intraoperative cholangiograms, all of which delineate the biliary tree to varying precision . HoweverIn reference to the extent of surgical therapy for patients with duplicate gallbladder, clinicians should be aware that duplicate gallbladders pose a unique risk of recurrent biliary complications despite cholecystectomy. The occurrence of a duplicate gallbladder alone does not increase the risk of infectious biliary disease in an individual and thus does not warrant further investigation if noted incidentally . Each ga4Duplicate gallbladder poses a risk for the unique presentation of recurrent cholecystitis despite cholecystectomy. For those presenting with disease in any one gallbladder, resection of both is ideal to prevent recurrence of disease.We the authors Samuel J. Pera, Sonia T. Orcutt, and Noah Huh do not have conflicts of interest to declare.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Our institution does not require IRB or ethics approval for case reports.Written informed consent was obtained from the patient for 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.Sonia T. Orcutt: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Writing – Original Draft, Writing – Review & Editing, Visualization, Supervision, Project Administration. Samuel J. Pera: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Resources, Writing – Original Draft, Writing – Review & Editing, Visualization, Supervision, Project Administration. Noah Huh: Formal Analysis, Investigation, Writing – Original Draft, Writing – Review & Editing, Visualization.This is not a “first in man” study, requiring registration as per the journal Guide for Authors.As authors of the study, Samuel J. Pera, Sonia T. Orcutt, and Noah Huh agree to be the Guarantors of this case study.Not commissioned, externally peer-reviewed.


Renal sarcoma is a rare and aggressive malignancy without proper guidelines for treatment. Due to the aggressiveness of this disease and the potential for recurrence, we believe that extensive surgical resection with healthy margins may be the best option to treat this condition during both initial resection and resection of the recurrent lesion. Clinical follow‐up is also important to monitor for tumor recurrence. The goal of our study is to improve understanding of the clinical and pathological characteristics of this disease, as well as pave the way for future surgical treatment options for patients presenting with this malignancy.2A 55‐year‐old patient initially presented with gross hematuria and left flank pain. His physical exam revealed a palpable left abdominal mass. Past medical history was consistent with hypertension and dyslipidemia. Computed tomography (CT) showed a large mass occupying most of the left kidney, consistent with renal malignancy. A left radical nephrectomy with ipsilateral lymph node dissection was performed through left subcostal approach and mobilization of spleen and pancreas. The patient normally recovered after the operation and was discharged four days later.The pathology indicated malignant sarcoma involving the left kidney and peri‐renal adipose tissue. The mass measured 13.0 × 9.5 × 6.5 cm. There was no involvement of the renal vein or adrenal gland, and the two lymph nodes examined had no evidence of malignancy. Most of the tumor showed hypercellular fascicles of spindle cells with elongated, hyperchromatic nuclei, and eosinophilic cytoplasm. Thin, pink, wavy fibers between the tumor cells were characteristic of collagen and were indicative of a sarcoma with fibroblastic differentiation  and portions of the tumor had similar morphological features to the previous case. There were areas with more myxoid stroma that contained elongated, thin‐walled blood vessels, resembling the morphology of myxofibrosarcoma  were negative for malignancy.3Renal sarcoma is a rare malignancy that occurs in only 1% of all kidney cancer.Our patient's tumor overexpressed the MDM2 gene, located on the short arm of chromosome 12. Amplification of MDM2 is the primary feature of well‐differentiated liposarcoma, dedifferentiated liposarcoma, and well‐differentiated osteosarcoma. Amplification of MDM2 can be detected by fluorescence in situ hybridization (FISH) or by an immunohistochemical stain which highlights the nuclei of tumor cells. Abbas et. al. reported 7 cases of spindle cell tumors of the kidney, where a large panel of immunohistochemistry and fluorescence in situ hybridization (FISH) techniques were used to correctly diagnose the pathology of spindle cell sarcoma, using the streptavidin‐biotin‐peroxidase method.To our knowledge, our patient is one of the few reported locally advanced renal sarcoma cases who has managed to maintain an excellent performance status for more than 14 years after the initial diagnosis. Mayes et al4Renal sarcoma is a rare and aggressive disease. Extensive surgical extirpation with clinical follow‐up post resection is the corner‐stone for best outcomes. Further investigation is needed to define proper treatment guidelines for this disease.No conflict of interest.The authors listed below have made substantial contributions to the intellectual content of the paper in the various sections described below. MA and GC: involved in conception and design. MA, IZ, and AY: involved in acquisition of data analysis and interpretation of data. MA, IZ, AY, and NM: involved in drafting of the manuscript. GC: involved in critical revision of the manuscript for important intellectual content and involved in supervising the article.


Pneumocephalus (PNC) is a rare complication of transsphenoidal surgery that can result from cerebrospinal fluid (CSF) leak, allowing air entry into the CSF. We report the case of a 49-year-old female patient who presented to the emergency department three weeks after a transsphenoidal pituitary tumor resection, with symptoms of generalized throbbing headache associated with nausea. The patient was alert and oriented without any focal neurological deficit. A head computed tomography (CT) scan showed air in the subarachnoid space and ventricles. She was admitted to the hospital and was initially treated conservatively. However, her symptoms persisted, and a repeat head CT scan demonstrated worsening PNC. She then underwent lumbar drain placement and sellar floor repair. Her symptoms resolved postoperatively.When PNC results in intracranial hypertension, it is referred to as tension PNC, a complication that can be fatal. Conservative treatment involves analgesics and therapy for intracranial hypertension. Surgical intervention to decrease intracranial hypertension and repair the CSF leakage may also be necessary. Transsphenoidal surgery for pituitary adenomas is the standard surgical approach for most pituitary adenomas. Despite the improvement in the technique and availability of more modern tools, complications can still occur in around one percent of all cases . PneumocA 49-year-old female with a history of acromegaly, status post-transsphenoidal pituitary resection three weeks prior, presented to the emergency room with a headache and clear nasal discharge present since the removal of a nasal splint. The patient described the cephalgia as severe, intermittent and throbbing, exacerbated by standing up and coughing and relieved by lying down and acetaminophen. On physical examination, her vital signs were normal and the results of neurological examination were normal, but a minimal clear nasal discharge was noted. A computed tomography (CT) scan of the head showed multiple air loculi in the basal cisterns, lateral, third and fourth ventricles and numerous air-filled spaces also scattered in the brain. No mass effect or midline shift was seen Figure .Initial management consisted of bed rest in the Fowler position at 30° and instructions to avoid Valsalva maneuver such as analgesia, coughing, and sneezing. Besides the supportive treatment, the headache worsened, and a repeat CT scan showed mild increased diffuse PNC with intracranial air loculi in the parafalcine region, anterior horn of the left ventricle, posterior fossa, and left middle fossa. There was also an increased amount of air in the posterior fossa causing a mass effect on the pons Figure .She underwent a transsphenoidal endoscopic exploration of the sphenoid and sellar floor, with septoplasty and packing of the sphenoid sinus with abdominal fat graft, and with the insertion of a lumbar drain. After these procedures, she showed a significant improvement of her symptoms, the lumbar drain was removed after five days, and her headache and nasal leakage resolved. She was discharged on day 10 of hospitalization. At the time of follow up, the patient was free of symptoms, and repeat CT-scan revealed resolved PNC Figure .Pneumocephalus, the accumulation of air in the epidural, subarachnoid, intraventricular, intracerebral and subdural spaces, has been reported as a complication of neurosurgical and otolaryngological procedures . Two mecCurrently, no consensus treatment guidelines exist for PNC. Supportive treatment involves bed rest, avoiding Valsalva maneuver such as coughing and sneezing, Fowler position of 30°, analgesia, osmotic diuresis, and antipyretics to prevent hyperthermia. High-flow oxygen through a nasal cannula and hyperbaric oxygenation therapy have been shown to be beneficial in particular cases -7. This Serial imaging with CT scan is an efficient and reliable way to follow the patient’s progression -9. TherePneumocephalus is an uncommon but potentially lethal complication of transsphenoidal surgery which can present as dull headache. As such, it could be overlooked at the time of follow up if the provider is not aware of this possibility. It is crucial to consider PNC as a differential diagnosis in patients presenting with headaches or neurological symptoms after transsphenoidal surgery.


Zinner syndrome is a rare congenital malformation characterized by the association of an ipsilateral renal agenesis, ipsilateral seminal vesicle cyst, and ipsilateral ejaculatory duct obstruction. This case is one of the first to be reported in the Kingdom of Saudi Arabia. A 20-year-old Saudi male patient presented complaining of chronic left groin pain radiating to the left testis and the medial aspect of the left thigh for the last 6 years. Patient is also complaining of painful ejaculation with no history of lower urinary tract symptoms, hematuria, or trauma. Physical examination was unremarkable. Ultrasound (US) report from the referring hospital mentioned that there is a left pelvic mass. Computed tomography (CT) and magnetic resonance imaging (MRI) showed diffuse distension of left seminal vesicle (9 X 7 cm) cyst with ipsilateral left renal agenesis which corresponds to Zinner syndrome. Left seminal vesicle cyst excision through a low midline incision was done. The patient was asymptomatic during his follow-up in our clinic with disappearance of the pain. The combination of a good clinical history and radiological assays aided in making the diagnosis. Surgical intervention is the mainstay in the management plan in symptomatic patients. Zinner syndrome is a rare congenital malformation characterized by the association of an ipsilateral renal agenesis, ipsilateral seminal vesicle cyst, and ipsilateral ejaculatory duct obstruction which was first described by Zinner et al. in 1914 . This caA 20-year-old Saudi male patient not known to have any chronic medical illness was referred to our urology department complaining of chronic left groin pain radiating to the left testis and the medial aspect of the left thigh for the last 6 years. Patient is also complaining of painful ejaculation with no history of lower urinary tract symptoms, hematuria, or trauma. Physical examination was unremarkable. Laboratory tests were ordered including complete blood count and renal function tests which all were within normal ranges. Ultrasound (US) report from the referring hospital mentioned that there is a left pelvic mass. Computed tomography (CT) and magnetic resonance imaging (MRI) showed diffuse distension of left seminal vesicle (9 X 7 cm) cyst  with ipsZinner syndrome is one of the rarest congenital anomalies of the urogenital tract and is usually discovered and diagnosed in the 2nd-4th decade of life . The freThe embryological origin of the kidneys and seminal vesicles is similar; the kidney is formed by the metanephric blastema which is induced by ureteral bud that originates from the dorsal aspect of the distal mesonephric duct. The mesonephric duct gives rise to most of the genital tract including epididymis, vas deferens, ejaculatory duct, and seminal vesicle . Any malRadiological modalities have a significant role in diagnosing and evaluating Zinner syndrome including US, CT, and MRI. US is a quick imaging modality that is used mainly in this condition to detect the absence of the ipsilateral kidney or to show some anechoic structures in the pelvis resembling the obstructed ejaculatory duct , 6. CT fManagement of the seminal vesicles cysts depends on the presentation and the presence of symptoms, and asymptomatic patients are usually observed until they start to complain of symptoms. Surgical intervention can be carried out by different modalities and techniques reported in the literature. First option is open surgical excision, and minimally invasive surgeries including the laparoscopic and robotic-assisted approaches are considered the best option due to their better outcomes, less blood loss, and shorter hospitalization –11. AnotThe association of ipsilateral renal agenesis and ipsilateral seminal vesicle cyst is a rare unique congenital presentation that is called Zinner syndrome. The combination of a good clinical history and radiological assays aided in making the diagnosis. Surgical intervention is the mainstay in the management plan in symptomatic patients. Relieving the patient symptoms and improving his quality of life were our main goal which was accomplished.


Syringomas are benign, eccrine sweat gland tumors frequently found on the eyelids and neck in post-pubescent women and may present in healthy individuals or be associated with various medical comorbidities. We present a case of an otherwise healthy 19-year-old female with an abrupt onset of disseminated syringomas on the bilateral forearms and dorsal hands. Eruptive acral syringomas have not been previously reported in adolescents, and this diagnosis should be considered in patients presenting with a papular eruption on the hands and forearms. Syringomas are benign, adnexal tumors of unknown etiology that derive from eccrine sweat ducts . They arA 19-year-old Hispanic female presented with complaints of an eruption of the hands and forearms that had started one year prior. She reported mild associated pruritus, which increased with exposure to natural sunlight. She denied the involvement of the head, trunk, lower extremities, or genitalia. She took no daily medications and had no chronic medical problems. There was no evidence of conditions associated with syringomas on history, physical exam, or workup. The physical exam revealed numerous, light brown, ovoid papules on the dorsal hands and fingers and on the dorsal and ventral surfaces of the forearms, with some areas of confluence on the lateral dorsal hands Figures . SimilarTo our knowledge, our case appears to be the first report of eruptive acral syringomas in an adolescent. Eruptive acral syringomas are extraordinarily rare with a total of 13 previous cases reported in the English-language medical literature (Table Lesional specimens will typically exhibit a “paisley-tie” pattern in the superficial to mid-dermis, with tadpole-shaped ducts embedded in a red, sclerotic stroma and will exhibit positive staining against keratin, carcinoembryonic antigen, and S-100 proteins . A diffeOur case demonstrates a unique example of a healthy, 19-year-old female with eruptive syringomas on the upper extremities. This diagnosis should be entertained in patients presenting with a papular eruption on the hands and forearms.


A 34-year-old male was admitted at our Department for back pain and a right paravertebral mass at the chest x-ray. His medical history was positive for beta-thalassemia major with normal routinely blood tests. A contrast-enhanced chest computed-tomography showed a 26 x 15 mm right solid paravertebral round-shaped lesion at T8-T9 levels, with a small inner component of adipose tissue (Panel A). Contrast-enhanced magnetic resonance-imaging showed irregular low signal intensity in long TR sequences, with mild enhancement after contrast administration . Surgical excision of the lesion by means of video-assisted thoracic surgery was scheduled for both definitive diagnosis and therapeutic purpose. Histopathologic examination revealed the presence of adipocytes mixed with mature hematopoietic cells (Panel D). Differential diagnosis included mediastinal myelolipoma (MM) and extramedullary hematopoiesis (EH). In fact, both of them are composed of fat and hematopoietic tissue. Mediterranean anemia is a common finding in patients with EH. However, the presence of a single capsulated tumor and the absence of abnormal hematopoietic cells led to a final diagnosis of MM. The patient is currently alive without recurrence 23 months after surgery. Myelolipoma is a benign tumor usually arising in adrenal glands. Less than 50 cases of MM have been described in the literature to date. Many Authors currently support the role of a triggering condition , which might be responsible for the growth of ectopic adrenal or hematopoietic tissue. Patient's history, radiologic, and pathologic features must all be taken into due consideration in differential diagnosis between MM and EH.


Isolated splenic hydatid cyst is a very rare manifestation of hydatid cyst. Rarely, patients present late after the cyst is ruptured. They might not present with usual presentations such as the acute abdomen, anaphylaxis, or urticarial rashes but only with a distended abdomen. Splenectomy is the emergency operative management. Isolated splenic hydatid cyst is a very rare manifestation of hydatid cyst. Rarely, patients present late after the cyst is ruptured. They might not present with usual presentations such as the acute abdomen, anaphylaxis, or urticarial rashes but only with a distended abdomen. Splenectomy is the emergency operative management. Once ruptured into peritoneal cavity, splenic hydatid cyst presents with features of acute abdomen, abdominal distension, urticarial rashes, or anaphylactic shock. We report a case of middle‐aged woman with ruptured splenic hydatid cyst who presented with distended abdomen.Hydatid disease is a zoonotic disease, common in Mediterranean region caused by Echinococcus granulosus and less frequently by Echinococcus multilocularis. Devleesschauwer et al reported echinococcosis is probably endemic and quantifiable in Nepal with DALYs of 667.2A 49‐year‐old Hindu woman presented to Tribhuwan University Teaching Hospital emergency with abdominal pain for 3 months and generalized abdominal distension for 10 days. Abdominal pain, intermittent in nature was localized on left upper quadrant with intensity of 4/10 in the numeric rating scale of pain. Her abdominal pain worsened abruptly 10 days back and had multiple episodes of vomiting and diarrhea on the same day followed by brief loss of consciousness and dizziness. She also complained of decreased urine output for 10 days following the episode along with gradual and progressive bilateral limb swelling. She had no fever, melena, yellowish discoloration of body, or history of abdominal trauma. She was an ex‐smoker and was regularly taking medications for COPD. She had no other comorbidities. She had not worked directly in contact with sheep or dogs before.On presentation at the ER, she was ill looking with bilateral lower limb edema. Her blood pressure was 90/60 mm Hg, afebrile with pulse rate of 96 bpm and normal respiratory rate. There were no rashes in her abdomen which was soft, distended, and nontender. On percussion, there were dull notes over the abdomen with shifting dullness. Spleen was palpable; however, liver was not enlarged. Chest and CVS examinations were unremarkable.Hematology revealed total white blood cell count of 4700/cc with 40% eosinophils. Hemoglobin was normal 12.4 gm/dL) along with normal coagulation essay. Biochemistry revealed normal renal function and normal liver function tests except hypoalbuminemia (24 g/L). Abdominal sonogram revealed gross free fluid in abdomen and pelvis. Ascitic fluid assay revealed white blood cell count of 1400/cc with 40% polymorph with negative ADA and low SAAG (9.5 g/L). Routine examination of stool and urine were unremarkable. CECT revealed splenomegaly with nonenhancing cystic lesion of size 14.5 × 11.5 × 10.6 cm within splenic parenchyma extending into perisplenic region with floating membrane within the cyst. .5%.2, 3, Hydatid cysts rupture either after trauma or spontaneously due to raised intracystic pressure. Beyrouti et al reported that only 1.7% of the total studied cases of hydatid cysts presented acutely with rupture in the peritoneal cavity.Emergency splenectomy is the treatment of choice in case of ruptured splenic cysts.4Ruptured splenic hydatid cyst, a very rare entity presents usually with acute abdomen, anaphylaxis but it can present with distended abdomen only. US/CT can be diagnostic and Emergency laparotomy and splenectomy should be done. Postsurgical albendazole therapy for 3 months is advised to prevent recurrence along with meticulous follow‐up.None declared.SA wrote the manuscript while BG and NK were involved in editing. All three authors were involved in management of patient.Not applicable.Patient provided informed consent for publications.


Multiple myeloma (MM) of the larynx is extremely rare. It can be either a laryngeal manifestation of a general multiple myeloma or it can occur as a primary laryngeal mass, which is then called extramedullary plasmocytoma (EMP). We present the case of an 81-year-old male patient who was admitted for dyspnea. He had a history of multiple myeloma but was in complete remission since some years. Histological and immunohistological examination of tissue samples revealed an EMP. The patient was first treated by laser surgery in order to reduce the tumor mass and secure the airway. Afterwards, he was systematically treated by radiation therapy with 60 Gy, which achieved a good response and complete remission proven by control laryngoscopy and histological examination of tissue samples taken from the former tumor area three months after laser excision. The latest literature in the field is reviewed. There were only ten cases of EMP in the larynx or laryngeal involvement of MM published within the last five years . Due to its rarity, there are currently no evidence-based therapeutic guidelines available. For their development, multicenter studies are required. Multiple myeloma is a clonal malignant systemic disease of terminal differentiated B cells (plasma cells). The annual incidence in Germany is 4/100000 [These monoclonal plasma cells can also exclusively involve soft tissues, which is then called extramedullary plasmocytoma (EMP). 80–90% of EMP is located in the head and neck which accounts for about 1% of all head and neck tumors . The mosCurrently, only few cases of EMP located in the larynx or laryngeal involvement of MM have been reported in the international literature so far. Due to the rarity, to date consistent criteria for staging and treatment do not exist. This makes diagnosis and therapy challenging.We here present a case of an extramedullary recurrence of a multiple myeloma involving exclusively the larynx.An 81-year-old male patient was referred to our department with dysphonia. There was no history of smoking. A status past multiple myeloma was known in his medical history that was in complete remission at the time of presentation. The patient denied dyspnea, dysphagia, pharyngalgia, and fever. Laryngoscopy revealed a diminished mobility of the right vocal cord and a thickening of the right vestibular fold so that a microlaryngoscopy with tissue sampling was performed. The histological examination of specimens obtained from this region revealed fibrosis. Computed tomography (CT) scans of the neck and the thorax were without any pathologic findings. The patient was discharged to outpatient care.Three months later, the patient was admitted with progressive dyspnea along with inspiratory stridor. The clinical examination revealed now a complete paralysis of the right vocal cord and a remaining glottic cleft of only 1 mm due to a supraglottic protrusion of the right vestibular fold. The CT scan  showed nAfter tumor debulking in order to expand and secure the airway, the excised material that consisted of several red brown elastic tissue fragments measuring together 24 × 12 × 10 mm was sent for pathological examination. Histologically, one could see tight lymphoid infiltrates. The cells had large nuclei and were irregularly shaped, and the proliferation was strongly enhanced in the staining for Ki67 (50%). The immunohistochemical analyses showed a negative result for CD20 and CD3, and a positive staining for CD138. BCL2 and CD10 were coexpressed . The cloThe patient was referred to the Department of Hematology and a systemic therapy with the proteasome inhibitor Bortezomib was discussed. Ultimately, instead of that, a local radiation therapy with 60 Gy was performed. In a control laryngoscopy with tissue sample taken after the radiotherapy, the myeloma could not be verified anymore. The patient is in continuous otorhinolaryngological and oncologic follow-up. To date, almost two years later, no recurrence of the myeloma has occurred so far.The monoclonal terminally differentiated plasma cells of MM occur in the bone marrow as well as in soft tissues. Usually, patients with MM suffer from weakness, loss of weight, an increased susceptibility for infections, osteoporosis, pathologic fractures, hyperviscosity syndrome, or nephrotic syndrome –7. The mThe laryngeal involvement is extremely rare and then can occur primarily as EMP (6–18%)  or seconThe histological examination is challenging because a clear delineation to other pathologies, i.e., chronic inflammatoric diseases or plasma cell enriched polyps as well as amyloid deposit, can be difficult , 15. TheImaging techniques, i.e., computed tomography or magnetic resonance tomography, are helpful in order to clarify the local involvement of anatomical structures as well as to exclude further osseous and soft-tissue lesions and lymphadenopathy . TypicalHere, we have reviewed the latest literature. Ten cases of MM in the larynx or laryngeal EMP have been published in the last five years according to our Pubmed search , 20–27. As far as therapy is concerned, it is the experience of the published cases in the last five years that the patients with preknown MM benefit from local treatment with radiation therapy and subsequent systemic therapy , 22. PatThe treatment performed in the present case fits well in the series of similar cases in the literature.2-laser excision in combination with radiotherapy, might be appropriate [The cases of the last five years show that there is no overall consensus regarding therapy for laryngeal EMP due to its rarity. There is some evidence that it is well treatable with radiotherapy with a good local control . Alternaropriate , 27. TheAutologous or allogenic stem cell transplantation is regarded as further alternatives to systemic therapy of MM . As therIn conclusion, EMP of the larynx or laryngeal involvement of MM is extremely rare. It should be taken under consideration in cases with subepithelial diseases of the larynx. For histological examination, a deep and submucosal tissue sample is mandatory and diagnosis can only be made histologically and immunohistologically since urinary Bence Jones proteins or serum multiple myeloma protein can only be found occasionally .


Bowel incarceration represents a dreaded complication amongst patients with hernias. The intraoperative evaluation of the bowel perfusion following hernia reduction with regard to the need for resection of ischaemic bowel can be challenging. In this case report we discuss intraoperative fluorescence angiography with indocyanine green (ICG) as an objective means of accessing bowel perfusion following hernia reduction.The case of a 92-year-old, caucasian, female patient presenting with symptoms of small bowel obstruction secondary to an incarcerated left sided obturator hernia is presented. An incarcerated segment of the small bowel was reduced during emergency laparoscopy. Intraoperative ICG fluorescence angiography revealed ischaemic changes in the normal appearing bowel, so that the involved segment was resected. The postoperative course was uneventful and the patient was discharged home safely on postoperative day seven.Intraoperative ICG fluorescence angiography provides an objective method of judging bowel perfusion and therefore represents a useful tool for assessing intestinal perfusion in patients with incarcerated hernia. Obturator hernia defines a herniation into or through the obturator foramen. Hernia obturator accounts for just about 1% of all hernias and is truly a rare entity. Obturator hernias occur more frequently in elderly multiparous women and patients with laxity of the parietal peritoneum . A positIntraoperative assessment of the bowel perfusion with the need for bowel resection due to irreversible ischaemic changes is of utmost importance in the management of incarcerated hernias. The observation of bowel colour and the presence of peristalsis constitute the most common means of judging intestinal viability. These observational features however, can be very subjective and might not be readily reproducible . IntraopA 92-year-old caucasian female with no previous history of abdominal surgery was admitted to our department with diffuse abdominal pain and vomiting. Physical examination revealed abdominal distension with muscle rigidity and absent peristalsis. Examination of her groins did not reveal any swelling. Bowel decompression via a nasogastric tube revealed small bowel content. A plain x-ray of the abdomen showed multiple dilated loops of small intestines. A CT of the abdomen identified the cause of the small bowel obstruction to be a herniation of the ileum between the internal and external obturator muscles (obturator foramen) with signs of incarceration, Figs. The case of a 92 – year old female patient presenting with bowel obstruction secondary to an incarcerated obturator hernia is presented. The diagnosis was confirmed following abdominal CT. Diagnostic laparoscopy was performed and the trapped small bowel loop was reduced. Real-time ICG fluorescence angiography indicated ischaemic changes of the trapped loop warranting resection.Traditionally, laparotomy has been considered the most common treatment option . HoweverIntraoperative evaluation of the intestinal perfusion with the need for bowel resection in case of irreversible ischaemic changes is of utmost importance in the management of incarcerated hernia. Judging the viability of the bowel segment in question might not always be easy. Intestinal coloration and the presence or absences of peristalsis are commonly used to judge bowel viability . Both paReal-time fluorescence angiography with ICG on the other hand is a reliable and objective means of assessing intestinal blood flow. This technique has been extensively employed in the evaluation of anastomotic perfusion in colorectal surgery –12. BesiICG can be injected intravenously and the presence of intestinal blood flow can be visualised using a laser beam or a near-infrared camera as it becomes fluorescent , 11.Obturator hernia is a very rare entity with a high risk of bowel incarceration. The laparoscopic approach should be favoured where necessary. Intraoperative ICG fluorescence angiography might be helpful in discrimination viable from ischaemic bowel thereby facilitation the decision for or against bowel resection.


SANT of the spleen is a benign lesion that does not recur after splenectomy with unknown etiology.We report a case of sclerosing angiomatoid nodular transformation (SANT) of the spleen mimicking a splenic abscess in a patient with imaging studies that failed to differentiate this lesion from other splenic lesions.SANT of the spleen is a rare condition, with only less than 100 cases reported in the literature. Clinically, SANT is only a kind of described pathological diagnostic conception. As in our case, these splenic lesions are often incidental findings on imaging studies performed for other reasons.The patient was treated with splenectomy, which has proved to be both diagnostic and therapeutic. Although histology can lead to the diagnosis of vascular tumor, immunohistochemistry is the only way to confirm the diagnosis. In this report, we present a new case of SANT mimicking a splenic abscess that had been treated with splenectomy successfully. We hope this report will help to accumulate more experience for an accurate diagnosis and proper therapy of SANT. The work has been reported in line with the SCARE criteria .2th. The pathological examination documented a splenic mass (4.5 × 3.5 cm) formed by many little nodules composed by “like capillary” vascular spaces surrounded by thick connective tissue. Immunohistochemical profiles was then performed and diagnosis of SANT was made  with a not uniform enhancement . At the was made . The pat3Splenic lesions are commonly encountered and are often incidental in nature. Benign splenic vascular neoplasms include hemangioma, hamartoma, lymphangioma, extramedullary hematopoiesis (EMH), and sclerosing angiomatoid nodular transformation (SANT) . SANT ofBecause the differential diagnosis for a hypodense mass in the spleen includes lymphoma, metastasis, and benign lesions such as hamartoma, diagnostic studies are essential in the management. On computer tomography scans (CT) and MRI, SANT is a hypodense mass . Karaosm4The present study reports a novel case of SANT that underwent splenectomy successfully. Further case studies are needed to elucidate the mechanism of SANT and its possible various etiologies. In the light of above splenectomy at now is the choice treatment both for diagnosis and treatment.The authors declare no potential financial conflict of interest related to this manuscript.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The study is exempt from ethnical approval.Written consent was obtained by the patient.Study concept and design: P. Fransvea, M. Capaldi.Data Collection: M. Capaldi.Data Analysis and interpretation: P. Frasvea, G. Ricci.Writing the paper: P. Fransvea, M. Capaldi.Revision: P. Marini G. Rcci.Not needed.Massimo Capaldi MD is the Guarantor of the study.Not commissioned, externally peer-reviewed.


Advanced hepatocellular carcinoma (HCC) with macrovascular invasion has an extremely dismal prognosis. We report a rare case of multiple HCC with tumor thrombosis in the portal vein and inferior vena cava that was initially treated with hepatic arterial infusion chemotherapy (HAIC); later resection revealed pathological complete response.2] + cisplatin [7 mg/m2]) via an indwelling port. Although the tumor shrank and tumor marker levels decreased rapidly, we abandoned HAIC after one cycle because of cytopenia. We resumed HAIC 18 months later because of tumor progression, using biweekly 5-fluorouracil only [1000 mg] due to renal dysfunction. However, after 54 months, the HAIC indwelling port was occluded. The patient therefore underwent a right hepatectomy to resect the residual lesion. Histopathological findings showed complete necrosis with no viable tumor cells. The patient has been doing well without postoperative adjuvant therapy for more than 10 years after initially introducing HAIC and 6 years after the resection, without evidence of tumor recurrence.A 75-year-old man presented with HCC in his right liver, with tumor thrombosis growing to the right portal vein and the inferior vena cava, and bilateral intrahepatic liver metastases. He underwent HAIC (5-fluorouracil [170 mg/mHAIC can be an effective alternative treatment for advanced HCC with macrovascular invasion. Advanced hepatocellular carcinoma (HCC) with macrovascular invasion has an extremely poor prognosis, with a reported median survival time (MST) of 2.7–3.1 months if left untreated . SorafenIn Eastern Asian countries, various treatment options are available for HCC with macrovascular invasion, including systemic chemotherapy, hepatic arterial infusion chemotherapy (HAIC), transcatheter arterial chemoembolization, and surgery. Treatments are selected individually, depending on the extent of tumor thrombosis, degree of underlying cirrhosis, and patient’s performance status, which can affect prognosis. However, no guidelines clarify a preferred non-operative treatment based on available evidence. We herein report a patient with multiple HCC with PVTT and IVCTT who survived after HAIC, followed by a resection that showed pathological complete response (CR) and tumor-free status for more than 6 years.In February 2009, a 75-year-old man with a history of alcoholic liver disease was referred to our hospital for evaluation of multiple liver masses on abdominal ultrasound sonography. The patient had no history of hepatitis of B or C infection. Abdominal enhanced computed tomography (CT) showed 13-cm hypovascular liver tumors  and cisplatin (7 mg/m2) continuously on days 1–5 via an implanted catheter system was administered. One cycle of HAIC consisted of 5 days of treatment and 2 days rest per week for 4 consecutive weeks. Despite significant decrease in tumor markers and remarkable regression of intrahepatic lesions, PVTT, and IVCTT on enhanced CT after one HAIC cycle  [HAIC uses high concentrations of anticancer agents administered directly into the hepatic artery via an injection port. It can enhance efficacy of drugs by localizing their application and minimizing systemic adverse effects. HAIC is frequently used against advanced HCC with macrovascular invasion in Eastern Asian patients. Among several HAIC protocols, the combination of 5-FU and cisplatin is one of the most common therapeutic regimens although there are slight differences of dose and duration setting in each study; a high response rate of 31–48% and improved MST of 14.0–31.6 months have been reported , 21–24. = 0.013) . Kudo et= 0.013) . While iIt is controversial whether duration of HAIC reflects therapeutic effect. In the previous reports that described pathological CR by HAIC alone, the treatment periods ranged from 3 to 26 months –20. In tEven though only systemic chemotherapy has been approved worldwide for patients with advanced unresectable HCC, the present case suggests HAIC has been effective and can be an alternative treatment option for advanced HCC with macrovascular invasion.


Intracranial metastasis of Gastrointestinal Stromal Tumors (GISTs) is rare but presents unique treatment challenges. We present a case of intracranial metastasis of GIST with a systematic review of the literature. A literature search using key terms “‘gastrointestinal stromal tumor’ AND brain AND metastasis”” was conducted through May 2019 via Embase and Pubmed according to PRISMA guidelines. Only cases describing intradural metastases rather than calvarial or intraorbital metastases were included.A 57-year-old woman with history of GIST metastatic to the liver presented with a six-week history of left facial weakness, left hearing loss, and left facial numbness, and a one-week history of headaches, gait disturbance, and dizziness. MRI revealed a contrast-enhancing dural-based left middle cranial fossa mass measuring 2.9 cm × 3.1 cm × 3.4 cm with extension into the internal auditory canal and cerebral edema. A left temporal craniotomy was performed to excise the lesion, and the patient was discharged to a rehabilitation facility at her preoperative baseline. Intraoperative pathology revealed a spindle cell neoplasm, postoperative MRI demonstrated gross total resection of the lesion, and microscopic analysis demonstrated sheets of spindled tumor cells with short ovoid, irregular, hyperchromatic nuclei and scattered large atypical nuclei without extensive necrosis. Immunohistochemical staining was positive for KIT proto-oncogene , and the patient was put on imatinib (400 mg/day).Of the 18 cases analyzed and our present case, metastasis typically involved the cerebrum with only one in infratentorial elements. The tumors in seven of the cases involved the dura, and one case metastasized to the pituitary. Eight patients died following treatment. Surgery remains the mainstay of intracranial metastatic GIST, however there are many reports of good responses to radiation or chemotherapy alone. More investigation is required to determine the best treatment course for these patients. Gastrointestinal Stromal Tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract, arising from the Interstitial Cells of Cajal. The most common location is the stomach (60%), followed by the jejunum and ileum (30%), duodenum (5%), and colorectum (< 5%), with rare reported cases arising in the esophagus, appendix, and gallbladder. Initially thought to be tumors of smooth muscle, advances in immunohistochemistry and molecular genetics have found that this is not the case. Specifically, most GISTs express KIT CD 117, c-KIT), a highly sensitive and specific marker for GIST, while leiomyomas and leiomyosarcomas do not 17, c-KIT. GISTs aImatinib, the mainstay medical treatment for GIST, does not cross the blood-brain barrier, and as such may offer limited clinical benefit to patients with intracranial metastasis . NeverthHere, we present a case of intracranial metastasis of GIST with a discussion of relevant literature regarding this rare clinical scenario. We aim to study our current case with respect to historical studies to better investigate the best course of treatment for patients with this rare manifestation of GIST.A thorough systematic review of the literature was performed through the databases Embase and Pubmed from dates of inception to May 2019 to identify cases of GIST metastatic to the brain. The string “‘gastrointestinal stromal tumor’ AND brain AND metastasis”” was used as either keywords or Medical Subject Headings terms to identify all eligible studies. Inclusion and exclusion criteria from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to vet the retrieved articles . For theA 57-year-old woman with known history of biopsy-proven GIST metastatic to the liver presented with a six-week history of left facial weakness, difficulty closing her left eye (House-Brackmann 4), complete left hearing loss, and left facial numbness. She had been previously diagnosed at an outside institution and initiated on imatinib (400 mg daily) 3 months prior to presentation, In the week prior to presentation, she had developed headaches, gait disturbance, and dizziness. MRI revealed a contrast-enhancing dural-based left middle cranial fossa mass measuring 2.9 cm × 3.1 cm × 3.4 cm with extension into the internal auditory canal and associated cerebral edema (Fig. The patient underwent left temporal craniotomy to excise the lesion without complication. Intraoperative pathology revealed a spindle cell neoplasm. Her post-operative course was uncomplicated; after an overnight stay in the ICU, the patient was transferred to the floor and discharged to a rehabilitation facility at her preoperative baseline. Postoperative MRI demonstrated gross total resection of the lesion. Microscopically, the tumor demonstrated sheets of spindled tumor cells with short ovoid, irregular, hyperchromatic nuclei and scattered large atypical nuclei without extensive necrosis Fig. a-d. ImmuThe initial database query yielded 192 publications after duplicates were removed. Screening of these publications based on abstracts yielded 24 publications, which was then further refined to 18 after the exclusion of 6 articles discussing GIST and metastases not to the brain Fig. . These 1In our review of the literature, only 18 cases of GIST with intracranial metastases were identified, and these are summarized in Table Metastatic GIST to the brain is a rare clinical entity requiring unique considerations for treatment. Interestingly, there was substantial variation in the treatment of these patients, reflecting the lack of evidence-based guidelines for treatment of intracranial GISTs. Nevertheless, treatment regimens in reviewed papers generally include combinations of surgery, radiotherapy, and systemic chemotherapy with tyrosine kinase inhibitors, similar in concept to treatment of other intracranial metastases. Thirteen of nineteen patients reported here underwent treatment with tyrosine kinase inhibitor therapy, while the other six patients received no specific chemotherapy. Traditionally, treatment of advanced or metastatic GIST has been challenging due to the tumor’s resistance to cytotoxic chemotherapeutic agents . With thGIST, similar to the histologically-similar soft tissue sarcomas, is generally considered to be radioresistant. As such, radiation has been considered to have a limited role in treatment. Nevertheless, some series have reported at least a good palliative effect of radiotherapy for GIST metastases that are refractory to therapy or not amenable to surgery . Eight pFinally, surgery consisting of local control of intracranial disease with adjuvant therapy remains a useful treatment modality for metastatic GIST, especially with regards to intracranial metastases , 17, 18.


Cystic lymphangioma is a benign malformative tumor. The abdominal localization is rare. The diagnosis is not easy in preoperative period. The surgery is the choice in the abdominal and symptomatic localization.We report a 26 years old women. She consulted with left hypochondrial pain. The exam found left hyphochondrial swelling with 10 cm of diameter. The biologic screeming was normal. The ultrasound showed a multiloculated cyst which measured 130*80 mm. the CT scan showed a mesenteri cyst mass measured 15 cm. A fine needle aspiration cytology guided by abdominal ultrasound was realized and the cytology doesn’t show malignant cell. A median laparotomy found a mesenteric cystic mass measured 15 cm of diameter. A resection was realized. The histologic exam membranous fibrosis cyst limited by an endothelium.Mesenteric localization of cyst lymphagioma is rare. The surgery is safe and efficiency for the treatment. It is a spontaneous malformation composed by lymphatics vessels and lymphoid tissue ,3. It is2The present case is a 26 years old woman, without medical antecedent. She consulted for abdominal pain in left hypochondrial and flank regions evolving for 72 h without transit disorders. The patient was afebrile with a normal hemodynamic monitoring. At the physical exam, there was a left hypochondrial swelling with 10 cm of diameter, slightly mobile. A biologic screening was performed with an elevated CRP at 96,6 mg, without elevation of leucocyte at blood count, a normal hepatic, pancreatic, and renal functions. The ACE and CA19-9 was normal respectively at 4 ng/ml and 32 UI/ml. The abdominal ultrasound showed a multiloculated cyst which measure 130*80 mm, with a thick wall localized at the infero-internal edge of the liver. The abdominal CT scan with contrast showed a mesenteric liquid mass, in the bilio-pancreatic intersession measured 15 cm and pushing back the adjacent organs, without secondary localization , Fig. 2.A median laparotomy was performed, and the exploration found a mesenteric cystic mass measured 15 cm of diameter, resecable. A resection was realized, and the mass sent for a histological exam. The histological exam revealed a membranous fibrosis cyst measured 10*6 cm with multiple cavities limited by an endothelium with striated muscle tissue. This histological result confirmed the diagnosis of cystic lymphangioma.3-a cystic formation,-the septa are constituted of a connective stroma with lymphoid tissue and striated muscle,-the cyst is lined with a lymphatic endothelium with a positive D2-40 marker, specific to detection of lymphangiogenesis and lymphatic vessel invasion .Cystic lymphangioma is a benign and rare tumor of lymphatics vessels. It is localized in subcutaneous tissue of face and neck (60%), limb 20%), thoracic 10%) and axillar regions. The abdominal (2–10%), and thoracic (5%) localizations are rare ,14. In a% and axi%, thoracIn case of accidental discovery of an asymptomatic lymphangioma cyst, therapeutic abstention with a regular follow up is recommended ,28. A spA total surgical excision is major to avoid recidivism and should be conservative for the adjacent organs because of the benign character of lymphangioma . During The aspiration of the cyst content with or without injection of sclerosing product has variable long-term results: frequent recidivism, up to 100% for certain series . This teAnother therapeutic alternative is the per cutaneous sclerosis with sclerosing products like sulfate de bleomycin, doxycycline, OK 432, acetic acid, absolute alcohol . The res4Cystic lymphangioma is a rare evolutive malformation benign tumor, requiring a complete surgical excision to minimize any recidivism. Aggressive surgery with extensive resection of adjacent organs to the cystic lymphangioma is prohibited because of its benign character. The positive diagnosis is histological. In case of surgical abstention, the patient should undergo a regular screening with ultrasound and a medical treatment. Persistent symptoms under medical treatment indicate a surgery. The per cutaneous treatment is reserved for cases requiring an extensive resection.The authors declare they have received no funding for the preparation of this documentThe ethical committee of the hospital gave the agreement to report this case.Written informed consent was obtained from the patient for publication of this case report and accompanying imagesThiam Ousmane, Faye Papa Mamadou these authors participated in the making and correction of this document. all authors agreed with the publication of the document.Researchregistry4759.Papa Mamadou Faye.Not commissioned, externally peer-reviewed.The authors declare no conflict of interest.


To the best of our knowledge, no study has reported mediastinal shift accompanied with obstructive atelectasis due to bulky primary esophageal tumor components treated with adaptive radiotherapy and concurrent chemotherapy.Here we report the case of a 65-year-old male patient diagnosed with locally advanced thoracic esophageal squamous cell cancer, clinical T4bN1M0, stage IVA. Bronchoscopy and computed tomography (CT) revealed an almost complete obstruction of the lumen of the left bronchus due to compression by bulky primary esophageal tumor components. On admission, the patient presented with dyspnea and decreased arterial oxygen saturation. Chest radiography and CT on admission revealed mediastinal shift with left atelectasis, as opposed to findings from the chest radiography performed 26 days before admission. Because of the patient’s overall good condition, we recommended definitive chemoradiotherapy instead of palliative bronchial stent placement. After obtaining the patient’s consent, chemoradiotherapy was initiated on the following day and it comprised three-dimensional conformal radiotherapy with 60 Gy in 30 fractions with concurrent administration of cisplatin and 5-fluorouracil. During chemoradiotherapy, tumor location was monitored with cone-beam CT and chest radiography. Chemoradiotherapy on day 8 revealed no evidence of the mediastinal shift. CT simulation was reperformed to adjust the radiotherapy fields to account for geometrical changes induced by the absence of the mediastinal shift. Subsequently, the mediastinal shift and bronchial obstruction did not recur during the course of chemoradiotherapy. The patient completed the planned radiotherapy with concurrent and adjuvant chemotherapy, and no non-hematological grade ≥ 3 adverse events were observed. Complete response was confirmed 7 months after initiating chemoradiotherapy. Currently, no disease recurrence, dysphagia, or respiratory symptoms have been reported at 13 months after initiating chemoradiotherapy.In this study, a bulky primary esophageal tumor caused mediastinal shift due to ipsilateral bronchial obstruction. The close follow-up for monitoring resolution of the mediastinal shift during the course of chemoradiotherapy enabled adequate dose delivery to targets, thus reflecting the geometrical changes induced by the absence of the mediastinal shift. Adaptive radiotherapy technique was crucial for favorable patient outcomes in this challenging clinical situation. Adaptive radiotherapy aims at adjusting the treatment plan during the course of radiotherapy to ensure correct target coverage and avoid normal tissue complications . Its cliTo the best of our knowledge, no existing studies in the literature have reported a mediastinal shift accompanied with ipsilateral obstructive atelectasis due to bulky thoracic esophageal cancer. Therefore, the usefulness of adaptive radiotherapy for treating thoracic esophageal cancer with mediastinal shift remains to be explored. The present study reports a case of locally advanced thoracic esophageal cancer with mediastinal shift accompanied with ipsilateral obstructive atelectasis due to primary esophageal tumor components successfully treated with adaptive radiotherapy plus concurrent chemotherapy.2 on day 1 and 29) and 5-fluorouracil (700 mg/m2 on days 1–4 and 29–32). Radiotherapy comprised four coplanar irradiation fields, including the gross tumor volumes with adequate margin and elective nodal irradiation for paraesophageal and paratracheal lymph nodes  and 5-fluorouracil (800 mg/m2 on days 1–5). The patient completed the planned treatment course with chemoradiotherapy and adjuvant chemotherapy with no grade ≥ 3 non-hematological adverse events. Complete response was confirmed by esophagogastroduodenoscopy and CT performed at 7 months after initiating chemoradiotherapy  Fig. a, a mediThe present case report highlights two important clinical observations of our clinical case. Firstly, bronchial obstruction due to a bulky primary esophageal tumor caused a mediastinal shift accompanied with atelectasis. Secondly, adaptive radiotherapy was required to deliver correct doses to the targets, thus reflecting the geometrical changes in tumor location and organs at risk during the course of chemoradiotherapy in patients with thoracic esophageal cancer.In the present study, bulky primary esophageal cancer components caused a mediastinal shift with bronchial obstruction and atelectasis. Bronchial obstruction, atelectasis, and pleural effusion are well-known associated findings in centrally located lung cancer , which hChemoradiotherapy for clinical T4 esophageal cancer provides long survival , 6. SuccIn conclusion, a bulky primary esophageal tumor caused mediastinal shift with ipsilateral bronchial obstruction in the present clinical case. A close follow-up with cone-beam CT or chest radiography during the course of chemoradiotherapy to confirm resolution of the mediastinal shift was key in ensuring the correct dose delivery to targets. Overall, chemoradiotherapy with adaptive radiotherapy appears to yield a curative treatment strategy for patients in such difficult clinical situations.


Since chondrosarcoma is a relatively rare type of malignant bone tumors characterized by its ability to produce a cartilage matrix and aggressive behavior, a consensus clinical management strategy has not been established. We report a 55-year-old woman who presented with renal metastasis arising from chondrosarcoma of the scapula. Chondrosarcoma of the left scapula was diagnosed 15 years earlier. After surgical resection of a local recurrence in the left scapula, she received focal radiofrequency ablation (RFA). She underwent focal RFA and surgical resection for a total of 21 times for lung metastases. Because invasion of the renal pelvis was suspected from urine cytology, she underwent laparoscopic nephroureterectomy. The histopathological findings showed metastatic chondrosarcoma involving the right renal parenchyma. The patient has remained clinically stable without recurrence for 18 months. To the best of our knowledge, this is the first report of metastatic chondrosarcoma of the lung and renal parenchyma with involvement of the renal pelvis in which remission was achieved with multimodal treatment including RFA and surgical resection. Chondrosarcoma is the second most common primary malignant bone tumor after osteosarcoma in the United States , 2. ChonA 55-year-old woman who presented with gross hematuria was admitted to our department for a slow-growing right renal mass monitored over time by computed tomography (CT). Chondrosarcoma of the left scapula was diagnosed 15 years earlier. She presented with left shoulder pain, and a left scapula X-ray revealed a 7 cm mass with calcification. Magnetic resonance imaging (MRI) displayed a low signal on T1-weighted and a high signal on T2-weighted. She underwent scapula and humerus wide margin resection of the primary tumor with artificial humeral head replacement. The tumor was composed of cartilage cells growing a lobular architecture with eosinophilic reticulum and myxoid stromal tissue and was diagnosed as Grade 2 chondrosarcoma . InitialAt the time of admission to the urology department, the patient's laboratory results were within normal ranges, except for the presence of red blood cells in the urinalysis. Three years before the latest admission, CT revealed a cystic tumor in the upper half of the right kidney. Over a period of 3 years, the cyst developed from 14 mm to 46 mm. No septa or calcifications were observed in the tumor . HydroneChondrosarcoma is a tumor that originates from cartilage . CompareMost chondrosarcomas are slow-growing tumors with low metastatic potential that are considered to be refractory to both chemotherapy and radiation therapy due to a low percentage of actively dividing cells and vascular components , 10. TheA review of literature identified nine case reports of primary chondrosarcoma of the kidney and three case reports of renal metastasis from chondrosarcoma –8 Table. These p


Superficial myofibroblastomas of the lower female genital tract are an unusual type of benign mesenchymal tumour. To the authors’ knowledge, there has been no previous imaging description of a superficial myofibroblastoma in the literature. Here, we describe a case that presented with symptoms consistent with vaginal prolapse. However, a mass was palpable on clinical examination with unusual features on MRI. Following surgery, the histopathological features were considered consistent with superficial myofibroblastoma. By presenting the MRI and histological findings, we aim to raise awareness about this lesion so that it may be considered in the differential diagnosis of a vaginal mass. MRI of vaginal lesions can pose a challenge to radiologists owing to the broad range of tissues in an anatomically small region. Various features should be considered when forming a differential diagnosis, including precise anatomical location, signal characteristics, enhancement and involvement of other anatomical structures. Clinical examination findings and patient history are critically important but despite this information, it may still be difficult to reach a specific diagnosis, and multidisciplinary team (MDT) discussion is required to guide appropriate management thereafter.A 73-year-old female was referred to our Trust by her general practitioner with a 5-month history of a painless vaginal mass, which extruded from the introitus on straining, but was otherwise asymptomatic. This was originally thought to be a vaginal prolapse; however, examination revealed a soft, well-defined pink mass occupying the upper vagina and an MRI of the pelvis was requested for further characterization.T1 weighted fast spin echo; small field of view axial, coronal and sagittal T2 weighted fast spin echo; and T1 weighted fat-saturated sagittal images before and after gadolinium contrast administration, obtained in the arterial and portal venous phases. Diffusion-weighted imaging was also acquired. The images demonstrated a 47 × 40 × 44 mm well-circumscribed, oval mass in the upper vagina. On the T1 weighted images, the signal intensity of the abnormality was intermediate, similar to that of the skeletal muscle , which is usually apparent on imaging with signal characteristics corresponding to the primary tumour. Primary vaginal carcinoma is rare, and includes several cell types, of which squamous cell carcinoma is the most common (85%), followed by adenocarcinoma (9%), melanoma (3%) and sarcoma (<3%). These lesions are usually ill-defined and infiltrative, unlike the described well-circumscribed lesion, where the vaginal wall was largely intact. Squamous cell carcinoma most commonly arises from the posterior wall of the upper one-third of the vagina and shows intermediate signal intensity on T1 and predominantly hyperintense on T2 sequences, with swirling and enhancing central soft tissue.10Another important entity occurring in the lower female genital tract is aggressive angiomyxoma, which is a mesenchymal tumour that occurs in premenopausal females, with the propensity to recur and rarely metastasize. The MRI signal characteristics would be iso- to hypointense on T2 signal areas with poor enhancement  was obtained from the patient(s) for publication of this case report.