Although squamous cell carcinoma accounts for the overwhelming majority of head and neck malignant neoplasms, extranodal follicular dendritic cell sarcoma (FDCS) of the pharyngeal region can have a similar clinical presentation. The histopathological features of this rare entity have been described and emphasised in the literature. We present the case of a 65-year-old male patient with FDCS of the tonsil to illustrate the radiologic findings of FDCS and also highlight this infrequent but salient differential diagnosis for adult head and neck neoplasia. The patient reported no weight loss, odynodysphagia, dysphonia or otalgia. On examination of the neck, it was observed that the mass measured 10 × 10 cm, was non-tender to palpation and was of a mixed consistency (both cystic and solid). Furthermore, the mass appeared to be mobile but felt attached to the inferior aspect of the ipsilateral parotid gland. Oropharyngeal examination revealed a small (< 1 cm) submucosal sessile polyp on the left tonsil. The rest of the clinical examination was normal.Biopsy of the left tonsil and cell block obtained from fine-needle aspiration of the left-sided neck mass revealed FDCS using immunohistochemical staining.Computed tomography (CT) of the neck and chest with intravenous contrast administration was carried out, followed by magnetic resonance (MR) imaging of the neck with intravenous gadolinium administration to further delineate the extent of the tumour and its relation to adjacent structures, in particular the parotid gland and the cervical vasculature. The neck CT demonstrated an ovoid iso-attenuating mass in the left tonsil, measuring 16 mm × 12 mm × 24 mm in diameter . The patient underwent a left-sided, modified radical neck dissection with a superficial partial parotidectomy (‘en block’) and bilateral tonsillectomy . The posGross macroscopic examination showed a solid and firm, well-circumscribed tumour involving the left tonsil, measuring approximately 2 cm. Left neck level II and III nodal metastases were present with most of the nodes in level III involved by tumour comprising solid and cystic spaces filled with gelatinous material. The tumour abutted the parotid gland capsule; however, frank invasion was not observed macroscopically.Microscopic examination revealed a malignant neoplasm partially involving the left tonsil, with intact overlying surface epithelium. The tumour comprised spindle-to-ovoid cells arranged in fascicles, in whorled and storiform patterns, demonstrating a pushing invasive front . OccasioFollowing the histological review, the patient’s pathological staging was T2N1. The role of adjuvant radiotherapy in sarcoma of the head and neck is controversial, with indications being extrapolated from the treatment guidelines of extremity sarcoma. In view of the large nodal disease with extracapsular extension, the multidisciplinary team’s decision was to offer adjuvant radiotherapy. The patient received 66 Gy in 2 Gy/# to the tumour bed and left level IB-V. This was delivered via volumetric modulated radiotherapy. Radiotherapy was tolerated well with minimal side effects, and during the last assessment, the patient was still in remission.4 identified a total of 41 cases of extranodal FDCS in the English literature, 51% of which were tonsillar in origin. Other primary extranodal sites of disease include the spleen, gastro-intestinal tract, liver, soft tissue, skin, lung and breast. Follicular dendritic cell sarcoma has a slight female predominance (1.2:1) and a wide patient age range for disease presentation, although it most often presents in the fifth decade of life.2 The World Health Organisation classification of haematopoietic and lymphoid neoplasms includes FDCS in the group of histiocytic and dendritic cell neoplasms.5Duan et al.3 reviewed 189 cases of DCS (including both FDCS and interdigitating DCS) and found that DCS was most often localised at diagnosis. In our case report, the patient’s tumour had metastasized to regional lymph nodes, with clinical and pathological features of extranodal invasion, suggesting a more aggressive biological nature of the tumour.Because of the rarity of dendritic cell sarcoma (DCS), its clinical behaviour and optimal management has not been consolidated. De Pas et al.3 Of note, our patient’s tumour demonstrated a low mitotic rate and absence of necrosis, despite its large nodal metastases with extranodal invasion.Anecdotal evidence suggests that abdominal tumours or those measuring more than 5 cm relate to an unfavourable prognosis. In addition, specific histopathological features, such as a high mitotic count and the presence of necrosis, have been studied in other soft-tissue sarcomas and proven their value in prognostication.6 The use of 18F-FDG-PET in surveillance imaging, recurrence detection and response to therapy has been highlighted in case report studies on parotid gland and cervical node FDCS.8The histological features of FDCS have been emphasised more often than the imaging findings. As of yet, characteristic findings of FDCS on 18F-fluoro-deoxyglucose positron emission tomography (FDG-PET) have not been established, as a variable radiotracer uptake has been found, presumably as a result of the diverse histological grade features demonstrated in these tumours.4 Our case not only highlights the clinical and histopathological findings of FDCS but also illustrates the imaging findings of the condition, in particular, the use of MR imaging, of which there is a scarcity in the literature.Due to its rarity, extranodal FDCS of the pharyngeal region is often not considered as part of the differential diagnosis in adult head and neck neoplasia.


Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignancy, but has been found more frequently with recent advances in diagnostic imaging. Local recurrence and metastases are frequent with this pathology, and prognosis is poor. We report a case of a patient with leiomyosarcoma of the IVC surviving for >10 years after the first resection despite local recurrence and two metastatic recurrences to the pancreas and liver, with successful excisions following early detection on positron emission tomography-computed tomography. Leiomyosarcoma of the inferior vena cava (IVC) is a rare malignancy of the venous system originating from smooth muscle cells of the middle layer of the IVC. Although a number of cases have been reported with recent advances in diagnostic imaging, local recurrences and/or distant metastases are often seen, and the disease shows poor prognosis. We report a case of a patient with long-term survival after the first resection of leiomyosarcoma of the IVC, with successful excisions of subsequent local recurrence and two metastatic recurrences after early detection on positron emission tomography (PET)-computed tomography (CT).A 58-year-old woman at the time of the first operation was referred after identification of a tumor embolus inside the hepatic vein on abdominal ultrasonography during a medical examination. The tumor was suspected to be leiomyosarcoma of the IVC localized to the middle segment on dynamic CT, and surgery was performed . Two years after the first operation, PET-CT showed an intense accumulation of fluorodeoxyglucose (FDG) at the anastomosis on the distal side of the graft, and tumor recurrence was suspected . However, local recurrences and metastases are frequent, and prognosis is poor with this pathology. Wachtel et al. analyzed and reported 377 cases of initial resection of a primary leiomyosarcoma of the IVC. They described 1- and 5-year disease-free survival rates of 57% and 6%, respectively, with most patients experiencing recurrence, and 1- and 5-year overall survival (OS) rates of 92% and 55%, respectively. Long-term survival is possible, but survival for 15 years is achieved by only a significant minority. A number of distant metastases have been reported, but postoperative distant metastases involved several organs such as the lungs, thighs, shoulder muscles, liver, bone, subcutaneous nodules, peritoneum, breasts, external iliac veins, small bowel, abdominal wall, chest wall, and inguinal lymph nodes.Leiomyosarcoma of the IVC is a rare malignancy originating from smooth muscle cells of the media with intra- or extraluminal growth. This entity was first reported by Perl in 1871, However, although resection with positive margins has been reported to affect declines in OS, local recurrence has been reported even with negative margins. Furthermore, treatment of distant metastases does not show any clear tendency due to the extent of metastases; the tumor may have grown at the time of discovery, making radical surgery impossible, and good results have not been obtained in several cases, even with radio- or chemotherapy. On the contrary, some patients with long-term survival despite distant metastases have undergone aggressive resection.For the treatment of leiomyosarcoma of the IVC, the importance of radical resection of the primary tumor has been widely proposed. We also believe that the early detection of local recurrences and distant metastases can reduce the invasiveness of resection.For long-term survival, detecting local recurrences and distant metastases soon after primary resection is important, along with performance of aggressive treatment.No tumor markers are currently available to accurately identify soft-tissue tumors, including leiomyosarcoma, and diagnostic imaging alone is the only option for early detection and clues to recurrences and metastases. Several reports have described Doppler ultrasonography and contrast-enhanced CT and MRI for the postoperative follow-up of leiomyosarcoma of the IVC. However, curative surgery may already be impossible when such imaging modalities raise the suspicion of recurrence. Distinguishing between intravascular tumor and thrombus is difficult on MR angiography and contrast-enhanced CT. However, PET-CT can discriminate tumor from thrombus due to differences in metabolism; hence, tumor recurrence can be detected at an earlier stage. In addition, PET-CT is useful for staging sarcomas with a high probability of metastasis, offers superior sensitivity and specificity in detecting local recurrence compared with conventional imaging, and is highly useful for diagnosing distant metastases.PET-CT shows high accumulation in leiomyosarcoma of the IVC, and its diagnostic effectiveness has been reported.In this case, the resection margin was negative at the time of the first operation, but local recurrence and two distant metastases were then identified. PET-CT for postoperative follow-up was able to detect these lesions early, and complete resection was possible without any major invasion. Twelve years after the initial operation and 10 years after local recurrence, no further local recurrence of the IVC has been observed. Although distant metastases remain possible, follow-up is being actively conducted.If possible, PET-CT every year after surgery for leiomyosarcoma of the IVC allows the early detection of local recurrences and distant metastases. In addition, we believe that early detection can reduce the degree of surgical invasiveness, allowing radical resection and raising the chance of long-term survival.


Acute appendicitis is a common surgical emergency in older adults. In the elderly, like in younger cohorts, acute appendicitis most commonly arises without neoplastic underpinnings. However, the occurrence of acute appendicitis in a patient with a concurrent abdominopelvic malignancy should trigger suspicion for the possibility of a metastatic appendiceal neoplasm. We present the case of a 66-year-old man with a background of a biochemically recurrent prostatic adenocarcinoma who presented to the emergency department with acute appendicitis. Histopathologic examination of the resected appendix revealed an unexpected metastatic spread from his prostatic adenocarcinoma. Acute appendicitis is a common surgical emergency in the elderly. In the United States, the incidence of acute appendicitis in the 60-69-year cohort is only about half as frequent as its peak incidence in the 10-19-year age group . ApproxiThe patient is a 66-year-old man who presented to the emergency department with a history of sudden onset of severe generalized abdominal pain of two-day duration associated with tenderness, fever (99°F), chills, nausea, and decreased appetite. The pain originated in the epigastric region, migrated to the right lower quadrant, and then became generalized. The pain was mostly constant but was also associated with intermittent episodes of slow, spontaneous improvement. The pain was worsened by sudden movement and oral intake. A known diabetic, home blood glucose measurements revealed concomitant increased levels despite his reduced oral intake.His medical history is notable for a primary Gleason pattern 4 and secondary Gleason pattern 3 (Gleason Score of 7) prostatic adenocarcinoma diagnosed seven years earlier. His tumor had several adverse oncologic features, including advanced stage (stage pT3b), high tumor volume (involved 60% of the prostate), multifocal extraprostatic extension, small vessel invasion, positive surgical margins, and BRCA2 mutation positivity.μg/L) in serum prostate-specific antigen (PSA). Leuprolide was discontinued following normalization of his PSA (to 0.0 μg/L) but was recommenced two years later with the addition of Enzalutamide due to the recurrence of PSA elevation (7.79 μg/L). The dose of Enzalutamide was subsequently reduced due to intolerable adverse effects. Bone and computed tomography (CT) scans showed no evidence of metastatic disease.Following an initial radical prostatectomy, he received radiotherapy and then hormonal therapy with leuprolide for persistent increase (up to 2.28 9 L−1 (reference range: 4.2 − 9.1 × 109 L−1) with an increased neutrophil count of 7.3 × 109 L−1 (reference range: 1.8 − 5.4 × 109 L−1) and a decreased lymphocyte count of 0.9 × 109 L−1 (reference range: 1.3 − 3.6 × 109 L−1), anemia with hemoglobin of 117 g/L (reference range: 137-175 g/L), and elevated serum glucose of 7.82 mmol/L (reference range: 3.31-5.45 mmol/L). CT scan showed an enlarged, inflamed appendix with inflammatory changes in the mesoappendix.At presentation, physical examination was notable for abdominal distention and tenderness, without guarding or rebound tenderness. Complete blood count at admission showed a decreased white blood cell count of 9 × 10Following the administration of intravenous antibiotics, an appendectomy was performed without complications. Findings at surgery included an inflamed appendix and dense inflammatory adhesions between bowel loops and the mesentery. On gross pathologic examination, there were gray-green serosal and mesenteric exudates, but the appendix was not perforated. The lumen was dilated and contained clear mucus secretions. Histopathologic examination showed malignant epithelial cells arranged in crowded tubules extending from the lamina propria to the muscularis propria Figures , with inThe patient's postoperative course has been notable for weakness, fatigue, and an unsteady gait. But he has a good appetite and no weight loss and continues working at this job.Bone is the most common site of metastasis from prostatic carcinoma . Other cAcute appendicitis is the second most common cause of acute abdomen requiring surgical intervention in patients 50 years of age and older . MalignaSecondary involvement of the appendix by a malignant tumor may occur by either lymphohematogenous spread, peritoneal dissemination , or direWith only rare reports of secondary spread of prostatic carcinoma to the appendix, metastatic disease might not be uppermost in consideration in elderly patients with acute appendicitis. However, the simultaneous existence of a biochemically recurrent malignancy with multiple adverse oncologic factors presents the perfect backdrop for the manifestation of this rare phenomenon. An appendiceal metastasis should thus be strongly considered in such situations.Suspicion for an underlying metastatic neoplasm will aid in the planning of appropriate treatment. For example, the administration of antibiotics is the sole treatment modality in selected patients with acute appendicitis , but thi


The authors report on a case of a patient who presented to the emergency department (ED) and was ultimately diagnosed with stage IV testicular non-seminomatous germ cell tumor. The patient was cachectic with a tumor on the neck, abdomen, and scrotum. Germ cell tumors (GCTs) exhibit characteristic symptoms at different points in development. Appropriate treatment can cure most GCTs. While cancer may not be thought of as an ED diagnosis, it can often be the place where patients first present, even when advanced. Recognizing it is important for prompt treatment. Approximately 95% of malignant testicular neoplasms are of germ cell origin and known as germ cell tumors (GCTs). It is the most common solid malignancy in men aged 15-35 years, even though it only accounts for one percent of all cancers in men . Non-semTypically, these tumors will present as an enlarging testicular mass with or without pain. Other symptoms may include pain at sites beyond the scrotum if the cancer is metastasized or gynecomastia from hormonal secretions ,5. For aThis is the case of a 30-year-old male that was sent by his primary care physician (PCP) for evaluation of abdominal distention and left-sided neck swelling. The patient had cerebral palsy and was a poor historian. His sister took him to his PCP because he was not eating well, losing weight, and had some shortness of breath. The patient’s PCP noticed an abdominal mass as well as a left-sided neck mass. Neither the patient nor his sister was aware when these symptoms appeared or how long they had been there. The patient had been having normal bowel movements; no abdominal pain, nausea, vomiting, or diarrhea; no chest pain; no fever, chills, cough, or any other complaints. On physical examination, he was tachycardic and cachectic with bitemporal wasting. On the left side of the neck, there was a solid golf ball size mass, which was non-movable. The chest evaluation revealed clear breath sounds and tachycardia. Abdominal examination revealed distention with a large palpable grapefruit-sized mass. There was some guarding but no rebound. Genitalia examination showed a hard, non-tender mass of the right scrotum.3, hemoglobin 10.1 gm/dL, a normal basic metabolic panel, aspartate transaminase (AST) 241 units/L, and alkaline phosphatase 1033 unit/L. We decided to add a beta-hCG because of the testicular mass. It was elevated at 5692 mIU/ml.Laboratory analysis revealed a white blood cell count of WBC 14.08 K/mmComputed tomography (CT) scans of the neck, chest, abdomen, and pelvis showed a large left neck mass 8.6 cm x 4.5 cm) with mediastinal lymphadenopathy versus metastatic lesions; multiple pulmonary nodules and masses; multiple liver and splenic lesions with retroperitoneal lymphadenopathy; large pelvic mass that extends from the level of the liver to the pelvic inlet (17 cm x 13 cm); large retroperitoneal mass that extends from the diaphragmatic hiatus to the aortic bifurcation (19 cm x 10 cm) resulting in mass effect to the abdominal viscera and vasculature; and a pancreatic head mass (5.9 cm x 3.7 cm)  and received four cycles of cisplatin chemotherapy.The etiology of GCTs is largely unknown. Cytogenetic studies suggest a different pathogenesis for each group of infantile/prepubertal GCTs, postpubertal GCTs, and spermatocytic tumor Figure .When patients, especially young adult male, present to the emergency department (ED) with testicular complaints, it is important to keep testicular GCTs on the differential diagnosis. Testicular GCTs are often found incidentally since they are often painless. Patients typically present with a painless solid mass in the scrotum and are well appearing. It is rare for a patient to present with metastatic disease like this case. It may be that his cerebral palsy made history taking challenging, or that his lack of complaining delayed the diagnosis up to this point. There is usually no history of trauma or infection. Other differentials to consider include testicular torsion, Fournier’s gangrene, traumatic testicular rupture, incarcerated inguinal hernia, epididymitis, orchitis, testicular abscess, hydrocele, and varicocele. Testicular ultrasound is the initial diagnostic testing of choice in the ED as it can quickly narrow down a diagnosis. CT scans may be ordered to further characterize the mass and for staging if GCTs are suspected. Patient with suspected GCTs will need urology consultation for orchiectomy and staging. Further management is guided by the staging of GCTs and interdisciplinary team collaboration.Among GCTs, seminoma is most common. It does not occur before the age of five years. Embryonal carcinoma is the most common component in mixed GCTs. Eighty percent or more of embryonal carcinoma component and vascular invasion are recognized predictors of occult metastasis for clinical stage I mixed GCTs. The most common pediatric GCT is prepubertal yolk sac tumor, which is usually stage I disease at presentation. Most choriocarcinomas present with metastatic symptoms because of the propensity for rapid hematogenous dissemination. Teratomas in children regardless of maturity and dermoid cysts in adults are benign; in contrast, teratomas in adults exhibit malignant behavior. With appropriate therapy, the majority of testicular GCTs are curable ,7.Pathology analysis of the tumor following orchiectomy will stratify the GCTs into seminoma and NSGCTs. Seminomas are usually slow-growing, localized tumors and rarely (less than 5%) spread beyond the retroperitoneal nodes . DistantFor seminomas, radical orchiectomy is usually curative (stage I) while the addition of radiotherapy may be necessary for stage II disease. In the rare event that there is extensive retroperitoneal nodal involvement of distant metastasis, cisplatin-based chemotherapy may be required. Management of NSGCTs depends on the staging that includes a combination of active surveillance, retroperitoneal lymph node dissection (RPLND), and/or chemotherapy. For stage 1 NSGCTs with low risk of relapse post-orchiectomy, generally active surveillance is sufficient, while patients with more advance stage and/or higher risk of relapse may require a combination modality stated above . UnfortuA systematic history and physical examination remain the mainstay of good medicine even in the emergency department. This case illustrates the diagnosis of testicular germ cell tumor that had clearly been present for a while but only picked up after the patient had presented to medical attention a few times. Testicular GCTs once correctly diagnosed can be treated according to the specific type.


Invasive mole is a subtype of gestational trophoblastic neoplasms (GTNs) that usually develops from the malignant transformation of trophoblastic tissue after molar evacuation. Invasive moles mostly occur in women of reproductive age, while they are extremely rare in postmenopausal women.We present the case of a 55-year-old postmenopausal Syrian woman who was admitted to the emergency department at our hospital due to massive vaginal bleeding for 10 days accompanied by constant abdominal pain with diarrhea and vomiting. Following clinical, laboratory and radiological examination, total hysterectomy with bilateral salpingo-oophorectomy was performed. Histologic examination of the resected specimens revealed the diagnosis of an invasive mole with pulmonary metastases that were diagnosed by chest computed tomography (CT). Following surgical resection, the patient was scheduled for combination chemotherapy. However, 2 weeks later the patient was readmitted to the emergency department due to severe hemoptysis and dyspnea, and later that day the patient died in spite of resuscitation efforts.Although invasive moles in postmenopausal women have been reported previously, we believe our case is the first reported from Syria. Our case highlights the difficulties in diagnosing invasive moles in the absence of significant history of gestational trophoblastic diseases. The present study further reviews the diagnostic methods, histological characteristics and treatment recommendations. Invasive mole is defined as a subtype of gestational trophoblastic neoplasms (GTNs) characterized by the presence of edematous trophoblastic tissue and hydropic chorionic villi invading the myometrium with or without vascular and extrauterine invasion. GTNs represent a heterogeneous group of pregnancy-related tumors including choriocarcinoma, placental cell tumor, and invasive moles . InvasivWe report the case of a 55-year-old postmenopausal Syrian woman who presented to the emergency department at our hospital with a history of massive vaginal bleeding for 10 days accompanied by constant abdominal pain with diarrhea and vomiting. Her obstetrical history reported natural menopause 15 months earlier and a history of 14 normal vaginal deliveries (G14P14A0), with the last delivery being 13 years before the current presentation. She had no history of spontaneous abortions, contraceptive drug use or molar pregnancies. Medical and family history were unremarkable.Physical examination revealed a palpable pelvic mass extending up to approximately 3 cm above the umbilicus. The serum beta-human chorionic gonadotropin (b-HCG) level was determined to be 542.250 mU/mL. Pelvic ultrasonography demonstrated an enlarged uterus the size of 24-week gestation, with a heterogeneous mass obliterating the endometrial cavity, with a vesicular appearance Fig.  and normGross examination revealed an enlarged uterus measuring 25 × 20 × 13 cm and weighing 3350 g, Fig. , 12, 13.5 m IU/mL = 4 points, largest tumor size including uterus > 5 cm = 2 points, site of metastases: lungs = 0 points, number of metastases < 4 = 1 point, previous failed chemotherapy: none = 0 points)Based on detailed observation of morphological features accompanied by clinical and radiological correlation, the diagnosis was confirmed as an invasive mole with pulmonary metastases and classified as high risk (stage III: score 14) according to the International Federation of Gynecology and Obstetrics (FIGO) staging system and World Health Organization (WHO) prognostic scoring system:  that usually develops from the malignant transformation of trophoblastic tissue after molar evacuation . It occuThe pathogenesis of invasive moles is not fully defined. These neoplasms are preceded by hydatidiform moles in approximately 95% of cases. Other risk factors include pregnancies at extreme reproductive age, history of spontaneous abortions, vitamin A deficiency, oral contraceptives, and paternal and environmental factors . As our et al. reported eight cases of invasive moles from a total of 20 cases of GTNs in women over 50 years of age. However, none of the invasive mole cases were reported in postmenopausal women [et al. reported an unusual invasive mole following a molar pregnancy in a postmenopausal woman after biologically confirmed menopause [et al. in 2006 [et al. [In 1985, Tsukamoto al women . Our cas in 2006 –10, and  [et al. .Table 1RAccording to their reports, uncontrolled vaginal bleeding and enlargement of the uterus are the most common clinical symptoms in invasive moles, as in our case. Clinical diagnosis requires the presence of these symptoms with persistent elevation of b-HCG levels after molar evacuation . Howeverd-glucose positron emission tomography/computed tomography (FDG-PET/CT) is mostly limited to identification of individuals at risk of developing GTNs following previous molar pregnancies [Transabdominal ultrasonography (USG) is considered the first-line imaging method for the initial diagnosis of GTNs and for demonstrating the characteristic vesicular appearance. It is also reliable for monitoring processes in patients with elevated serum b-HCG . Howevergnancies , 13.Invasive mole is considered a malignant tumor due to its aggressive behavior of local destruction, invasion of the myometrium and the adjacent structures, and the high rate of metastasis . The most common site of metastasis is the lung (30%), followed by the vagina (30%), the liver (10%), and less commonly the brain, bones and the breast , 14. Thuet al. reported a case in 2009 of an invasive mole labeled with immunohistochemical staining. The trophoblasts revealed strong positivity for inhibin/activin subunits, Ki67, p53 and glycodelin A [In most cases, invasive moles are diagnosed and treated based on clinical findings. However, histological examination is essential in challenging cases with no typical history, as in our case. The pathological diagnosis of invasive moles is challenging due to the difficulties in differential diagnosis and comparing morphological features . Makovitodelin A . HoweverInvasive moles have a high risk of transforming into choriocarcinoma, which is considered the first differential diagnosis of this neoplasm. Choriocarcinomas can be differentiated by multiple morphological features including the absence of villi, high cytologic atypia, and atypical pattern of syncytiotrophoblasts and cytotrophoblasts. Other differential diagnoses include malignant mixed Müllerian tumors (carcinosarcomas), which can easily be excluded by the absence of the biphasic growth pattern of malignant mesenchymal and epithelial components , 17. In Notwithstanding the aggressive behavior and high metastatic rate of invasive moles, they are highly sensitive to chemotherapy, which is considered the first-line treatment, while surgical procedures might be recommended in specific cases including postmenopausal patients and invasive moles with uncontrolled vaginal bleeding , 10, 14.et al. reported a case of a severe life-threatening hemothorax induced by methotrexate in a metastatic invasive mole [et al. reported another case of a metastatic invasive mole with sudden death [The chemotherapy regimen is typically designed according to the International Federation of Gynecology and Obstetrics (FIGO) anatomic staging system . Low-risive mole . Cauhan en death . UnfortuAlthough invasive moles have rarely been reported in postmenopausal women, we managed to confirm the diagnosis of a metastatic invasive mole despite the absence of a relevant history of trophoblastic diseases. We also aimed to highlight the importance of clinical correlation, detailed diagnosis and the appropriate procedure, with subsequent careful follow-up due to the possibility of rapid progression and subsequent mortality despite significant response to chemotherapy.


Background: The clinical usefulness of concurrent chemoradiotherapy before surgery in the treatment of primary, locally advanced sinonasal low-grade, non-intestinal type adenocarcinoma (LG non-ITAC) is unclear.Methods: We present the first case report of the efficacy of super-selective intra-arterial cisplatin (CDDP) infusion concurrent with conventional fractionated radiotherapy (RT) for LG non-ITAC in a Japanese patient.Results: A white, rugged-marginal mass that was histopathologically diagnosed as LG non-ITAC occupied the right nasal cavity. Based on the imaging findings, including computed tomography, magnetic resonance imaging, and positron emission tomography, the tumor was diagnosed as T4aN0M0, stage IVa. After treatment, the nasal tumor disappeared leaving only a small bulge in the medial wall of the middle turbinate. The patient also underwent right transnasal ethmoidectomy performed as salvage surgery. A histopathological examination revealed that the lesion was replaced by granulation tissue with lymphocytic infiltration and hemosiderin-laden macrophages, and no viable tumor cells remained. In the seven years after treatment, the patient has not experienced any local recurrence or regional or distant metastasis.Conclusions: Super-selective intra-arterial CDDP infusion concurrent with conventional fractionated RT followed by salvage surgery might be useful for the management of sinonasal LG non-ITAC. In Japan, the frequency of the sinonasal cancer among patients with head and neck cancer is approximately 8% . The mosfollowed by salvage surgery. Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article.Many authors consider that surgery followed by radiotherapy represents the gold standard in the management of sinonasal adenocarcinoma , 7, 8. TA 41-year-old man presented to the otolaryngological department of another hospital with a 12-month history of right nasal obstruction, epistaxis and periorbital pain. Because the nasal tumor was found in the right nasal cavity, he was referred to our university hospital. Nasal endoscopy revealed a white tumor with a rugged margin that occupied the right nasal cavity . The colThe patient did not agree to be treated by radical resection , Chiba, Japan; however, he declined the suggestion because the location was far from his home. After we presented him other options, the patient selected super-selective intra-arterial infusion of CDDP concurrent with radiotherapy (concurrent chemoradiotherapy) at our university as a radical treatment. After being explained about the risks and possible complications in response to concurrent chemoradiotherapy, we obtained his informed consent.On September 14, 2011 (day 1), radiotherapy was started with administration by a megavoltage linear accelerator with a photon beam energy of 6 MeV. The radiotherapy was applied to the tumor and margins, with the radiation field also including the nasal cavity, the maxillary, ethmoid, and sphenoid sinuses, nasopharynx, base of the skull and hard palate. The radiotherapy was administered to the patient at a dose of 2.0 Gray (Gy), 5 times per week for 6 weeks, for a total radiotherapy dose of 60.0 Gy.via an infusion pump. The tip of the microcatheter was placed in the feeding vessel of the tumor. For hydration, lactated Ringer's solution started 24 h prior to CDDP infusion was intravenously administered at 100 ml/h. Hydration was continued during and after CDDP infusion for 48 h. To neutralize the toxicity of the CDDP, an intravenous administration of sodium thiosulfate was started immediately before the CDDP infusion and was continued during the CDDP infusion. To minimize nausea and vomiting, a 5HT3-receptor antagonist was given to the patient for 4 days. By 4 days after the conclusion of radiotherapy (day 48), the patient had undergone 4 treatments with intra-arterial CDDP (1 injection every 2 weeks for 8 weeks).On day 9, selective angiography of the right maxillary artery was conducted by experienced radiologists using the Seldinger technique to evaluate the appropriate arteries supplying the tumor. CDDP at a dose of 150 mg/body was rapidly infused through a microcatheter for 20 min During treatment, blood tests including hemograms, blood chemistry, and renal function were checked periodically. Acute toxicities related to the treatment were observed according to the National Cancer Institute-Common Toxicity Criteria (NCI-CTC). The patient experienced grade 1 non-hematologic side effects that consisted of ear pain (grade 1), mucositis oral (grade 1), nausea (grade 1), oral pain (grade 1), and alopecia (grade 1). There were no hematologic side effects.At 10 days after CDDP infusion (day 19), the patient felt that his nasal obstruction had decreased. On day 60, endoscopy showed the disappearance of his right nasal polypoid mass filling the whole common meatus, and thereby, the right common meatus was well-open. In addition, only a bulge remained on the medial surface of the middle turbinate . The mucfollowed by a salvage surgery, the patient is alive without any local recurrence or regional or systemic metastasis. Thus, complete remission was clinically achieved in response to concurrent chemoradiotherapy followed by salvage endonasal endoscopic surgery, according to the new response criteria in solid tumors: Revised RECIST guideline (version 1.1).On day 128, right transnasal endoscopic ethmoidectomy was performed as salvage surgery. The middle and superior turbinates were completely removed along with the surrounding structures, which included the ethmoid sinus mucous membrane and the upper half of the nasal septum. No bone defects of the lamina papyracea, nasal septum or skull base were apparent. Histopathological examination revealed that the lesion had been replaced by granulation tissue with lymphocytic infiltration and hemosiderin-laden macrophages, and no viable tumor cells remained . The hisSinonasal non-ITAC is an adenocarcinoma without the histopathological characteristics of salivary or intestinal-type adenocarcinoma . Non-ITAThe origins of LG non-ITAC have varied in previous reports. Stelow et al. reported that 64% of the LG non-ITACs arose in the nasal cavity, frequently in the middle turbinate, with 20% arising in the ethmoid sinus . BhaijeeHistopathologically, LG non-ITAC tumors present varied architectural forms with exophytic papillae and tubular or glandular patterns having a LG cytology, round and uniform nuclei, and very rare mitotic figures . In our CK7 and CK20 are low molecular weight cytokeratins. The expression of CK7 was reported in a majority of epithelial neoplasms, with the exception of carcinoma arising from the colon, whereas CK20 positivity was seen in virtually all cases of colorectal carcinoma . As for P16 is a tumor suppressor protein inhibiting cyclin-dependent kinase 4A. p16 showing a strong and diffuse pattern of immunostaining is considered a highly sensitive surrogate marker for identifying HPV-driven tumors . Bishop The gold-standard treatment for primary sinonasal adenocarcinoma continues to be meticulous surgical tumor removal aiming at achieving free margins, followed by radiotherapy, and is indicated for the majority of patients . When thp = 0.041). The 5-year DFS rate in Group B was 66%, whereas that in Group A was 40%. In patients who received the PLF combination as induction chemotherapy, cardiovascular complications were reported to be a limiting toxicity  concurrent with conventional fractionated radiation   . CraniofSurgery is still the primary treatment for sinonasal adenocarcinoma, and if the surgical margin is pathologically clear , can achfollowed by salvage surgery might be useful for the management of sinonasal adenocarcinoma, which is rare but more common in elderly patients.We reported the first case of a Japanese patient in whom locally advanced sinonasal LG non-ITAC was successfully treated with concurrent chemoradiotherapy to achieve pathological and clinical complete remission. The administration of super-selective intra-arterial CDDP infusion concurrently with conventional fractionated radiotherapy The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article.HTac, HTak, and HidS: conception and design, literature search, and writing the article. HTac, HTak, HidS, MF, KA, HK, NN, HirS, KN, SM, JI, and YM: obtain the images. All authors: critical revision and final approval of the article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Evaluation of undifferentiated pediatric abdominal pain presents a unique set of challenges, especially in the setting of inconclusive and limited diagnostic imaging. In this case report, a female child presented to the emergency department with persistent abdominal pain, normal lab studies, and unusual trans-abdominal pelvic ultrasound findings. Urgent exploratory laparoscopy was completed, demonstrating a torsed adnexa rotated around a very large, mature teratoma, with irregular masses consistent with fully developed teeth. Early recognition of atypical pediatric abdominal pain in the setting of equivocal diagnostic imaging findings and collaboration with surgical colleagues resulted in a positive outcome for this patient. The approach to pediatric abdominal pain in the emergency department (ED) is often limited by both the patient’s participation in the assessment and a desire to be judicious with diagnostic testing and imaging. When ultrasound provides abnormal but inconclusive results, concern for ionizing radiation exposure can limit additional imaging options . OvarianAn 8-year-old female who was previously healthy, fully vaccinated, with no history of abdominal surgery presented with an acute onset of periumbilical abdominal pain. The pain was described as constant in nature, non-radiating, and not associated with any recent falls or trauma. The mother reported one episode of non-bloody vomiting and denied associated urinary or bowel movement symptoms, atypical food/drink intake, recent travel history, or sick contacts. A thorough chart review did not demonstrate features concerning for abuse, and the patient was pre-menarchal.On physical examination, the patient’s vital signs revealed mild hypertension , and she was noted to be crying in bed and unable to lay comfortably in the gurney. Her abdomen was soft with normal bowel sounds, no distension, with left greater than right lower quadrant tenderness to palpation, voluntary guarding, and no rebound. Her external genital examination was unremarkable, with no bleeding or obvious evidence of trauma, and an internal examination was deferred due to patient discomfort and parental preference.Emergency physicians were strongly concerned for ovarian torsion, especially with the mother reporting a similar presentation when she was a child. The team engaged surgical consultation with both gynecology and pediatric surgery departments early, who requested an appendix ultrasound in addition to the adnexal imaging already ordered.Blood count, chemistry, and urinalysis were completed and unremarkable, and a pregnancy test was negative. Multiple ultrasound views were obtained due to the patient’s larger body habitus, with the requested right lower quadrant ultrasound reporting an inability to visualize the appendix. Subsequently, a trans-abdominal ultrasound of the pelvis reported “Left ovary not visualized. Right ovary w/ large cyst measuring 8.2 x 6.5 x 6.4 cm w/ mural thickening, no Doppler flow visualized.” Figures , 2 GivenIntra-operatively, a large ovarian cyst with multiple tan-brown, irregularly shaped, soft tissue masses embedded in the cyst wall was extracted from the left adnexa, with a large amount of congested, coagulated blood evacuated as well Figures , 4 The aSurgically, the patient's ovary was able to be successfully salvaged, and she was both pain-free and back to her normal baseline function one month after hospital discharge.Key differential diagnoses for pediatric patients presenting with vague, non-specific abdominal pain include acute appendicitis, gonadal torsion, volvulus, intussusception, and obstruction. Other common diagnoses include pyelonephritis/cystitis, constipation, and gastritis . For pedOvarian torsion is a rare cause of abdominal pain in girls, accounting for 2.7% of all diagnosed causes of pediatric abdominal pain. An ovarian mass (cyst or neoplasm) is a primary risk factor for torsion; however, up to 52.8% of incidents in one case series demonstrated torsion of a normal ovary/adnexa without malformations . While tThe laterality of the patient’s symptoms, ultrasound results, and confirmed pathology are very unusual in this case. The patient initially complained of left-sided pain, whereas imaging formally reported a right-sided cystic structure and, surgically, the torsion and teratoma were found on the left side. Given the patient’s obesity for age and large cyst size, our suspicion is that the initial ultrasound views of the cystic mass were actually of the left adnexa and displaced so much volume toward the midline that it appeared to exist on the right side of the abdomen, resulting in limited visualization of the left ovary.Teratomas, or mature dermoid cysts, are the most common type of germ cell tumor, with the majority of them being benign in nature (>95%). While most teratomas are asymptomatic, torsion is a known complication, with rupture and subsequent spillage of contents being relatively uncommon -4. If diBoth dermoid cysts and cases of ovarian torsion are most prevalent in women in their 20s and 30s and are closely related to reproductive hormonal peaks and cycles. It is important to note that torsion may occur in females of all ages (even fetuses and neonates), including post-menopausal women, particularly if a mass is present -6.The mainstay of treatment is operative, direct visualization of the rotated ovary, tube, or cyst, with an assessment of ovarian viability. Historically, salpingo-oophorectomy was completed due to concern for leaving behind potentially necrotic tissue, whereas the modern surgical approach balances visualization of cystic structures, suspicion of malignancy, and gross appearance, with the likelihood of ovarian conservation with detorsion, particularly in young children -3.Missing or delaying diagnosis of torsion can result in delayed surgical treatment and preventable loss of reproductive structures, both of which are highly undesirable outcomes from both a clinical and medico-legal perspective. Laterality in both imaging and examination may be inconsistent due to a patient’s age and inability to appropriately verbalize, but it may also be due to the mass effect of pathologic structures altering anatomy and decreasing diagnostic imaging specificity. Ultimately, high clinical suspicion, serial examinations, and early involvement of surgical colleagues can provide the best clinical outcomes for these pediatric patients.


A 13-year-old male mixed-breed dog was examined because of hematuria and pyrexia. Ultrasonographic examination of the genitourinary tract showed the presence of a migrating grass awn in the right prostatic lobe. Laparotomy allowed, under ultrasonographic guidance, to remove entirely the migrating grass awn from the prostatic parenchyma. The recovery was uneventful and four months after the surgery the owner reported that the dog showed the complete resolution of the clinical signs and full return to normal activity. To our knowledge, this case report describes for the first time the clinical presentation, imaging findings, management and outcome for a dog with prostatic localization of a migrating grass awn. Migrating grass awns are a frequent cause of foreign body disease in dogs and cats during the spring and summer seasons ,2,3,4,5.Imaging techniques such as ultrasonography, computed tomography (CT) or MRI can be useful to identify and guide the removal of grass awns that have migrated into body tissues or cavities ,14,15,16To the best of our knowledge, no reports have described the prostatic localization of migrating grass awns in dogs. Therefore, the aim of this case report is to describe the clinical presentation, imaging findings, management and outcome for a dog with a migrating grass awn in the prostate.A 13-year-old, 15 kg, male mixed-breed dog was referred to the Veterinary Teaching Hospital of University of Perugia for a suspected foreign body in the genitourinary tract. The owner reported that the dog showed hematuria and pyrexia (40 °C) 10 days before the presentation and the referring veterinarian visualized a hyperechoic structure in the prostate during the ultrasonographic examination. The dog was treated with enrofloxacin for 10 days and an improvement of clinical signs after onset of antimicrobial treatment was observed. At presentation, the physical examination was within normal limits. All diagnostic and surgical procedures were performed after obtaining written consent from the dog’s owner. Complete blood cell count showed a mild neutrophilia and serum biochemical analysis was unremarkable.Ultrasonographic examination of the genitourinary tract showed the presence of a linear, spindle-shaped, hyperechoic structure of 2 cm in length localized in the prostatic parenchyma. This structure, suggestive of a migrating grass awn, was visualized in the right prostatic lobe and was surrounded by a hypoechoic/anechoic zone, consistent with a focal inflammatory response and fluid accumulation . The awnAn abdominal pre- and post-contrast CT was performed in order to identify accessory lesions in the genitourinary tract and to confirm the presence of the vegetal foreign body. CT showed no lesions secondary to the migration of the grass awn, except for the presence of irregular prostatic margins localized in the ventro-lateral right lobe . A mild After the CT, urethral and bladder endoscopy was performed with a 2.7 mm diameter fibroscope and 1.8 mm diameter working channel , but no anatomical alterations and mucosal injuries were detected.A diagnosis of prostatic migration of a grass awn was made and surgical removal of the foreign body was recommended.®, Fatro Spa, Italy) and methadone  , induced with lidocaine   and propofol  intravenous to effect and maintained with isoflurane  in 100% oxygen and sufentanil  constant rate infusion [®, Zoetis, Italy) and postoperative buprenorphine  . Preoperative abdominal ultrasonography was also performed with the dog under general anesthesia to visualize the position of the migrating grass awn in the prostate. After the scrub, the dog was placed in dorsal recumbency at the operating table, and a ventral and caudal midline celiotomy was performed through a 6 cm incision matching the location of the migrating grass awn, to allow the best-targeted approach with a minimal and effective incision. To isolate the surgical field into the abdominal cavity and to allow the intraoperative ultrasonography of the prostate, fat was gently separated by blunt dissection. The ultrasound probe  was encased in a sterile sheet . The probe was located on the ventral surface of the prostate, just above the awn, with the marker of the probe in cranial position. Under direct ultrasonographic view of the vegetal foreign body, a 20 G × 60 mm spinal needle was introduced through the prostate towards the tip of the awn   until bacteriological response. At the time of suture removal, abdominal ultrasonography showed an improvement of the affected prostatic lobe and no signs of peritoneal post-operative infection. Complete resolution of the clinical signs and full return to normal activity was reported from the owner four months after the surgery.Vegetal foreign bodies can penetrate through intact skin or natural orifices  and subsequently migrate into the body ,3,4,5,6.Abdominal ultrasonography is a safe, noninvasive and readily available imaging technique that can be useful to assess the size of the prostate and the homogenicity of its parenchyma . In our Consistent with findings in our case report, CT examination can fail to identify migrating grass awns but can be useful to visualize the tissue reactions ,10,11. IEndoscopic examination of the lower urinary tract is a diagnostic tool frequently used in dogs with urethral and urinary bladder diseases. This allows the evaluation of the inside of organs and collection of material for further examinations ,26,27. TIn the dog of this report, a surgical approach by mini-invasive ventral midline laparotomy permitted an excellent visualization of the prostate and the ultrasonographic probe could be easily positioned close to the diseased region. Moreover, the dog did not suffer post-operative complications and the clinical signs due to the migrating grass awn resolved after the surgery.To the best of our knowledge, this is the first report describing ultrasonographic findings of a migrating grass awn in canine prostatic parenchyma. Migrating vegetal foreign bodies can be a diagnostic challenge for veterinarians and imaging tools, as the ultrasonographic examination, can be useful for the visualization and subsequent removal of migrating grass awns.


Mucinous cyst neoplasm of the liver (MCN-L) comprise less than 5% of all cystic liver lesions and is characterized by the presence of ovarian stroma and absence of bile duct communication.Here, we discuss a 45-year-old woman who presented with symptomatic liver mass. Diagnostic workup detected a 4.2 × 3.6 cm septate cyst located in segments I, V, and VIII of the liver in communication with the right hepatic duct. An open right liver resection with total bile duct excision and hilar lymphadenectomy was performed. Pathology revealed a multiloculated cyst with lined mucinous epithelium and ovarian-like stroma, consistent with low-grade MCN-L.This case shows that unusual location and bile duct communication can be present in MCN-L. Cystic liver disease affects 5–10% of the world population . RecentlMCN-Ls have a female predominance, presenting with relatively nonspecific abdominal symptoms and are usually an incidental finding on imaging, since laboratory values are often normal . Of thosRadiologically, this neoplasm is a solitary multiloculated cystic lesion, typically centrally located (mainly in segment IV), with slow-growth . Bile du2), presented with upper abdominal pain, anorexia, malaise, mild jaundice and pruritus for 6 months. The liver function tests were normal, and CA 19–9 was slightly elevated (37 U/ml).A 45-year-old-female with no significant past medical history other than grade I overweight  scan demonstrated a 4.2 × 3.6 cm multiloculated cystic lesion within segment I, V and VIII of the liver, communicating with the right hepatic duct. The biliary system was dilated with thickening of the common hepatic duct, and extrinsic compression of the biliary confluence. The image also revealed a hepatic lesion in segments V/VIII, suggestive of hemangioma. Radiologic findings were confirmed by magnetic resonance imaging (MRI) Fig. .Fig. 1AbAfter multidisciplinary discussion, the patient was considered to present with a resectable complex cystic lesion, compatible with IPN-B associated to cholangiocarcinoma. Anatomic right hepatectomy and hilar lymphadenectomy was the proposed procedure for surgical resection. The tumor was involving the bifurcation of the main biliary hepatic ducts (right and left), then a decision was made not to submit the patient to an endoscopic retrograde cholangiography procedure due to its invasiveness characteristics and complications associated to the papillotomy, since it would not change the surgical plan at that moment in time.Preoperative liver volumetric assessment was performed to estimate the future liver remnant (FLR) Fig. . Total lThe abdominal cavity was assessed thought a J-shape incision. No unexpected peritoneal seeding or metastasis were found. A 4 cm cystic lesion in segments I, IV and VIII was observed. Intraoperative cholangiography through the cystic duct confirmed communication of the cyst with the bile ducts and extrinsic biliary compression. The intraoperative ultrasound assessment confirmed no macrovascular invasion, with cystic biliary communication to the right hepatic duct.After defining the resectability, complete skeletonization of the hepatoduodenal ligament was performed. Thereafter, the distal common bile duct was isolated and divided at the level of the intrapancreatic portion, and the remainder was sent for frozen biopsy (negative). Hilar lymphadenectomy included stations 12, 8a and 13 with en-block of extra-hepatic and biliary confluence resection was performed. The right hepatic artery and right portal branch were ligated and divided, with careful dissection not to damage the vascular inflow to the FLR.Subsequently, the liver was mobilized by dividing all ligamentous attachments. Anatomic right hepatectomy including the caudate lobe  was performed using ultrasonic harmonic scalpel device (Ultracision™) along with the demarcation line marked by the ischemic color change of the liver surface. The left intrahepatic bile duct was resected at its origin in the umbilical fissure.Left sided bile duct was reconstructed after removal of the specimen from the abdominal cavity. The Roux limb was placed up in a retro colic fashion, and hepaticojejunostomy was performed using a 5-0 PDS single-layer running suture. Thereafter, jejunojejunostomy was performed. A closed drainage catheter was placed around the resection plane of the liver and the hepaticojejunostomy. Abdominal closure was performed after hemostasis was achieved.Despite abdominal drainage, the patient experienced a biloma that was treated by non-surgical approach with a percutaneous catheter insertion for drainage and spontaneous closure. Patient was discharged on postoperative day 12.At the 2-months follow-up, the patient is asymptomatic with normal liver function tests and no recurrent lesions.Surprisingly, histopathological examination of the resected specimen Fig.  confirmeThe most recent WHO classification defined mucus-producing bile duct tumors of the liver into MCN-L and IPN-B . MCN-L aFeatures of MCN-L on abdominal contrasted CT scan are hypodense lesions with internal septations which enhance with contrast . PresencPeculiar features of the current case are the unusual location in right lobe, presentation with jaundice which is a rare clinical manifestation due to biliary obstruction , and comUnlike the case presented, this unique neoplasm is usually characterized by having no communication with the bile duct . A previAlthough in the past cystadenomas of the liver have been treated by marsupialisation, internal Roux-en-Y drainage, aspiration, sclerosis or partial resection, currently the best procedure is the complete surgical excision because of the potential of malignant degeneration . The mosMCN-L is a rare pre-malignant tumor with some typical clinical and radiological features. Despite these characteristics, unusual presentations of MCN-L should be considered in the differential diagnosis of patients with cystic neoplasm and jaundice. Although biliary communication typically speaks against the diagnosis of MCN-L, it can occur in rare cases.


Although noninvasive prenatal testing is not intended to identify maternal genomic information, it can provide other information that may lead to the incidental discovery of coexisting conditions including maternal malignancy. Although noninvasive prenatal testing is not intended to identify maternal genomic information, it can provide other information that may lead to the incidental discovery of coexisting conditions including maternal malignancy. In Japan, NIPT of trisomies 21, 18, and 13 has become available since April 2013 as a nationwide clinical trial. Over 60 000 tests were performed by the Japan NIPT consortium in the first 6 years since its introduction, with more than 90% of cases analyzed via massively parallel sequencing (s‐MPS) for the DNA analyses. Among the pregnant women tested, 1.8%, 97.9%, and 0.3% obtained positive, negative, and inconclusive results, respectively.2A 35‐year‐old gravida 3 para 1 woman presented to our hospital at 12 weeks of gestation with no remarkable prior medical history except for thyroid tumor. Ultrasound examination revealed that her ovary and uterus were normal and that the fetus had normal growth and did not have any significant abnormality. She requested for NIPT after precise genetic counseling, and NIPT was performed at 12 weeks of gestation. Because the fraction of fetal cfDNA was approximately 12%, and multiple fetal aneuploidies were suspected , and an 11 × 12 cm solid mass was detected in the pelvis. The tumor showed similar characteristics to that of a leiomyosarcoma or gastrointestinal stromal tumor Figure .The recurrence was not detected 24 months postpartum. Informed consent was obtained from the patient to report the clinical course.3Because NIPT analyzes the cell‐free DNA in maternal plasma, the result is affected by the maternal pathology. In cases in which the test result is discordant with the fetal status, further assessments should be performed to determine the underlying biological conditions, such as confined placental mosaicism, a twin demise, and maternal malignancy. Cancer rarely coexists with pregnancy, with an incidence of approximately 1 in 1000 pregnant women.Bianchi et alIn the present case, NIPT result indicated multiple aneuploidies that would not be expected in a living fetus, leading to a nonreportable test result at 12 and 14 weeks of gestation. Although no abnormal mass was detected in the abdominal cavity on ultrasound examination at 14 and 16 weeks of gestation, repeated NIPT showed increasing Z‐score in multiple chromosomes, and the alterations were believed to have reflected further tumor growth. The initial detection of the alteration at 12 weeks of gestation was limited, but it was markedly enhanced at 14 weeks and then 18 weeks in a stepwise manner as shown in Figure In a position statement of the American College of Medical Genetics and Genomics, they recommend that patients and providers should be aware of the potential for inadvertent discovery of other information during NIPT, including maternal malignancy, and the potential for additional follow‐up testing unrelated to the pregnancy, although NIPT is not intended to identify clinically relevant maternal genomic information.In conclusion, we experienced a case of nonreportable NIPT result that was affected by Ewing's sarcoma during pregnancy. The CNAs were enhanced during the pregnancy according to the growth of the tumor, and the alterations disappeared after the chemotherapy. These findings indicated that CNAs are a potential marker for detecting and monitoring the existence and growth of the tumor. Furthermore, the case shows that the presence of maternal malignant tumor should be considered when abnormal NIPT result is obtained. Moreover, repeat NIPT or MRI should be considered for the differential diagnosis of malignancy. Clinicians should be adequately knowledgeable about the implications of NIPT findings and should inform pregnant women about the potential for incidental findings during pretest genetic counseling.We do not have any conflict of interest.KM and RM: wrote this report. MT and NS: examined the patient. MI and TH: provided genetic counseling. AS: oversaw the production of the manuscript. All authors: managed the patient in the clinical setting and contributed equally. All authors: read and approved the final manuscript.


To describe the multimodal imaging findings and treatment outcomes in choroidal neovascularization secondary to Choroideremia.A 13-year-old male presented with reduced visual acuity in the left eye. He gave a history of nyctalopia. His best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/40 in the left eye. Based on multimodal imaging, the diagnosis of choroideremia in both eyes with a subfoveal choroidal neovascularization in the left eye was made. He underwent five intravitreal anti-vascular endothelial growth factor (VEGF) injections of Ranibizumab over a period of 3 years, with the final injection given due to recurrence of neovascularization. Post-treatment, his BCVA improved to 20/20 in the left eye with regression of the neovascular network.This case highlights the role of OCTA in diagnosis of choroidal neovascularization in choroideremia as well as its successful management with anti-VEGF injections with long term follow up. We describe the role of multimodal imaging in the diagnosis and monitoring of a case presenting with CNV secondary to choroideremia, and the long-term outcomes following prompt treatment with anti-vascular endothelial growth factor (VEGF) injections.2A 13-year-old boy, presented with complaints of reduced vision in the left eye (LE) for one month. He gave a history of night blindness for the past one year. He did not have any systemic illnesses. Both the parents and his only sibling were asymptomatic and were normal on ocular examination. On examination, his best-corrected visual acuity was 20/20 in the right eye (RE), and 20/40 in the LE. Anterior segment examination was unremarkable in both eyes. Fundus examination of both eyes revealed pigment clumping with areas of widespread chorioretinal atrophy with visible network of large choroidal vessels sparing a large island of perifoveal area with pseudopodia like extensions suggestive of choroideremia. A and B. 3,CNV is a rare manifestation of choroideremia with only a limited number of case reports available in the literature.Choroideremia-related CNV may present with a small subretinal hemorrhage and a subretinal neovascular membrane, as seen in our patient. Presentation with significant exudation in the form of clinical and tomographic evidence of subretinal and intraretinal fluid is rare. Fluorescein angiography also reveals only minimal neovascular leakage due to the atrophic nature of surrounding choriocapillaris.,,With prompt anti-VEGF treatment with Ranibizumab, our patient has maintained a visual acuity of 20/20 in the affected eye. Owing to propensity for spontaneous resolution, CNVs secondary to choroideremia have been just observed in older reports.To conclude, the preservation of the central visual acuity is of prime importance in an eye with extensive peripheral visual field loss due to choroideremia. Multimodal imaging especially OCTA is useful for close monitoring in choroideremia, which can help in early diagnosis of CNV, a rare manifestation of the disease. Initiating prompt treatment with anti-VEGF would help to maintain good central acuity by stabilizing the CNV complex and preventing subretinal fibrosis.An informed consent has been obtained from the legal guardian for publication of data and ocular images.No funding or grant supportAll the authors of this case report have no financial disclosures .All authors attest that they meet the current ICMJE criteria for authorship.


Although most subepithelial lesions are benign, the malignant forms could present as serious life-threating cancers. Their accurate diagnosis depends on complete surgical resection. Different endoscopic methods have been recommended for the resection. Recently, the EMR has been considered as a safe and effective technique, while various revised EMR techniques have been introduced. In this study, a new version of EMR has been evaluated in two patients. Two middle-aged cases with gastric subepithelial tumors were admitted to Taleghani gastrointestinal department. The polyps were resected via our new Endoscopic Mucosal Resection (EMR) technique. In this technique, the needle knife was used for un-roofing the mucosal surface. Then, the polyps were resected with hot snares. The hemoclips were applied for ligation too. We found no early or delayed complications. Furthermore, the microscopic margins of the lesions were free. Our study represented a safe and cost-beneficial technique for subepithelial lesions and no complications was found and the margins were free. However, further investigations are required for confirming the validity of this new EMR technique. Subepithelial tumors (SETs) include a wide range of spectrum from benign to malignant forms of polyps. These lesions can be either serious such as GIST or benign such as lipoma, leiomyoma, or schwannoma . RetrospCase presentation 1An Iranian 50-year-old man attended Taleghani Gastrointestinal Clinic for recurring epigastric pain. This patients complaints included epigastric pain, heartburn and dysphagia. He suffered from these signs and symptoms from four months before the tumor detection. No weight loss was detected. Past surgical history and family history of the patient were negative too. He did not smoke or drink alcohol. He was treated several times with omeprazole, anti-acids, and baclofen. Finally, he was referred to Taleghani Hospital Clinic by food sensation. In our setting, he was evaluated by endoscopy and a submucosal mass in cardia was detected.On physical examination, his temperature was 37.1°C, heart rate was 82 beats per minute, respiratory rate was 10 breaths per minute, and blood pressure was 130/80 mm-Hg. Abdominal examination showed neither distention nor tenderness. No organomegaly or palpable mass was found. Furthermore, laboratory tests had no remarkable findings. The evaluations included endoscopy of upper and lower gastrointestinal tract at the same time. The result of colonoscopy was normal. Endoscopy of the upper GI tract showed a 19×13 mm homogenous and hypoechoic submucosal lesion, with smooth and defined border in cardia at the third layer. In addition, EUS reported a small calcification in the center of lesion.Case presentation 2An Iranian 40-year-old lady was referred to the gastroenterology department of Taleghani Hospital with a submucosal mass lesion. The patient described her symptoms as intermittent epigastric pain, discomfort, dyspepsia, and heartburn from more than six months before the admission. No significant weight loss was detected in our case. She revealed two caesarean sections as the past medical history and the family history of gastrointestinal malignant disorders was negative. In addition, she denied any positive history of alcohol drinking or smoking.On physical examination, her temperature was 37.6°C, heart rate was about 84 beat per minute, and blood pressure was 110/70 mm-Hg. Abdominal examination showed a soft and non-tender abdomen with no sign of organomegally or palpable mass. The rest of the physical examinations and laboratory tests were normal.The evaluations before the referral included upper and lower GI tract endoscopy and ultrasonography. Endoscopy reported a polyp-like lesion in the antrum, while the mucosa in this place was normal. In addition, EUS showed a 16.3 mm subepithelial, iso-hyperechoic lesion originating from the submucosal layer. The pillow sign of the mass was negative. The gross feature of the lesion was in favor of lipoma.Endoscopic devices and proceduresA soft, straight, transport cap with an inside rim  was fitted on to the tip of a standard single channel endoscope . Other devices included Needle Knife (Olympus), Hot snares, and Hemoclips .Under sedation with intravenous propofol in standard position, endoscopy was performed. The procedures included the following steps and all of them were attended by an expert and single endoscopist . Follow-up assessment The submucosal lesion was detected by retroflexed maneuver. Then, after the estimation the site of the polyps. The mucosal surface was unroofed with needle knife (this part is different with other previous known methods.). The lesion was retracted with grasps, and the mass was enucleated. It was resected with standard polypectomy hot snares. After resection, the mass was sent to a pathologist. Two hemoclips for each mass were inserted on the base of the lesion . Follow-In both cases, second look endoscopy was performed after six hours of the resection. The outcomes were followed up by endoscopy after the two months following the procedure, to confirm the healing of the artificial ulcers and other complications. The assessment of endoscopic parameters included resection rate, early and delayed perforation rate, early and delayed bleeding rate, dehiscence rate, and recurrence rate.Histopathological examinationsIn both cases, the tissue specimens were fixed in formalin solution. The histological analysis included the identification of cell types, nuclear atypia, histopathological type, tumor size, and tumor invasion. In the first case, immunohistochemical study was also performed. Furthermore, the margins of resection were examined macroscopically and microscopically.Histopathological resultsCase 1 The specimen consisted of a polypoid creamy tissue fragment measuring 1.7×1.5×1 cm and tiny fragments of creamy soft tissue measuring 1×0.7×0.3 cm. \4The primary histopathological analysis suggested gastrointestinal stromal tumor (GIST). IHC study included Smooth Muscle Antibody (SMA), Desmin, CD117, and DOG1. Desmin and SMA were positive but CD117 and DOG1 were negative. IHC and histologic findings were in in line with leiomyoma.Case 2The specimen consisted of adipose tissue fragment measuring 1×1×0.5 cm. Histologic findings of endoscopic biopsy confirmed lipoma.Follow upRe-endoscopy, after six hours of resection reported no early complication, in both cases. After 12 hours of the procedures, both patients were discharged. Once discharged, the patients were prescribed daily oral Proton pump inhibitors (PPI) for two months. After two months, patients were evaluated by endoscopy again. Repeated endoscopy revealed, the hemoclips were spontaneously removed and the mucosa of the antrum was normal, in both cases. No macroscopic evidence of tumor was detected. Furthermore, the resection margins of the polyp were evaluated microscopically. Microscopically, all margins were free. Delayed perforation or delayed bleeding were not detected after 2 months.Gastric SETs are usually detected incidentally during the upper GI tract endoscopy . Althoug


Pancreatoduodenectomy with resection of the portal vein or superior mesenteric vein confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the portal vein or superior mesenteric vein. In recent years, left-sided portal hypertension, a late postoperative complication, has received focus owing to increased long-term survival with advances in chemotherapy. Left-sided hypertension may sometimes cause fatal gastrointestinal bleeding because of the rupture of gastrointestinal varices. Here, we present a case of colonic varices caused by left-sided portal hypertension after pancreatoduodenectomy with portal vein resection.A 69-year-old man diagnosed with pancreatic head cancer was referred to our department for surgery after undergoing chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Computed tomography showed a mass 25 mm in diameter and in contact with the portal vein. He had undergone subtotal stomach-preserving pancreatoduodenectomy with portal vein resection. Four centimeters of the portal vein had been resected, and end-to-end anastomosis was performed without splenic vein reconstruction. We had to completely resect the right colic vein, accessary right colic vein, and middle colic vein due to tumor invasion. The pathological diagnosis was ypT3, ypN1a, ypM0, and ypStageIIB, and he was administered TS-1 as postoperative adjuvant chemotherapy. Seven months after therapeutic radical surgery, he presented with melena with progressive anemia. Computed tomography revealed transverse colonic varices. He was offered interventional radiology. Trans-splenic arterial splenic venography showed that transverse colonic varices had developed as collateral circulation of the splenic vein and inferior mesenteric vein system. An embolic substance was injected into the transverse colonic varices, which halted the progression of the anemia caused by melena. Fifteen months after therapeutic radical surgery, local recurrence of the tumor occurred; he died 28 months after the surgery.When subtotal stomach-preserving pancreatoduodenectomy with portal vein resection is performed without splenic vein reconstruction, colonic varices may result from left-sided portal hypertension. Interventional radiology is an effective treatment for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices. Pancreatoduodenectomy (PD) with resection of the portal vein (PV) or superior mesenteric vein (SMV) confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the PV or SMV. There are reports demonstrating that splenic vein (SpV) reconstruction is unnecessary, but there is no consensus on this –3. In reA 69-year-old man was referred to our gastroenterology department because of worsening diabetes. Computed tomography (CT) revealed a mass measuring 22 mm in diameter, in contact with the PV in the pancreatic head. It was identified as an adenocarcinoma by endoscopic ultrasonography (EUS)-guided fine needle aspiration (FNA). He was diagnosed with pancreatic head cancer, but he was not offered therapeutic radical resection because the tumor had invaded the PV. He was referred to our department again for surgery after receiving chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Although the CT scan showed a mass measuring 25 mm in diameter and still in contact with the PV, we judged that the mass was resectable and he had subtotal stomach-preserving pancreatoduodenectomy (SSPPD) with PVR 11 months later. The PV had 4 cm of its length resected, and end-to-end anastomosis was performed without reconstruction of the SpV. We had to completely resect the right colic vein (RCV), accessary right colic vein (accRCV), and middle colic vein (MCV) which received reflux directly from the PV-SMV due to tumor invasion Fig. . This haPD with combined PVR can be performed safely with improved surgical techniques , and recSome have considered reconstructing the SpV to prevent LPH. Although there have been reports that it is important to preserve the flow of the LGV and MCV directly into the PV-SMV when SpV reconstruction is unnecessary –3, it maFor varices, local treatment with IVR may be useful, but splenectomy or splenic embolization may be considered if control of bleeding varices is difficult . In the When SSPPD with PVR is performed without reconstruction of the SpV, colonic varices may result from LPH. IVR is one of the effective treatments for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices.


Molluscum contagiosum virus. Direct contact with the infected skin and autoinoculation are the main ways of transmission. MC usually presents with pinkish to skin-colored and rounded umbilicated papules varying in size and shape. The diagnosis is usually based on the clinical features [Molluscum contagiosum (MC) is a viral infectious skin disease caused by features . Here weA 28-year-old man having a painless plantar lesion noticed 2 weeks previously was referred to our department with a preliminary diagnosis of plantar wart. Physical examination revealed a 3-mm skin-colored lesion on the plantar surface of the right foot . DermoscMC is a common infectious condition that may affect both sexes and all age groups. It may present with single or multiple lesions. Lower abdomen, thighs, genitals, and perianal areas are the common sites involved . PlantarMC may have atypical presentations including giant and eczematous lesions. The atypical manifestations may imitate many conditions including warts, basal cell carcinoma, intradermal nevus, and amelanotic melanoma . The cliDermoscopy has recently become an indispensable diagnostic tool in daily dermatology practice. Dermoscopic features of MC are well described. Roundish white-to-yellow structures and peripheral crown vessels are the typical dermoscopic findings. Radial and dotted vessels can also be seen. In our case, we observed a central yellowish structureless area surrounded by circumferential vessels. The main differential diagnosis was plantar verruca, in which dermoscopy usually reveals a lobulated surface with thrombosed capillaries giving a so-called “frogspawn appearance” in metaphorical language.To the best of our knowledge, dermoscopic features of plantar MC have not been described previously.


With the rarity and benign nature, angioleiomyoma is a tumor of disputed etiology that originates from the tunica media of the blood vessels. Lacking any characteristic clinical or radiological features, often leading to preoperative misdiagnosis, it is only diagnosed confidently on the basis of histopathology; for this reason combined with the rarity, angioleiomyoma would not be usually found at the top of the differential diagnosis list. Local excision is usually curative with excellent prognosis.This report discusses a case of a 60-year-old healthy lady who complained of a chronic painless mass in the right 2nd digit. Originating from the proper ulnar digital artery, it was excised with no complications. Histopathology results confirmed the diagnosis of angioleiomyoma. No recurrence was observed 6 months following the procedure.Out of the handful published papers concerned with angioleiomyoma in hands, few report the origin to be the digital artery.Further awareness about this tumor is required and it should be included in the differential diagnoses list of the treating surgeon. The han2A 60-year-old right-handed lady, not known to have any medical conditions, presented to the plastic surgery clinic at our institute complaining of a painless mass on the right index finger for a long time. No history of trauma was documented. On examination it was a small, firm mass located on the ulnar base of the right 2nd digit’s proximal phalanx. Magnetic resonance imaging (MRI) showed a soft tissue nodule measuring 1 × 0.8 × 1 cm at the ulnar aspect of the 2nd digit base, close to the palmoulnar side of the flexor tendon. Hypointense signal was evident on T1 while T2 demonstrated inhomogeneous hyperintense signal. PD mode showed an internal hypointense ring with a central hypointense dot; nerve sheath tumor was proposed based on the aforementioned radiological findings. Intraoperatively Bruner incision over the mass was done under general anesthesia followed by dissection and flap creation. The mass was found to sprout from the proper ulnar digital artery and was excised with the branches were clipped; there were no intraoperative or postoperative complications. The patient was sent home on analgesia, antibiotics and dressing. Two weeks following the operation, pathology report concluded the diagnosis of angioleiomyoma. The patient’s wound healed by that time and no pain was reported. No recurrence was reported on a follow-up visit 6 months later , Fig. 3.3With a tendency towards females, male to female ratio of 1: 1.7, and those ageing between thirty to sixty years old, angioleiomyoma appears as a slowly growing, firm mass when found in the hands . It is pHistologically angioleiomyoma is divided to three types: Cavernous, venous and solid, with the last one being the most common in the extremities and more likely to be painful ,3,8. TisThere are scarce reports about cases of angioleiomyoma in the hands ,10. Evenin toto with segmental resection of the involved artery could be sufficient, as described by Robinson and Kalish [Treatment by local excision is sufficient, as described in this paper; On the same manner, simple wound closure is also sufficient. However, Houdek et al. 2013) performed a wide local excision on the premise of high preoperative suspicion of an undifferentiated pleomorphic sarcoma. Likewise, they reported different methods of wound closure in two of their twenty-four cases. A patient required a local, proximally based rotational flap in order to cover the fifth digit while the other underwent split-thickness skin grafting of the index finger 3 perform,5 and vad Kalish . In thisFive cases of recurrence have been published with the maximum point of recurrence in time being seven years postoperatively . A pecul4Many different tumors may arise from the hand. An uncommon subset of which is the benign angioleiomyoma. Contrary to typical belief, its origin maybe arterial, adding to its rarity. It can present as a painless or painful, firm swelling in middle-aged ladies, characters that do not contribute to differentiation from other conditions. To complicate matters more, imaging modalities provide limited insight into the nature of the lesion. Histological studies remain the cornerstone of diagnosis. Local excision should suffice in most of the conditions. This paper reports a case of a typical angioleiomyoma of the hand, yet rare in its origin, from the ulnar digital artery. The treating surgeon should consider this condition in the differential diagnosis when encountered.None.None.Exempted from the IRB approval.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.1.Abdullah Kattan; Supervision; Treatment of the patient and manuscript editing.2.Khalid Arab: Manuscript editing.3.Mohammed Alswayyed: Manuscript editing.4.Emran Al Gadiem: Manuscript editing.5.Qutaiba Shah Mardan: Literature review and overall writing of the manuscript.This paper does not require registry as it is a case report about a condition that has been discussed in prior papers. There is no additional harm to the patient nor an intervention is being applied on the patient.Abdullah Kattan.Qutaiba Shah Mardan.Not commissioned, externally peer-reviewed.


With the increasing number of laparoscopic nephrectomies, trauma to lymphaticchannels has become an increasingly recognised complication. Early diagnosis andprompt management are key to avoid highly morbid sequelae including severemalnutrition and immunodeficiency. This case reviews the important complicationof a retroperitoneal chylous collection following laparoscopic radicalnephrectomy. A previously healthy 71-year-old male presented to primary care with 1-week historyof chest symptoms while on a holiday overseas. A CT pulmonary angiography (CTPA) wasdone; which confirmed the clinical suspicion of a pulmonary embolism. The inferiorlimit of the CTPA demonstrated a suspicious left renal mass. A subsequent CT abdomenand pelvis with contrast was arranged that showed 7.4 × 6.3 cmmalignant mass thought to be a renal cell carcinoma in the left kidney. Left-sidedradical nephrectomy was performed utilising an anterior retroperitoneal approach;with the removal of the left kidney, surrounding fat and local retroperitoneal lymphnode dissection. The patient represented with back pain and fever 2 weekspost-operatively. A post-operative CT abdomen and pelvis with contrast demonstrateda large (approximately 1080 ml) left retroperitoneal collection indicating aworking diagnosis of a post-operative abscess.Following the patient’s acute presentation of a pulmonary embolism and theincidental finding of a suspicious looking left renal mass, a staging CT scan wasorganised. The chest, abdomen and pelvis were imaged in the portal venous phase. An8 × 5.5 cm left renal mass was demonstrated with no size-significantnodal involvement . Histolo−1 with a normal white cell count of 7.9× 10*9/L. A repeat CT abdomen and pelvis with contrast was performed. Imagesof the abdomen in the portal venous phase were obtained and demonstrated a largeleft retroperitoneal collection with enhancing walls and minimal internal densityvariation  to restrict his dietary intake offat. Follow-up CT was performed which showed partial resolution of the collectionfollowing the insertion of the drain, with clear fat–fluid level within thecollection; which is a pathognomonic feature of chyle on CT .1 It has becomemore prevalent due to the increased number of laparoscopic operations compared tothe classic open surgery approach; which entailed better visibility and directligation of the lymphatic channels..2 Since the advent of laparoscopic practice, surgical outcome andrecovery times have demonstrated its multitude of merits. However, awareness of theconstraints of the operating field of view associated with laparoscopy is key to theprevention of lymphatic trauma associated complications.Iatrogenic injury to lymphatic channels is a recognised albeit rare post-operativecomplicatio3 Thus, chylousinjury is a recognised complication of radical nephrectomies which involvesretroperitoneal lymph node dissection.Lymph formed in the kidney drains from the hilum through small lymphatics, into theextensive network of the retroperitoneal space then cyterna chyli and lastly thethoracic duct where the lymphatic system enters the systemic circulation via theleft subclavian vein. The retroperitoneal lymphatics represent the primary drainingsites of renal lymph and extend between the first and the fifth lumbarvertebrae.2Intraabdominal pooling of chyle may be clinically indistinguishable from other typesof post-operative collections on imaging. Symptoms can be attributed to otherdifferentials and include abdominal pain, distension with or without a febrileillness. Patients may also complain of other symptoms such as nausea, vomiting,shortness of breath or surgical wound oozing.4A review of the available literature suggests an average of 4.1 post-operative daysis usually the time needed for a chylous collection to form when normal dietaryintake is commenced.5 Since this is rarely the case, medical imaging is oftenperformed first; of which, CT scan remains the modality of choice. However, the lackof CT findings specific for chylous fluid makes it a non-specific diagnostic markerfor lymphatic contents. The only pathognomonic feature of chylous collection on CTscan is the presence of a “fat–fluid level,”  the chylous collection is not suspected timely and othertreatment options are initiated like antimicrobial therapy for infective causes.Delays in considering lymphatic injury and chylous accumulation can lead to failureof conservative measures resulting in further morbidity. The initial intervention toconsider is drainage of the collection percutaneously, usually under imagingguidance. Drainage enables removal of a potential for infection and allows theinjured lymphatics to heal. Drainage alone is rarely sufficient and is combined withdietary modification including low-fat and high-protein diet, the use ofsomatostatin analogues and occasionally, total parenteral nutrition may be necessaryin refractory cases.2 Conservativemanagement is more likely to be successful with early diagnosis and dietarymodifications. This would subsequently reduce morbidity; hospital stay lengths andlead to better management outcomes. Very few cases fail to respond to theaforementioned measures and require direct surgical ligation of the leakingvessel.6The aim of management of chylous collection is symptom relief and replacement ofnutritional losses.2,3,6,7. Due to its reported rarity, lymphatic injury is stillan overlooked differential potentially leading to considerable diagnostic andtherapeutic delay. Although most cases resolve spontaneously, this case emphasisesthe importance of early consideration of chylous leakage in the differentialdiagnosis of patients presenting with intra-abdominal collections followinglaparoscopic renal surgery.As the practice of laparoscopic nephrectomy has gained a foot hold, the associatedlimitations became more prevalent. A number of case reports studied thepresentation, diagnosis and response to treatment of chylous leakage afterlaparoscopic nephrectomiesChylous leakage resulting from lymphatic injury has become more prevalentwith laparoscopic nephrectomies.Most cases respond well to conservative management which involves amultidisciplinary approach. The aim of which is to reduce lymphatic flow tothe damaged channels, reducing risk of infection, optimising nutritionalrequirements along with providing symptomatic relief.Conservative treatment is more successful with early diagnosis and prompttreatment depending on the severity of the chylous leakage.Image-guided minimally invasive drainage of chylous collections is afeasible, safe and effective option offering less recovery time and lessmorbidity risk compared to re-look surgery.