Spontaneous iliac vein rupture is a rare, but frequently lethal condition. It is important to timely recognize its clinical features and immediately start adequate treatment. We aimed to increase awareness to clinical features, specific diagnostics, and treatment strategies of spontaneous iliac vein rupture by evaluating the current literature.A systematic search was conducted in EMBASE, Ovid MEDLINE, Cochrane, Web of Science, and Google Scholar from inception until January 23, 2023, without any restrictions. Two reviewers independently screened for eligibility and selected studies describing a spontaneous iliac vein rupture. Patient characteristics, clinical features, diagnostics, treatment strategies, and survival outcomes were collected from included studies.We included 76 cases (64 studies) from the literature, mostly presenting with left-sided spontaneous iliac vein rupture (96.1%). Patients were predominantly female (84.2%), had a mean age of 61 years, and frequently presented with a concomitant deep vein thrombosis (DVT) (84.2%). After various follow-up times, 77.6% of the patients survived, either after conservative, endovascular, or open treatment. Endovenous or hybrid procedures were frequently performed if the diagnose was made before treatment, and almost all survived. Open treatment was common if the venous rupture was missed, for some cases leading to death.Spontaneous iliac vein rupture is rare and easily missed. The diagnose should at least be considered for middle-aged and elderly females presenting with hemorrhagic shock and concomitant left-sided DVT. There are various treatment strategies for spontaneous iliac vein rupture. An early diagnose brings options for endovenous treatment, which seems to have good survival outcomes based on previously described cases. Spontaneous iliac vein bleeding is such a rare cause, with a poorly understood etiology. Patients mostly present with symptoms and/or signs of a deep vein thrombosis (DVT), but evidence is lacking to prove it as the actual cause of the bleeding.3 Compression of the left common iliac vein by the right common iliac artery, an anatomical variant called the May-Thurner syndrome (MTS), might explain why spontaneous iliac vein ruptures commonly affect the left side.Spontaneous causes of retroperitoneal bleeding are easily missed due to its rare entity and uncommon presentation. Many cases of spontaneous iliac vein rupture have been published since and new endovenous treatment techniques have been developed. Improved knowledge on the etiology, clinical presentation, treatment and outcomes of spontaneous iliac vein rupture may help to timely recognize, diagnose, and treat these patients.The frequently deathly consequences of a spontaneous iliac vein rupture emphasize the need to raise awareness for the wide clinical presentation, understand its underlying etiology, and learn from previous clinical decisions. The most comprehensive literature review on spontaneous iliac vein rupture was published in 2006 and included 33 patients.This systematic review aims to provide an overview of patient characteristics, etiology, diagnostics, and treatment modalities of spontaneous iliac vein rupture.The protocol for this systematic review was entered in the International Prospective Register of Systematic Reviews PROSPERO network (CRD42023392812), and conducted according to the PRISMA statement.Appendix A.A systematic search was conducted in EMBASE, Ovid MEDLINE, Cochrane, Web of Science, and Google Scholar from inception until January 23, 2023, without any restrictions. A library scientist was consulted to develop the literature search. Terms such as “spontaneous”, “unexpected”, “non-traumatic”, “vein rupture”, “tear”, and “iliac vein” were included. The complete search strategy is shown in All English full-text available case reports and case series were reviewed after screening for title and abstract. All studies describing one or more cases of spontaneous iliac vein ruptures and its management were eligible for inclusion, including case-reports, case-series, and reviews. Non-spontaneous iliac vein ruptures, such as trauma, ruptured aneurysm, arteriovenous fistula, complications, and iatrogenic ruptures were excluded. Editorials, letters, comments, and abstract publications were also excluded. Ruptures of other veins than the iliac veins, such as femoral vein, collaterals, or inferior vena cava were also excluded. References from included review articles were checked manually, and considered for additional inclusion if data was described sufficiently.The CARE checklist was considered to check the completeness of studies.Two authors  independently screened studies for eligibility after duplicate removal. Articles were first screened by titles and abstracts, and full-text screened thereafter. Disagreements for study in- and exclusion were resolved by negotiation in which a third reviewer (MR) was involved. The main authors of the studies were contacted if full-text was missing, or data were described insufficient for collection. Study selection was visualized using PRISMA flow diagram for study inclusion.Data on patient characteristics, clinical presentation, and procedural characteristics were extracted from the included studies and are shown as count with percentages, mean with standard deviation, or median with interquartile ranges. Date of publication and countries where cases came from were also extracted.667 Most patients underwent open surgery, the first reported in 1961. Endovenous procedures were reported since 2004. Patient and procedural characteristics are shown in The literature search identified 224 articles after duplicate removal, the complete study selection is shown in Patients underwent either conservative, endovascular, hybrid, or open surgical repair . ConservData on imaging was available for 50 cases and are shown in In 31 cases (62.0%), the iliac vein rupture remained undiagnosed before start of treatment, even after imaging in some cases . These p After open surgery, 38 out of 51 patients survived, while all patients except for one, survived after endovenous or hybrid treatment. One patient died after stent placement, because she developed abdominal compartment syndrome due to the large retroperitoneal hematoma caused by the iliac vein rupture. Laparotomy for abdominal decompression and removal of ischemic intestines was of no avail.Overall, 59 patients (77.6%) survived the spontaneous iliac vein rupture and 17 patients died, shown in  One patient presenting with severe right lower back pain was misdiagnosed with lumbosacral strain and died from cardiac arrest after returning to the ER multiple times. Another patient received thrombolysis because of an extensive left-sided iliofemoral DVT. In the presence of an iliac vein rupture (conformed during autopsy) the patient started to bleed massively once the thrombus resolved and died before laparotomy could be performed.All conservatively treated patients survived except for 2 cases in which the rupture was missed and one case who died before reaching the hospital.35 Pulmonary embolism was present in four cases.67A concomitant DVT was reported in 84.2% of the cases, This is the first systematic literature review of spontaneous iliac vein rupture, describing 76 cases. Spontaneous iliac vein rupture mainly occurs in middle-aged or elderly women, is located predominantly on the left side, often with a concomitant DVT and over half of the cases present with signs of hemorrhagic shock. These ruptures often remain undiagnosed before a treatment strategy is chosen, even after imaging. Undiagnosed patients frequently undergo open surgery, while diagnosed patients are almost always treated with endovascular or hybrid repair.The overrepresentation of case-reports and case-series in the current literature, emphasize the rare entity of the disease. Increased awareness of symptoms and signs of left-sided DVT, especially in middle-aged or elderly women, may help to early recognize spontaneous iliac vein rupture as the cause of hemorrhagic shock. but its actual etiology is poorly understood. Tannous et al. describe three potential etiologies of a spontaneous iliac vein rupture: mechanical, inflammatory, and hormonal. A combination of these factors is thought to explain spontaneous iliac vein rupture by increasing pressure, loss of vessel compliance and weakening of the vessel wall. A common presentation on the left side supports a mechanical cause as a result of compression of the left common iliac vein (MTS), while a concomitant DVT (found in 84%) leads to inflammation of the vessel. The finding that most patients were female and around 60 years-old may support a hormonal cause. While MTS was reported in only 21 patients within our review, the actual prevalence may have been underestimated, since left iliac vein compression is not routinely investigated and imaging was missing for several patients. Also, it is unclear whether the DVT is the cause or the result of the spontaneous iliac vein rupture as external compression from the retroperitoneal hematoma can provoke the DVT.Various potential causes of spontaneous iliac vein rupture are hypothesized, Due to publication bias, especially with case reports, we have to be careful to interpret these findings to optimistically, as less successful cases may remain unpublished. Selection bias may also have affected our findings. Patients that are hemodynamically stable may had more time to get diagnosed and set-up for endovascular interventions than unstable patients who went straight into the operating room. This most certainly will have affected survival outcomes.Timely recognition of spontaneous iliac vein rupture after radiological imaging gives the opportunity to consider endovascular treatment. Endovascular and hybrid procedures for spontaneous iliac vein bleeding reported promising survival rates. In case of concomitant DVT, start of anticoagulant therapy should be considered when the bleeding is stopped. The length of anticoagulant therapy should depend on the cause of DVT, either provoked or unprovoked.Spontaneous iliac vein rupture is rare, but frequently lethal and should be considered as a cause of hemorrhagic shock in patients presenting with a concomitant left-sided DVT, especially in middle-aged and elderly women. It is difficult to diagnose, even with the use of various imaging techniques. Multiple treatment methods are available including conservative, open, endovascular, or hybrid procedures. Timely identification gives the opportunity to consider endovascular treatment.Click here for additional data file.Supplemental Material for Spontaneous Iliac Vein Ruptures: A Systematic Review by Alexander L. Kooiman, BSc, Jay M. Bakas, MD, Joris M. K. van Fessem, MD, Willem P.A. Boellaard, MD, Sandra A.P. Cornelissen, MD, and Marie Josee E. van Rijn, MD, PhD in Vascular and Endovascular Surgery


Surgical therapy following lenvatinib (LEN) plus transarterial chemoembolization (TACE) is a useful therapeutic option for intermediate-stage hepatocellular carcinoma (HCC). A 66-year-old man with a history of hepatitis C was detected four masses in the caudate lobe and segment 6/7 of the liver, with a maximum lesion diameter of 14 cm by computed tomography. The patient was diagnosed with intermediate-stage HCC and received LEN plus TACE. After resuming LEN for 8 weeks, computed tomography showed weakened stained areas of the tumors, and no new lesions. Thus, the patient was evaluated as having a partial response in the modified Response Evaluation Criteria in Solid Tumors. The patient underwent hepatic caudate lobectomy, partial hepatectomy of S6/7, and S6 microwave coagulation therapy for radical resection. The patient is currently alive and recurrence-free at 12 months postoperatively. In patients with multiple HCC lesions, hepatic resection combined with local therapy might be an effective treatment option. Patients with intermediate-stage hepatocellular carcinoma (HCC) are diverse and the treatments are controversial. In recent years, the efficacy of molecular-targeted agents like lenvatinib (LEN) for unresectable HCC has been reported, with some studies reporting favorable results when combined with transarterial chemoembolization (TACE) , 2. FurtIn this report, we describe a case in which a patient received LEN plus TACE for intermediate-stage HCC and eventually underwent complete resection of a giant HCC and multiple smaller HCCs.A 66-year-old man presented to his previous doctor with abdominal pain. He had a medical history of hepatitis C for which he had achieved a sustained virological response with direct-acting antivirals 5 years ago. Laboratory findings showed increased concentrations of alpha-fetoprotein  and protein induced by vitamin K absence or antagonist-II , and normal liver function . Computed tomography (CT) and magnetic resonance imaging (MRI) at the initial examination revealed four mass lesions: a 14-cm-diameter and 3-cm-diameter lesion in segment 1 (S1), a 5-cm-diameter lesion in S6/7, and a 1-cm-diameter lesion in S6 .The patient was diagnosed with HCC . The patient received LEN (8 mg once daily for 1 week), followed by TACE of the S6 hepatic artery (A6) and A1. One week after TACE, the patient resumed LEN (12 mg once daily) but developed fatigue; therefore, the dose of LEN was alternated between 8 and 12 mg once daily. The patient was referred to our department to evaluate the indication for hepatic resection at 4 weeks after resuming LEN, and we decided to reevaluate at 8 weeks after LEN resumption.At 8 weeks after resuming LEN, laboratory findings showed decreased concentrations of AFP (9 ng/ml) and PIVKA-II (6636 mAU/ml), preserved liver function , and minimal elevation of fibrosis markers .CT and MRI showed weakened stained areas of the S1 and S6/7 tumors with internal lipiodol deposition and poor enhancement. Positron emission tomography-CT showed no abnormal fluorodeoxyglucose accumulation suspicious for lymph node metastasis or distant metastasis . The patHe underwent hepatic caudate lobectomy, partial hepatectomy of S6/7, and microwave coagulation therapy of S6 . The liver was in a state of chronic hepatitis and the S1 tumor was highly adherent to the pancreatic body; therefore, the upper margin of the pancreatic body was partially resected. A nodule, which was not detected on preoperative CT, was found in the Morrison’s fossa, and excised.Histopathological findings showed extensive necrosis and hemorrhage of the tumors, probably because of LEN and TACE. One of the S1 tumors was a well to poorly differentiated HCC with a total size of 135 × 80 mm and viable lesion size of 39 × 31 mm . The othPostoperatively, tumor marker concentrations were normalized promptly after surgery . The patIn recent years, combined treatment with LEN plus TACE that have synergistic effects by enhancing antitumor effects has shown good results for advanced HCC , 5. Howeet al. [The effectiveness of treatment for HCC is evaluated by CT and MRI with reference to the modified RECIST . In addiet al.  reportedA previous case report showed that surgical treatment after LEN was effective and suggested that curative surgery after LEN plus TACE might lead to prolonged survival . For mulWe herein reported a case of curative surgery after LEN plus TACE for intermediate-stage HCC. Hepatectomy combined with local treatment might be an effective curative therapy option for patients with multiple lesions.


Sarcoidosis is characterized by the presence of noncaseating granulomatous inflammation in the affected organs. Isolated involvement of the hypothalamic-pituitary axis in patients with sarcoidosis is rare. We report a rare case of a female patient in whom hypophysitis, mimicking a pituitary macroadenoma, resulted in pituitary transsphenoidal surgery. A female patient had been complaining of bilateral temporal headaches for over a month. Brain MRI showed a pituitary adenoma of height 16 mm, width 16 mm, and depth 12 mm. Hormonal assay showed central hypothyroidism and elevated level of prolactin. Histological examination revealed granulomatous hypophysitis. A specific search for Mycobacterium tuberculosis was negative on the pituitary tissue. After the exclusion of differential diagnoses, the combination of clinical, laboratory and radiological tests led to the diagnosis of neurosarcoidosis. This report presents an uncommon case of a pituitary localization of neurosarcoidosis mimicking a macroadenoma. Understanding the different MRI aspects of neurosarcoidosis is essential to avoid interpretive blunders that could result in an incorrect diagnosis. Hypophysitis is a rare condition characterized by infiltration and possible destruction of the pituitary gland. The incidence is not exactly known but approaches one case per 9 million people per year . HypophyHistologically, hypophysitis is further divided into three pathological subtypes: xanthomatous, lymphocytic, and granulomatous. Granulomatous hypophysitis, such as sarcoidosis, is likely to be the second most common subtype and features widely distributed multinucleated giant cells, histiocytes, some forming granulomas, and variable amounts of lymphocytic infiltration and fibrosis .Sarcoidosis is a multisystem disorder of unknown aetiology, belonging to the spectrum of granulomatosis. Involvement of the central nervous system is a well-known manifestation of the disease occurring in approximately 5% of patients and including some rare cases of hypophysitis .The clinical spectrum of hypophysitis usually includes headache, visual symptoms, and anterior pituitary insufficiencies depending on the extent of inflammation. Enhanced magnetic resonance imaging (MRI) mostly reveals sellar and pituitary stalk lesions, with iso or hypointense signals on T1- and T2-weighted images, a picture that may mimic pituitary adenomas (PA) . It is cHerein, we present a rare case of a female patient diagnosed initially on an MRI secondary to chronic headaches and visual impairment as pituitary macroadenoma, which resulted in a pituitary transsphenoidal surgery rectifying the diagnosis as SIH.A 49-year-old woman had been complaining of a bilateral temporal headache for over a month. As for her medical history, she was treated 20 years ago for tuberculous lymphadenitis and had a metabolic syndrome for four years. She started her menarche at the age of 12 and used to have regular menstrual cycles. She had her menopause at the age of 42.The pain was essentially retro-orbital and was slightly alleviated by analgesics. The headache was associated with inflammatory arthralgia and occasionally with pain and redness in her right eye. The patient denied a history of trauma or seizures; she also reported recent visual blurriness. Physical examination found an alert and conscious patient. Pulmonary auscultation and skin examination were normal. A complete neurologic examination was normal, including sensorium, cranial nerves, motor, sensory, cerebellar and reflexes.Ophthalmological examination confirmed the presence of right panuveitis with multiple choroidal granulomas.Brain MRI showed a pituitary adenoma of 16x16x12 mm diameter with parasellar extension and without compression of the optic chiasm. The mass was hypointense on T1- and hyper-intense on T2-weighted images and homogeneously enhanced after the administration of Gadolinium . Wegener’s granulomatosis, syphilis, and histiocytosis X were ruled out on the basis of physical examination and initial biological tests. Tuberculosis and sarcoidosis were the most plausible aetiologies. Laboratory parameters showed an elevated angiotensin-converting enzyme (ACE) and hypercalciuria. A chest and abdominal CT scan revealed hepatomegaly but no lymphadenopathies. Polymerase chain reaction, for the specific detection of Mycobacterium tuberculosis, was negative on the pituitary tissue.After excluding the differential diagnosis, a combination of clinical, laboratory, and radiographic findings led to the diagnosis of neurosarcoidosis. The patient was initially supplemented with desmopressin for a transient post-surgical diabetes insipidus and the hypothyroidism was corrected with standard replacement therapy.The patient remained on replacement thyroxin and hydrocortisone therapy. She was subsequently switched to prednisone for its anti-inflammatory action for her sarcoidosis at the dose of 1 mg/kg body weight. On the six-month follow-up, clinical examination showed an improvement in uveitis.In this case, we reported a rare situation of SIH mimicking pituitary macroadenoma. In fact, the clinical presentation of hypophysitis is variable. Headaches and visual abnormalities, such as visual field defects and decreased acuity, are the most common symptoms of sellar compression . LateralSome hypophysitis can occur with a typical clinical and radiological presentation, including diabetes insipidus and pituitary enlargement, therefore, easily differentiated from PA.Some granulomatous hypophysitis may occur as pituitary apoplexy or mimic a pituitary abscess ,7. SIH mIn our case, the lack of specific symptoms of hypophysitis induced the medical staff to errors and led to surgery in order to save the visual prognosis. In the presence of a pituitary mass and a pituitary hormonal dysfunction, trans-sphenoidal exploration and histological examination are necessary to reach the final diagnosis. Surgery provided tissue for histological diagnosis and allowed the rapid decompression of the lesion, therefore resolving the headache and visual deficits immediately. Histopathological findings allowed for the diagnosis of granulomatous hypophysitis. With the histology evidence and high erythrocyte sedimentation rate (ESR) and ACE levels, the diagnosis of neurosarcoidosis was retained. The most accurate imaging method for diagnosing neurosarcoidosis is brain MRI. The two most typical neurosarcoidosis findings are the periventricular distribution of lesions and leptomeningeal enhancement, which were missing in our case . Along wThe originality of our case is that surgery, considered later on as a biopsy, indirectly allowed the diagnosis. Neurosarcoidosis with pituitary involvement is rare and has been characterized only through case series ,10. In cThere are no guidelines on the therapy objectives for SIH, and no controlled prospective trials have been conducted in this area. Two key objectives of medical care for SIH are the replacement of pituitary hormone deficiency and optical care. The main early treatment for individuals with neurosarcoidosis remains with high doses of glucocorticoids .Involvement of the nervous system in sarcoidosis can occur alone or in conjunction with systemic inflammation. Due to its non-specific symptoms and clinical similarities to other diseases, isolated neurosarcoidosis may be difficult to diagnose. This case describes a rare instance of neurosarcoidosis that mimics a pituitary macroadenoma. Understanding the range of magnetic resonance imaging (MRI) findings in neurosarcoidosis is essential to avoid interpretive blunders that could result in an incorrect diagnosis and course of treatment.


Intramedullary ependymomas should be treated with surgical resection. Different surgical techniques are described for these tumors, such as skipped and long-segment myelotomies. A 31-year-old male patient with a giant thoracic spinal cord ependymoma extending from the level of T5 to T10 was operated on with a skipped myelotomy technique. Although the patient had urinary incontinence and muscle weakness in both legs, the patient’s complaints were nearly completely resolved in the fourth postoperative month. Operating with the smallest possible myelotomy has given us preferable results; however, more studies are needed to hypothesize the superiority of this technique over conventional myelotomy. Intramedullary spinal cord tumors (IMSCT) are rare and comprise less than 4% of central nervous system tumors and 30% of intradural spinal neoplasms. The most common tumor types are ependymomas and astrocytomas . IntrameMany patients with intramedullary ependymomas present with back pain and dysesthesias without sensory loss because intramedullary ependymomas cause symmetrical expansion around the central canal, interrupting the spinothalamic tract's crossing fibers . On MRI,Intramedullary ependymomas are treated by surgical resection, and gross-total resection can be accomplished without significant morbidity. However, significant neurological deficits may occur in such cases -8. AlterA 31-year-old male patient was admitted to our department with complaints of right leg pain, numbness in both legs, and difficulty walking. He stated that his difficulty in walking started about seven months ago, and he decided to come to the hospital when his pain became unbearable. In muscle strength testing, 4/5 muscle strength was noted in the extension and flexion of the hip and both knees. The remaining muscle strengths were found to be normal. The straight leg raise test was positive on the right side. Bilateral deep tendon reflexes were hyperactive. Babinski's sign was positive bilaterally. Contrast-enhanced MRI of the thoracic spine showed a large solid mass extending from the vertebral level of T5 to T10 and located in the intramedullary compartment Figure .After the patient's consent, he underwent the operation under general anesthesia. A posterior midline incision and subperiosteal dissection of the muscles were performed until complete laminar exposure was achieved. The laminoplasty technique was performed under intraoperative neuromonitoring with somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs). After confirmation by fluoroscopic imaging, the laminae (from one level above to one below the level of the lesion) were cut using a bone excavator  and removed as a whole Figure . The durThere was a decrease in muscle strength after the surgery (1/5 reduction for the right lower extremity and 2/5 reduction for the left lower extremity). Furthermore, the patient complained of urinary incontinence. The early rehabilitation program was started for the patient, and he underwent rehabilitation service on the eighth postoperative day. Currently, he can stand up and walk without support. The patient's urinary incontinence complaint was almost entirely resolved. Pathology reports resulted in ependymoma WHO Grade II  Figures .Ependymomas are the most common intramedullary tumors in adults . They maThe most effective treatment method is surgery. Complete resection is the primary goal of surgery to reduce tumor recurrence and, whenever possible, to preserve neurological function . About 5The patient’s postoperative neurological function was worsened compared to the preoperative state. This might result from the traction of the posterior column, microtrauma resulting in transient edema, or vascular damage. Patients with spinal cord ependymomas in the thoracic spinal cord are more likely to develop neurological deficits after resection because of the limited blood supply in this region and the narrow spinal canal . HoweverAccording to our knowledge, most patients experience the resolution of their somatosensory deficits within a few months -20. ThusThe skipped myelotomy technique should be considered the smallest possible myelotomy during the preoperative planning of large intramedullary tumors. In our case, the best possible outcome has been accomplished regarding neurological deficits. However, more studies with more cases are needed to hypothesize the superiority of this technique over long-segment myelotomy and other techniques.


Accurate differentiation between epidural hematomas and lumbar disc extrusion is essential due to the potential overlap in clinical presentations. We present a case report highlighting a significant challenge in which a massive lumbar disc extrusion was mistaken for an epidural hematoma.This is a case report of a 38-year-old male patient who developed cauda equina syndrome four days after experiencing an audible cracking in the lower back during weightlifting activity. Magnetic resonance imaging (MRI) was inconclusive, unable to distinguish between an extruded nucleus pulposus and a spinal epidural hematoma. Subsequently, an urgent operation revealed a large herniated disc at the L4-L5 level, ruling out any hematoma. The patient's post-operative follow-up showed significant improvement, with almost complete recovery of motor and sensory functions.This case emphasizes the challenges faced when distinguishing between epidural hematomas and lumbar disc herniations, particularly on MRI. The lumbar disc herniation's substantial size, cranial and caudal migration on multiple levels, and signal intensity contributed to the misdiagnosis, underscoring the importance of careful interpretation and awareness of such complexities. The intervertebral discs consist of three main components: the inner nucleus pulposus (NP), the outer annulus fibrosus (AF), and the cartilaginous endplates that connect the disc to the adjacent vertebrae . Disc heOn the other hand, spinal epidural hematoma (SEH) could be another rare cause of acute neurologic symptoms after trauma, coagulation disorders, and surgical/invasive spinal acts. Its pathophysiology is often unclear, but in the lumbar spine, it may result from the rupture of the Batson vertebral venous plexus .To make the diagnosis, magnetic resonance imaging (MRI) is the preferred modality with 75% sensitivity and 77% of specificity in detecting lumbar disc herniation .As a result, lumbar disk herniations that resemble the presentation of spinal epidural hematoma might go unnoticed and be inadequately documented.We present here a case of traumatic disc extrusion mistaken as a hematoma on MRI in a 38-year-old male patient who was operated on the same day of the presentation with a good outcome at the follow-up.This is a case of a 38-year-old patient who presented to the emergency department (ER) complaining of moderate lower back pain radiating to the left leg (L5 and S1 dermatomes), saddle hypoesthesia (S2-S3-S4-S5), anorectal dyschezia, and sexual impotence, four days after lifting 160 kg during a deadlift activity.At the initial accident, he experienced an audible cracking in the lower back, followed by dizziness, discomfort, and severe back pain radiating to the left leg that lasted only a few minutes. After the trauma, the patient presented to the ER, where X-rays and physical exams were normal, without any sign of radiculopathy, and he was discharged only on painkillers. Afterward, he developed neurologic symptoms that were progressive and led him again to the ED after four days.On the second physical examination, the patient had weakness of left toes extension graded 3/5 on the Medical Research Council's (MRC) muscle power scale, left plantarflexion graded 2/5, ankle dorsiflexion was also weak and graded 3/5 and ankle plantarflexion was 2/5. Whereas knee and hip joints had a full range of motion and normal muscle strength. There was no incontinence, but the anal sphincter tone was weak, the bulbocavernous reflex was negative and the plantar reflex was normal. Sensory hypoesthesia was observed at the L5-S1 level in the left foot, and the patient was unable to perform a left heel rise, indicating S1 motor involvement.The MRI was done when he presented again and showed a T1 iso-signal Figure -3 longitAfter gadolinium injection, no enhancement was observed in the epidural region Figure  excludinSix hours after presentation, surgical intervention was conducted. Utilizing a posterior approach, a 10 cm skin incision was made at the L4-L5 level, followed by a longitudinal opening of the aponeurosis. The gutters were then released up to the transverse processes while respecting the subperiosteal space on the left side. Subsequently, the ligamentum flavum on the left side between L4 and L5 was opened, along with a hemilaminectomy of L5. The dural sac and L5 root were reclined medially, revealing a significant extrusion of disc material from the L4-L5 disc space. This extrusion occupied the anterior left side of the spinal canal from L4 to S1, consistent with the findings in the MRI. Multiple fragments anterior to the spinal cord and causing compression were extracted (Figure After the operation, it was discovered that the patient had a neurogenic bladder. Sensory and motor symptoms remained similar, but the shooting and radiating pain had resolved.Six months post-surgery, the patient's urinary symptoms improved, motor power was rated ⅘ in muscles involved in hip abduction and ankle dorsiflexion, the anal reflex was still negative, but the anal tone had improved, and sensory symptoms had disappeared.A herniated disc is when the nucleus pulposus, or part of it, protrudes outside the annulus fibrosus and into the spinal canal. The symptoms can vary from no noticeable signs to radiculopathies, which involve motor, sensory, or mixed nerve root compression, and in extreme cases, cauda equina syndrome. This condition arises due to nerve compression and inflammation, unlike mechanical back pain, which lacks radiating pain, shooting sensations, and neuromuscular deficits .The most common cause of a herniated disc is degenerative changes that lead to dehydration of the nucleus pulposus. The second most frequent cause is after an acute traumatic event. In most cases, conservative treatment is attempted, as herniations tend to heal within eight to 12 weeks. However, in refractory cases, severe or progressive symptoms require surgical intervention .On the other hand, SEH is one of four types of spinal hematomas, alongside subdural, subarachnoid, and intramedullary hematomas. SEH refers to the collection of blood between the dura mater and the posterior wall of the vertebral body. The causes of SEH can be iatrogenic, spontaneous, or traumatic . SpontanSymptoms of SEH can vary from being asymptomatic and resolving without detection to experiencing a sudden onset of back pain with progressive paresis or paresthesia, which can lead to partial or complete paralysis if left untreated, and death especially if it is located in the cervical spine . TypicalMRI is the imaging technique of choice for assessing both disc herniations and SEH , as it pIn our case, the MRI findings were a T1 hypointense, and T2 mixed hypo-hyper intense mass. This finding, with the progressive nature of the symptoms over more than 72 hours, led to our conclusion that this might be a SEH more likely than disc herniation. But we could not eliminate a disc herniation due to the possibility of signal change of the latter depending on the chronicity and the cause of the lesion  and the In the literature, we found five other cases with diagnostic ambiguity like ours. We added our case to the tables done by Basile et al. and Kim et al. , 17 (TabOn magnetic resonance imaging, spinal epidural hematomas and acute lumbar disc herniations can cause diagnostic challenges. However, the key to differentiate between the two conditions lies in carefully correlating the clinical symptoms and signs with the imaging findings. When patients present with symptoms suggestive of neural compression, such as cauda equina syndrome or radiculopathy, and there is uncertainty regarding the precise etiology based on imaging alone, surgical intervention becomes essential to relieve neural compression and address the underlying cause.Therefore, careful clinical evaluation and the consideration of surgical intervention based on the patient's presentation are essential steps in effectively managing cases where SEH is suspected. Timely surgical intervention can be vital in providing accurate diagnosis, alleviating neural compression, and promoting a favorable outcome for the patient.


Hypercalcemia crisis is a rare but severe form of hypercalcemia complicated by multiple organ failure. Hypercalcemia crisis due to hyperparathyroidism is commonly caused by a parathyroid tumor, which often requires surgical resection. However, there are no clear recommendations on when the surgery should be performed.A 64-year-old female patient developed hyperparathyroidism due to a parathyroid tumor and hypercalcemic crisis, which was complicated by severe circulatory and respiratory failure refractory to medical therapy, and an emergent surgery was planned to resect the parathyroid tumor. To prevent intraoperative circulatory and respiratory collapse, venoarterial-extra corporeal membrane oxygenation (VA-ECMO) was introduced, resulting in a safe operation and anesthetic management.In patients with hypercalcemic crisis complicated by severe circulatory and respiratory failure, induction of prophylactic VA-ECMO was useful for safe anesthetic management. Surgical resection should be performed as soon as the diagnosis is made before VA-ECMO is required. Hypercalcemia crisis is a rare but severe form of hypercalcemia complicated by multiple organ failure. The most common cause of hypercalcemia crisis is primary hyperparathyroidism caused by a parathyroid tumor, which often requires surgical resection . However2 was 94% in room air, and body temperature was 36.4˚C on admission. The blood pressure was 78/50 mmHg, and the heart rate were 100/min with sinus rhythm but marked QT prolongation   with a history of ureteral stone was referred to our hospital for asymptomatic hematuria. She was alert, SpO2)/fractional inspired oxygen concentration (FiO2) ratio of 212 mmHg due to acute respiratory distress syndrome (ARDS). Besides noradrenaline 0.2 μg/kg/min, adrenaline 0.04 μg/kg/min and vasopressin 0.02 unit/min, administration of etelcalcetide for regulating PTH secretion and denosumab, an anti-receptor activator of NF-κB ligand (RANKL) antibody for inhibiting osteoclast activation was started. The respiratory condition worsened further to a PaO2/FiO2 ratio of 76.7 mmHg with rapid progressing bilateral lung infiltrate shadow . Vasoactive drug requirements were reduced in response to improved cardiac function, and the patient was weaned from ECMO on day 6. She was discharged from the ICU on day 8 with a serum calcium level of 11 mg/dL and an ionized calcium level of 1.14 mmol/L (Fig. Hypercalcemic crisis is a rare but potentially fatal condition with multiple organ damage . Its incT and U waves, and an enhancement of U wave, observed in hypokalemia. Intracellular hypercalcemia causes impaired diastolic relaxation due to impaired myocardial repolarization [Hypercalcemic crisis triggers numerous symptoms , from mirization , and myorization .Hypercalcemic crisis patients with impaired cardiac function should be monitored for the development of intracardiac thrombi. Chan et al. reported a case of intracardiac thrombi in a patient with hypercalcemic crisis under VA-ECMO . HyperpaIn this case, two potential etiologies are postulated as causes of respiratory failure and ARDS. First, pulmonary edema due to infusion overload for hypercalcemia symptoms. Infusion overload due to acute renal failure or acute pancreatitis may also act in an additive manner. Second, animal studies have shown that hypercalcemia causes pulmonary edema via activation of inducible nitric oxide synthase and increased nitric oxide production and inflammatory cytokines .There is much debate regarding the timing of surgical treatment in cases of hypercalcemic crisis, varying from emergency to elective surgery after correction of electrolytes , 5, 6, aIn conclusion, we experienced parathyroid tumor resection in a patient with hypercalcemic crisis complicated by severe circulatory and respiratory failure. We performed the surgery after introducing prophylactic VA-ECMO for intraoperative circulatory and respiratory collapse. In patients with the most severe form of hypercalcemic crisis, surgical resection should be performed as soon as the diagnosis is made.


Surgery for renal cell carcinoma (RCC) with an inferior vena cava (IVC) tumor thrombus can be done via a robotic approach. While this approach is thought to minimize blood loss, it may still result in significant losses  and currThe patient was a 77-year-old male found to have a right upper pole renal mass on CT urogram. On MRI , a renalRobotic console time was 150 minutes. The patient had an excellent outcome, with all tumor thrombus removed, less than 50cc of blood loss, and was discharged within 24 hours of the operation. The tumor pathology came back as papillary, high grade, and was stage pT3bN1.The robotic approach with split and roll technique is a great surgical option for urologists to consider in patients with RCC and a level I or II thrombus, which can minimize blood loss and expedite discharge. Available at:http://www.intbrazjurol.com.br/video-section/20230245_Rodriguez_et_alInt Braz J Urol. 2023; 49 (Video #12): 650-1


Our patient presented with an elastic soft mass of his left index finger. Hematoxylin and eosin staining showed a high cellular density with spindle-shaped cells in a storiform pattern. Immunohistochemical staining was positive for CD68, factor XIIIa and α-smooth muscle actin, and negative for CD34, STAT6, S100 protein, and desmin. Fibrous histiocytomas (FHs) are benign tumors that mostly arise from the skin, which have been referred to as dermatofibromas, sclerosing hemangiomas, and fibrous xanthomas. Approximately 1% of all FHs originate from soft tissues and were previously known as benign fibrous histiocytomas or deep benign fibrous histiocytomas (DBFHs) , but werDFH is most common in the extremities and the head and neck, and typically presents as a painless, slowly growing mass. Although it is a benign tumor, its local recurrence rate is at least 20%, and distant metastasis may rarely occur ,2. In maThe patient was a 34-year-old male with no medical or family history of disease. He became aware of a rice grain-sized tumor in his left index finger 8 months previously. Because the tumor gradually grew and he experienced numbness in his finger, he visited a doctor and was referred to our department with a suspected soft tissue tumor.On physical examination, an elastic, soft mass 1 cm in diameter was observed on the volar and ulnar side of the middle phalangeal area of his left index finger. The overlying skin was normal and there was no redness or local heat. There was no adhesion to the skin, but adhesion to the deep tissue was found. He had mild tenderness and Tinel’s sign was observed. There was mild numbness distal to the tumor and the Semmes–Weinstein monofilament test showed a mild decrease on the ulnar side of the index finger: 3.22 on the ulnar side and 1.65 on the radial side. There was no limitation in the range of motion of his index finger.A plain radiograph showed a soft tissue shadow, but there was no abnormality in the bone. Magnetic resonance imaging (MRI) revealed a well-defined mass, 1 cm in diameter, on the volar and ulnar side of the flexor tendon. The mass showed an isotense signal on T1-weighted images (T1WI), a low signal intensity with partial high signal intensity inside the mass on T2-weighted images (T2WI), and contrast enhancement on the margin of the mass was seen with gadolinium . Based oBecause the size of the tumor had increased and numbness and hypesthesia were observed, we performed surgical resection after obtaining informed consent from the patient. After making a Bruner’s skin incision, a yellowish-red mass was detected and it was easily dissected from the skin and the tendon sheath. However, it strongly adhered to the neurovascular bundle on the ulnar side , so requHE staining showed that the tumor was relatively well-circumscribed and contained no cutaneous adnexa . The les, which were used for genetic analysis. Although we conducted an RT-PCR assay for three genetic fusions using formalin-fixed paraffin-embedded tissues in accordance with a previously reported method [PRKCB and PRKCD. However, no differential expression that could be attributed to the oncogenic fusion gene was observed. Based on these results, we concluded that abnormal genetic fusions were unlikely in this case. To rule out DFSP, COL1A1-PDGFB, a genetic abnormality invariably found in DFSP, was analyzed with fluorescence in situ hybridization and this fusion gene was not detected.There have been two reports on genetic abnormalities in DFH, both of which indicate abnormalities in the protein kinase system ,5. Plaszd method , none ofd method , we predAccording to the WHO classification of tumors, 5th edition, 2020, DFH is defined as a benign FH arising from soft tissue and rarely metastasizing . About hAlthough no studies on DBFH/DFH imaging have been identified, preoperative MRI, in this case, showed an isotense signal on T1WI, low signal intensity with partial high signal intensity inside the mass on T2WI, and contrast enhancement by gadolinium on the margin of the mass. Benign soft tissue tumors, that frequently occur in the hand, include tenosynovial giant cell tumors, fibromas, lipomas, schwannomas, and hemangiomas ,10. Of tCOL1A1-PDGFB was not detected.HE staining of DFH typically shows spindle-shaped cells that are densely arranged in a storiform pattern, usually without nuclear pleomorphism or hyperchromasia . From thPDPN–PRKCB, LAMTOR1–PRKCD, and CD63–PRKCD) associated with FH by RT-PCR, but none was detected. We also used an imbalance assay [PRKCB and PRKCD; however, no difference in expression that could be attributed to fusion genes was observed. These findings suggest that the previously reported genetic abnormal fusions were unlikely in this case. However, not all cases of DFH show these fusion genes, and most are negative [Several cytogenetic abnormalities in DFH have recently been reported ,5. Here,ce assay  to estimClick here for additional data file.


Sinonasal teratocarcinosarcomas (SNTCSs) are malignant and highly aggressive neoplasms arising in the nasal cavity and paranasal sinuses with extension into surrounding structures and intracranial extension in few instances. They are commonly found in males . They pose difficulty in diagnosis due to their diverse histology. Ideal treatment modalities have not been devised yet due to the rare and highly aggressive nature of SNTCSs as shown in this case report. A 29-year-old Asian male was initially misdiagnosed on biopsy. Surgical debulking was performed initially which showed SNTCSs with radiological evidence of residual disease for which gross tumor clearance was done. He presented within a short span of a month, post re-resection with gross local recurrence. Urgent palliative radiotherapy was planned and started but unfortunately, he developed pulmonary and hepatic metastasis during radiation therapy and was commenced on palliative care only due to significant deterioration of performance status. Treatment of SNTCSs is often delayed due to their difficulty in diagnosis. Its highly aggressive nature prompts an urgent and aggressive treatment approach with adjuvant chemoradiation. Any type of adjuvant therapy is better than surgical resection only given its timely administration and close surveillance. Sinonasal teratocarcinosarcomas (SNTCSs) are histologically and morphologically heterogenous malignant neoplasms. They are very rare, aggressive tumors typically arising in the nasal cavity and paranasal sinuses (ethmoid and maxillary sinus) that can also extend into the nasopharynx, anterior skull base, and rarely oral/orbital cavity . In abouA 29-year-old male patient presented with a history of nasal obstruction and epistaxis for three months. He had no past medical history. Examination showed no remarkable findings. Initial local tissue biopsy was performed which was diagnosed as exophytic transitional cell papilloma due to inadequate samples. The patient then underwent right medial maxillectomy via the lateral rhinotomy approach, and piecemeal excision was done at the previous hospital by a head and neck surgeon and was sent for histopathology, which revealed the tumor to be teratocarsinosarcoma. So for further evaluation and treatment, he visited our hospital facility. Figure Post-resection staging, CT chest, abdomen, and pelvis showed no residual mass or locoregional nodal disease or distant visceral metastases. Bone scan done was also unremarkable. Clinically, the patient complained of right nasal obstruction and stuffiness while the rest of the examination findings were unremarkable. As per hospital policy, the patient discussed with the multidisciplinary tumor board who suggested to have a detailed clinical assessment and get a positron emission tomography (PET) scan for any residual disease or recurrence. The patient was physically unremarkable with good ECOG (eastern cooperative oncology group) performance status. The PET scan showed uptake in the right maxillary sinus (SUVmax 6.7) concerning residual disease, so he was referred to a head and neck surgeon and further debulking of the tumor was done via right medial maxillectomy with the Weber Ferguson approach. Operation findings showed that the tumor involved the right maxillary sinus, ethmoid sinus, and orbital periosteum along with the floor of the orbit. Gross tumor clearance was done with nasal packaging. Histopathology was consistent with teratocarsinosarcoma. One-month post-re-resection of the tumor, he developed pain and swelling of the post-operative site, right cheek, and eye and had developed new onset headaches. Upon assessment by a surgeon after a month of re-resection, early massive recurrence was detected. Urgent CT face and neck was performed which showed localized progression as shown in Figure He was referred for palliative radiotherapy. Radiotherapy was initiated after assessment. High-dose palliation was planned (50 Gray doses in 25 fractions to the affected area). After three weeks (15 fractions) of radiotherapy, his re-planning CT was done which showed tumor shrinkage as shown in Figure SNTCSs are unusual tumors, usually arising in the nasal cavity and paranasal sinuses. These tumors are mostly found by otolaryngologists during their examination of patients presenting with symptoms like epistasis, nasal congestion, and headaches . They caSNTCSs are diagnosed on the basis of malignant epithelial elements with two or more malignant mesenchymal components. These components may seem to be strange in the sinonasal tract and are more likely similar to bronchial or intestinal structures. These mesenchymal components can appear as different muscle types, cartilage, and/or bone as shown in Figure Multimodality treatment consists of surgical resection of tumor, adjuvant radiotherapy (the average dose being 54.9 Gray with range between 10-70 Gray and/or chemotherapy (most commonly cisplatin) depending on extent of disease and performance status of the patient . We deciThe best five years of survival is seen by a combination of surgical intervention with radiotherapy 50%); followed by only surgery 47%). Adjuvant chemotherapy may show some survival benefits in recurrent or metastatic lesions . Current0%; follo%. AdjuvaSNTCSs are uncommon, highly aggressive, and generally misdiagnosed neoplasms due to their diverse histopathology. They have a high recurrence rate of 38% which prompts urgent diagnosis and aggressive treatment. Most commonly, the bimodal approach with adjuvant radiotherapy is utilized, followed by trimodality in local recurrence and distant metastasis, whereas the trimodal approach may be more effective than the bimodal approach in controlling local recurrence and metastasis, and for managing SNTCSs, the surgery alone is not as effective as any form of adjuvant therapy given its initiation on time and timely diagnosis.


Mucormycosis is an invasive fungal infection. The prevalence is low for this disease, and the most common site of its occurrence in the gastrointestinal system is the stomach. The clinical signs and symptoms of gastric mucormycosis are vague such as pain in the abdomen, nausea, vomiting, haematemesis, etc. In the current study, a 42-year-old male patient came with complaints of pain in the abdomen associated with vomiting and mild-grade fever based on vague clinical presentation and imaging like upper gastrointestinal endoscopy and computer tomography angiography of the abdomen. Our preoperative diagnosis was gastrocolic fistula secondary to acute on chronic pancreatitis, which was managed by emergency exploratory laparotomy, resection, and anastomosis. Histopathological examination was successful in confirming the diagnosis of mucormycosis. Through this case report, we intend to draw surgeons' and physicians' attention to gastrointestinal mucormycosis, an emerging cause of gastric necrosis in young patients in the post-coronavirus disease era, and that physicians need to be more aware of the consequent high mortality and morbidity. Early diagnosis followed by aggressive debridement, antifungal therapy, and managing the underlying disease is the most efficient way to reduce mortality associated with the disease. The estimated prevalence of mucormycosis in India is 70% higher than global data; out of these, 2-8% accounts for gastrointestinal mucormycosis . MucormyA 42-year-old chronic alcoholic male presented to the emergency room with the chief complaint of pain in the abdomen and vomiting for 12 days. Abdominal pain was sudden and excruciating, localizing in the epigastric region and radiating to the back. It was relieved by lying in the prone position and by medications. Vomiting that followed meals was non-bilious, non-projectile, with contents such as food and water. It was associated with mild-grade fever. The patient had no other significant medical history. Abdominal and digital rectal examination revealed no significant findings.3), deranged coagulation profile , raised lipase (326 U/L), hyperglycemia (random blood sugar [RBS] of 243), glycosylated hemoglobin (HbA1c) of 8.65%, hyponatremia of 128 mmol/L. On further evaluation with ultrasound and computer tomography of the abdomen and pelvis, a definitive diagnosis of emphysematous gastritis with a cystic lesion in the head of the pancreas, most likely a pseudocyst of size 4x4 cm, and associated bilateral lung consolidation was made. In view of emphysematous gastritis to rule out gastric necrosis, an upper gastrointestinal endoscopy was performed, which showed diffuse ulceration in the body, antrum, and pylorus of the stomach with a bulge seen at the body of the stomach  and computer tomography angiography (CTA) of the abdomen. They concurrently showed significant thinning with concealed perforation from the anteroinferior stomach wall, along with acute pancreatitis with an area of necrosis within the pancreas and peripancreatic fluid . There was evidence of emphysematous gastritis, with the stomach showing adhesions to the pancreas and small pockets of air in the peritoneal cavity. After angiography, there was a small aneurysm arising from the gastroduodenal artery, which was embolised on the same day and was a suspected cause of hematemesis. Assuming a provisional diagnosis of a complicated case of acute on chronic pancreatitis with hematemesis, the conservative line of management with a nasojejunal tube, intravenous fluids, and enteral nutrition was continued.With this approach, the patient improved over seven days but suddenly had a novel complaint of melena for which prophylactic UGIE and colonoscopy were performed. UGIE revealed similar findings as before. Colonoscopy successfully led us to diagnose a gastrocolic fistula along with small bowel communication with walled-off pancreatic necrosis . It revealed a defect in the transverse colon with normal-looking mucosa around it. The necrotic cavity was in communication with the stomach, small bowel, and colon. In-situ nasojejunal tube and WOPN were also evident. At this site, a visible vessel with a blood clot was identified, which seemed to be the likely source of the bleeding. For this reason, an adrenaline injection was administered around the source of bleeding, and the vessel was hemoclipped endoscopically.In view of a gastro-colic fistula secondary to acute on chronic pancreatitis, we planned exploratory laparotomy. Intra-operatively, the necrotic part of the pancreas was identified. Distal two-thirds of the stomach was found to be necrosed; only the fundus and pyloric end were spared. Two rents in the transverse colon and one rent in the small bowel at the duodenojejunal junction were evident due to necrosis. Pus collection was noted in the para-duodenal area. The left lobe of the liver was found to be necrosed.Hence, the patient underwent a necrosectomy for necrosed part of the stomach, wall of the pseudocyst, liver, and pancreas. Gastrointestinal continuity was maintained with duodenal stump closure, jejunojejunostomy, and gastro-jejunostomy (Bilroth-2), followed by colo-colic anastomosis Figure . Intra-oPostoperatively, the patient was managed in the intensive care unit by a multi-disciplinary team comprising Intensivists, surgeons, and a gastroenterologist. On postoperative day two, the patient experienced anuria which led to acute renal failure. His renal system was managed aggressively, but his health eventually deteriorated due to progressive acute kidney injury, sepsis, multi-organ dysfunction, and hypotension. On postoperative day three, the patient went into multiple organ dysfunction syndrome and, despite all the possible efforts, succumbed to sudden cardiac arrest. The histopathological examination confirmed the diagnosis of mucormycosis and gangrenous necrosis of the stomach and excised portion of the jejunum with inflammation and necrosis of the transverse colon and omentum was made Figure . SpecimeMucormycosis or zygomycosis is an angioinvasive fungi known to cause lethal opportunistic infection . The funThough the whole of the alimentary tract is susceptible to mucormycosis infection, the stomach is most commonly affected, followed by the colon and ileum. This infection occurs following the ingestion of infected sputum or secondary colonization of pre-existing ulcers. Clinically, it presents with non-specific symptoms, fever, gastrointestinal bleeding, and perforation. In premature neonates, gastrointestinal mucormycosis infection may present as necrotizing enterocolitis . MucormyGastric mucormycosis is diagnosed based on histopathology showing aseptate, broad periodic acid-Schiff (PAS)-positive fungal hyphae adjacent to the necrotic areas, though the organism, genus, and species are identified only on culture and are aimed for epidemiological, therapeutic, and prognostic implications.Amphotericin B, a polyene antifungal agent, is highly effective against fungal infection. Though for a complete cure, combining an antifungal agent with debulking surgery to remove all infected tissue is necessary. Roden et al., in their review, have confirmed the significance of multimodality treatment with surgery and amphotericin B . To prevGastric mucormycosis is rare and difficult to diagnose pre-operatively. In this post-coronavirus era, there have been more cases of mucormycosis. Therefore, this demands attention on early diagnosis followed by aggressive management of invasive fungal infection.The era of invasive fungal infections seems to be on the rise. Though rare, the incidence of mucormycosis has seen a significant rising trend. Hence, there is an urgent need to direct the focus on new techniques and methods for early diagnosis and management of complications secondary to invasive fungal diseases. The above case report demonstrates that despite the rigorous effort through multiple upper gastrointestinal endoscopies, we failed to diagnose the disease and manage it efficiently.


The purpose of this case report is to share the rare presentation of multiple giant tuberous xanthomas. Tuberous xanthomas are papulonodular skin lesions that are typically seen in patients with lipoprotein metabolism disorders. The patient in this report presented with large swellings on the right elbow and bilaterally on the Achilles tendons. Surgical excision of the mass in the right elbow revealed a tuberous xanthoma. Tuberous xanthomas are commonly seen in patients with lipid metabolism disorders which predisposes patients to developing morbid conditions. Therefore, while tuberous xanthomas are benign growths, patients should have a systemic workup performed in order to prevent or provide early intervention for morbid conditions. Xanthomas are benign plaques, papules, or nodules that are composed of accumulated lipid-laden macrophages within the subcutaneous tissue . XanthomBy contrast, tuberous xanthomas are less commonly seen and are defined as yellow nodules, usually less than 2 cm in diameter, located on the extensor aspects of the knees, elbows, and buttocks . HoweverA 41-year-old female presented to the family medicine clinic with complaints of a right elbow mass that had been present over the course of several years and was beginning to limit her range of motion due to pain. On examination, the mass was firm, non-tender to palpation, mobile, without any skin changes, and measuring 5 x 5 cm : 161 mg/dL; triglyceride (TG): 107 mg/dL; high-density lipoprotein (HDL): 57 mg/dL.Ultrasound of the right elbow was performed with a high-frequency linear array transducer. It revealed a 5.0 x 1.7 x 5.4 cm heterogenous mass lesion of intermediate echogenicity in the subcutaneous soft tissue. There are a few non-shadowing echogenic foci internally along with areas of increased Doppler flow. The mass did not meet the criteria for a fluid collection of simple lipoma. Since the ultrasound findings were inconclusive, an MRI without contrast was recommended for further evaluation of the mass.Due to the mass effects the patient was experiencing, she was referred to orthopedic surgery to remove the mass which was reviewed by a pathologist. The report indicated foam cells, also known as lipid-laden macrophages, which are indicative of tuberous xanthomas.Upon further examination, the patient was found to have similar masses on the Achilles tendons bilaterally. The patient was advised to follow up with an MRI of the ankles bilaterally to confirm the presence of tuberous xanthomas over the affected areas; however, the MRI was denied on multiple occasions. The patient was not started on any medications at the family medicine clinic since she was referred to and received an upcoming appointment with an endocrinologist and lipidologist for genetic testing and preventative care related to her presentation. For the management of cholesterol, the lipidologist started the patient on oral atorvastatin 40 mg once per day. For weight loss, the endocrinologist started the patient on subcutaneous Ozempic 0.25 mg once per week which was titrated up to 0.50 mg per week after four weeks.Xanthomas are palpable masses that are characterized by the accumulation of lipid-laden macrophages within the subcutaneous tissue . They moAs previously stated, tuberous xanthomas are typically less than 2 cm in diameter. Therefore, the presentation of our patient with a tuberous xanthoma that was 5 cm in diameter is atypical. Upon initial evaluation, a tuberous xanthoma must be differentiated from a tumor which can be done with imaging. Ultrasound has been demonstrated as an effective form of imaging for identifying xanthomas .Once a patient is diagnosed with a tuberous xanthoma, it is essential to complete a systemic workup in order to prevent or provide early intervention for morbid conditions such as familial hypercholesterolemia. Workup consists of fasting laboratory tests of plasma TG, plasma cholesterol, serum LDL, and HDL . These pFundamentally, tuberous xanthomas are palpable masses that are characterized by the accumulation of lipid-laden macrophages within the subcutaneous tissue which are most commonly seen in patients with lipid metabolism disorders. Ultrasound can contribute to the diagnosis; however, it is not a diagnostic method for xanthomas. MRI and US can improve the accuracy in identifying xanthomas, but a biopsy is required for confirmation when deemed necessary. Patients with a diagnosis of tuberous xanthoma should have a systemic workup performed in order to prevent or provide early intervention for morbid conditions. Interventions with medications such as HMG-CoA reductase inhibitors have reportedly reduced the size of xanthomatous lesions, but surgical intervention may be required in patients who experience pain or limited range of motion due to mass effects.


A 52-year-old man was scheduled to undergo an elective laparoscopic cholecystectomy for an increasingly symptomatic cholelithiasis. The pre-operative diagnosis was established clinically and confirmed with ultrasonography (US), showing gallstones and thickened gallbladder wall. Intraoperatively, extensive dense adhesions of the omentum to the entire subdiaphragmatic surface of the liver and the diaphragm were encountered. The adhesions of the omentum and colon were completely obscuring the Morrison’s space with cartilage-like consistency at the supposed anatomical projection of the gallbladder fundus. Due to these unexpected pathological findings and uncertain disease biology, a decision was made to abort and re-schedule the surgery after obtained tissue biopsy results, magnetic resonance cholangiopancreatography (MRCP), and tumor markers carbohydrate antigen 19-9 (CA 19-9), carcinoembryonic antigen (CEA), and alpha fetoprotein (AFP) were available. CA 19-9 was found elevated 10-fold, while AFP and CEA levels were within normal limits. A follow-up cholecystectomy was performed, and final pathology revealed diffuse xanthogranulomatous cholecystitis (XC) and extensive inflammatory changes, adhesions, and fibrosis and no malignancy. The patient tolerated the procedure well and was discharged home on day two after surgery. His follow-up examination was unremarkable. Distinguishing between XC and gallbladder carcinoma is important to appropriately guide management and treatment. Diseases involving the gallbladder account for up to 6% of men and 9% of women with gallstones in the United States ,2. XanthA 52-year-old man presented to surgery clinic for evaluation and consideration for possible cholecystectomy following a two-week history of non-radiating, intermittent right-sided abdominal pain. He had an unremarkable surgical history and prior medical history significant for benign prostatic hyperplasia, gastroesophageal reflux disease, Barrett’s esophagus, and asthma. The patient admitted that for a long time he has had more or less constant right abdominal flank pain with dull and sharp aches exacerbated by coughing, deep breaths, or sitting up in bed and leaning forward. The patient denied any associated nausea, vomiting, diarrhea, constipation, fevers, or changes in the characteristics of the pain with respect to food intake. Family history was negative. The patient was previously diagnosed with symptomatic cholelithiasis; however, no intervention was suggested at the time.At initial evaluation, his vital signs were within normal limits with a body temperature of 98.5°F, a pulse rate of 74 beats per minute, a respiratory frequency of 18 breaths per minute, and a blood pressure of 148/75mmHg. Abdominal examination revealed a soft, non-tender and non-distended abdomen with normal bowel sounds and negative Murphy sign. A 2-cm, non-reducible umbilical hernia was noted. Complete blood count (CBC) and comprehensive metabolic panel (CMP) laboratory results were unremarkable except for elevated total alkaline phosphatase (ALP) (155 U/L). Alanine aminotransferase (ALT) (9 U/L), aspartate aminotransferase (AST) (12 U/L), and total bilirubin (0.7 mg/dL) were within normal limits. A right upper quadrant ultrasound (US) showed cholelithiasis with a thickened gallbladder wall. Surgical consultation led to recommendation of an elective laparoscopic cholecystectomy. Initial intraoperative inspection of the abdomen revealed extensive adhesions involving the omentum and colon along with the diaphragmatic and inferior surfaces of the liver completely obscuring the Morrison’s space. A meticulous dissection was undertaken to free up the diaphragmatic liver surface from adhesions; however, the adhesions and fibrotic tissue at the projection of the gallbladder fundus were extremely dense with cartilage-like consistency that raised suspicion for possible malignancy. Pathology was consulted intraoperatively and they recommended a tissue biopsy of the fibrotic for histopathology. Due to these unexpected intraoperative findings and since the surgery team was not prepared for possible more extensive resection, a decision was made to defer surgery pending pathology results and to order further workup, including abdominal MRI/MRCP as well as tumor markers CA 19-9, AFP, and CEA. The pathology report returned negative for neoplasm; however, omental tissue demonstrated evidence of chronic lymphoplasmacytic infiltration. CA 19-9 was found elevated to 282 U/mL , AFP and CEA were within normal limits 2.3 ng/mL  and 0.9 ng/mL , respectively. The MRI of the abdomen with MRCP revealed cholecystitis with impacted large stone in the gallbladder neck and possibly contained perforation involving the gallbladder fundus. There was gallbladder wall thickening, diffuse pericholecystic soft tissue inflammation with mild biliary ductal dilatation of uncertain etiology without evidence of choledocholithiasis Figure , 1B. Given the workup findings, differential diagnoses included diffuse XC, gallbladder carcinoma (GC), or cholangiocarcinoma. Sixteen days after his first surgery, a decision was made to proceed with a re-do laparoscopic cholecystectomy prepared for exploratory laparotomy and possible more or less extensive surgical resection of the extrahepatic biliary tree and the liver. Intraoperatively, the diaphragmatic liver area was still free of adhesions. Significant inflammatory and fibrotic changes diffusely involving the entire Morison’s space were again encountered. A very careful dissection of the dense fibrotic adhesion of the omentum and colon to the projected fundus of the gallbladder was undertaken that allowed us very slowly to free up the anterior surface of the gallbladder wall. An area of possible perforation in the fundus of the gallbladder draining infected bile was encountered that was evident of gallbladder empyema. The adhesion of the duodenum to the infundibulum of the gallbladder and surrounding structures were less dense and inflamed, which allowed us to identify the gallbladder neck and the proximal cystic duct with the cystic artery. Cholecystectomy was achieved laparoscopically after needle aspiration of purulent material due to infection and associated abscess formation. Surgical pathology revealed marked acute calculous cholecystitis, with transmural abscess and xanthomatous reaction, ulceration, fibrosis, and extensive adhesions Figure -1F. The Post-operatively, the patient recovered well and was discharged home on day two after surgery without complication. The patient did not report any abdominal pain, issues or any other complaints on his two-week follow-up visit in clinic. His labs including CBC and CMP were within normal limits and the tumor marker CA 19-9 went down to normal postoperatively 12 U/mL . While the pathogenesis of diffuse XC is not fully understood, it is suspected that gallstones may cause increased intraluminal pressure, leading to ruptured Rokitansky-Aschoff sinuses, such as in the present case . This maDiffuse XC can present with a wide spectrum of otherwise nonspecific symptoms including fevers, nausea, vomiting, jaundice, right upper quadrant pain postprandial pain, and in some cases presents with weight loss in patients -13. The These changes often result in similarities on diagnostic imaging , including diffuse gallbladder wall thickening, nodules of low echogenicity, and the presence of low-density bands ,14. TherThe mechanisms that cause elevations in tumor marker CA 19-9 are not completely understood. CA 19-9 is known to be synthesized by many cells in the gastrointestinal tract, including pancreatic, biliary, gastric, colonic, and salivary epithelial cells . Some suWhile it is very challenging to distinguish between XC and GC, it is crucial to guide management and treatment. Helpful approaches include CT, MRI, biopsy, and evaluation of tumor markers. Laparoscopic cholecystectomy has shown to be the gold-standard therapy for benign gallbladder disease and is also the standard treatment for XC . HoweverThis case highlights the importance of intraoperative team dynamics and the decision-making process. When surgeons find themselves in doubt for possible but unexpected gallbladder malignancy during an elective cholecystectomy case, it is a valuable option to consider postponing the completion of the surgical procedure until additional workup and careful analysis of the results are performed. Increasing awareness of XC will better ensure this rare condition remains a differential diagnosis and thus expedite the clinical workup and promote patient wellbeing.


Cardiac lipoma, which is exceedingly rare in both adultA 14-year-old boy with a chief complaint of atypical  chest pain was referred to our department for transthoracic echocardiography (TTE) and further evaluation. The patient denied any cardiac problems in their personal or familial medical history. The patient’s vital signs and physical examination were unremarkable. A TTE revealed a large homogeneously hyperechoic immobile mass without echolucency of the posteromedial papillary muscle and with normal appearance of the anterolateral papillary muscle  and 2. T,Primary cardiac tumors are rare benign tumors. In adults, the incidence is between 0.2% and 0.4%, among which lipoma is an extremely rare benign tumor that accounts for 8% in autopsy series.et al.et al.et al.,15In the review of these 3 cases, 2 had lipoma in the anterolateral papillary muscle and 1 in the posteromedial papillary muscle, as in the mentioned case. Koshy Acoustic characteristics alone cannot routinely differentiate benign lipomas from other malignant tumors, and CMR is the preferred complementary noninvasive imaging technique to assist in diagnosing cardiac masses since it offers improved tissue differentiation. Due to the very low prevalence of cardiac lipoma, there is no specific guideline for the treatment of such tumors. However, in symptomatic patients, surgery will be indicated.This case study presents a young patient with an unusual location of a cardiac lipoma in the posteromedial papillary muscle. After extensive consultation with the heart team, considering the mass size and the absence of clinical or hemodynamic symptoms, it was concluded that we should proceed with conservative management consisting of serial clinic visits, physical examinations, and TTE. Should there be any changes in the TTE findings, a CMR should be performed to help guide treatment decisions.Transthoracic echocardiography can primarily detect papillary muscle lipoma, and CMR can provide more details as a complementary modality. Careful considerations are required according to mass location, size, and clinical symptoms to select an appropriate treatment method.Complete written informed consent was obtained from the patient  for the publication of this study and accompanying images.The authors declare that the work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.The authors declare that this report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors report no conflict of interest.


This paper presents a rare case of an asymptomatic colo-ovarian fistula in a 45-year-old female with acute psychosis and a history of bipolar disorder, seizure disorder and substance misuse. The intricate diagnostic challenges arising from the patient’s complex medical history underscore the significance of a multidisciplinary approach. The absence of typical gastrointestinal symptoms and the presence of a tubo-ovarian abscess complicated the diagnosis of acute on chronic sigmoid diverticulitis and colo-ovarian fistula. Surgical intervention, including sigmoid resection, anastomosis and left salpingo-oophorectomy, led to successful resolution. This case highlights the need for further understanding of colo-ovarian fistula pathophysiology, improved diagnostic strategies, and the nuanced interplay between medical and psychiatric conditions in complex clinical scenarios. Fistula formation is a recognized complication in approximately 10–13% of cases of diverticular disease .Colo-ovarian fistulas have rarely been described in current literature. Documented cases are most frequently reported in the context of primary ovarian neoplasms, ovarian abscesses, Crohn’s disease, and less often colonic diverticulitis , 4. We pA 45-year-old female with a significant past medical history of bipolar disorder, seizure disorder and substance misuse was referred to the hospital for altered mental status. She reported a questionable history of metastatic cervical and pancreatic malignancies that could not be confirmed by outside records. She also recounted 8 years of cancer treatment that appeared to be absent from her medical records. Upon arrival, vital signs were stable and labs were unremarkable. Haloperidol was administered to manage her agitation, and a diagnosis of acute psychosis linked to bipolar disorder was established.There was a suspicion of underlying abdominal infection causing her altered mental status given the presence of abdominal pain and low grade fever. A computed tomography (CT) scan of the chest, abdomen and pelvis was completed to assess for prior or current malignancy. Acute on chronic sigmoid diverticulitis with a left colo-ovarian fistula and a 4.3 cm left adnexal abscess was found  and 2; yShe underwent CT-guided drainage of the abscess, extracting 10 cc of purulent fluid and insertion of a drainage catheter. Following the procedure, her agitation subsided, and she experienced only mild abdominal discomfort. She was discharged to a subacute rehabilitation facility 14 days after admission, with normal mental status and an abdominal drain in place.She was readmitted for acute psychosis, 8 days following discharge. A follow-up CT scan of the abdomen and pelvis revealed progressive reduction in inflammatory changes and complete resolution of the abscess. The drain was removed at this time. Subsequently, twenty-three days after initial discharge, the patient was readmitted for the second time regarding worsening abdominal pain. Outpatient CT scan revealed redemonstration of the abscess and acute diverticulitis. She was again treated with intravenous antibiotics, without any relief in symptoms.The patient underwent an uncomplicated exploratory laparotomy involving sigmoid resection with anastomosis and left salpingo-oophorectomy. The post-operative recovery was complicated by respiratory failure requiring ventilator support due to mucus plugging and atelectasis. However, the patient’s condition improved, and she was discharged home in a stable condition one week following the surgery.This complicated clinical scenario of a 45-year-old female initially presenting with altered mental status highlights the challenges in diagnosing and managing patients with intricate medical histories and the importance of a multidisciplinary approach in such cases. The patient’s history of bipolar disorder, seizure disorder, and substance misuse adds a layer of complexity to her presentation. It is well established that individuals with bipolar disorder are at an increased risk of various medical comorbidities, which can complicate the diagnostic process [The absence of classic abdominal tenderness or gastrointestinal symptoms further confounds the clinical picture, emphasizing the variability in presentation and the need for a high index of suspicion. The absence of gastrointestinal symptoms might have been influenced by the patient’s altered mental status or masked by her psychiatric history. The patient’s history of questionable malignancies was the only indication to order a CT scan, yet the subsequent discovery of acute on chronic sigmoid diverticulitis with a left colo-ovarian fistula and an adnexal abscess adds to the diagnostic challenge.Diverticular disease is particularly prevalent among the elderly, especially individuals aged 60 and above , 6. NotaThe rarity of this condition hinders the establishment of a standardized imaging algorithm for suspected colo-ovarian fistulas . AlthougIn conclusion, the pathophysiology underlying the development of an asymptomatic colo-ovarian fistula in this case remains intriguing. This case underscores the need for further research to elucidate the precise mechanisms driving the formation of such fistulas, as well as to determine the best diagnostic approach and treatment options. It also highlights the intricate interplay between medical and psychiatric conditions, diagnostic challenges and the importance of a multidisciplinary approach.


Urachal cysts (UCs) are rare congenital anomalies, especially in adults. They often mimic a variety of intra-abdominal pathologies, making the diagnosis difficult. Laparotomy and excision of the cyst along with the umbilicus has been the traditional technique. A 33-year-old female presented with painful umbilical swelling. A CT scan was suggestive of a UC. We performed an umbilicus-preserving laparoscopic excision of the cyst. We describe this rare case and review literature related to the surgical treatment of UCs. The true incidence of urachal anomalies as well as urachal cysts (UCs) is largely unknown. Ucs are uncommon anomalies that are generally seen in children and very rarely if ever present in adulthood .Retrospective studies of small samples of pediatric autopsy records and radiological databases show that 1.03% of the general pediatric population was found to have urachal anomalies. The estimated incidence of UCs is 1 in 5000 births, with a ratio of 2:1 for males compared to females [Urachal cysts go undetected as unless they are infected, they usually remain asymptomatic. When infected, patients can present with various non-specific symptoms such as abdominal pain, fever, umbilical discharge, and the sensation of a midline mass in the abdomen. Appendicitis, diverticulitis, urinary tract infection, pelvic inflammatory disease, and bladder carcinoma are some of the conditions that are common misdiagnoses due to the overlap in symptomatology .We report a rare case of a UC in a 33-year-old female that was successfully managed by laparoscopic surgery.A 33-year-old married female who was generally free of any ailments presented to us with painful umbilical swelling for a few days duration. Her body mass index (BMI) was 28.3 kg/m2. Clinical examination revealed a tender swelling about 1.5 cm in diameter within the umbilicus. Initial abdominal ultrasonography showed features suggestive of a cystic swelling in the sub-umbilical plane with no evidence of communication with the peritoneal cavity with the tentative diagnosis of a UC. An abdominal contrast enhanced computed tomography (CECT) scan elucidated a non-enhancing lesion measuring 2.3 cm x 1.9 cm with imperceptible walls further suggesting a diagnosis of UC  extending from the cyst's inferior aspect up to the bladder's dome was excised Figure .A trocar was retained at the entry point to provide counter traction to the abdominal wall during the dissection of the cyst Figures -3 while No obvious bladder involvement was found. Two endo-clips were applied close to its insertion in the bladder. The specimen was retrieved in an endo-bag. The operating time was approximately 90 min with minimal blood loss. The entry defect was closed with a port closure suture. The postoperative period was uneventful, and the patient was doing well up to 6 months of follow-up. The histopathology report confirmed the diagnosis of the UC with no evidence of malignancy.The urachus is a fibrous vestigial cord connecting the urinary bladder's dome to the umbilicus. It is the remnant of the fetal allantois and is postulated to serve as a channel for the excretion of fetal nitrogenous waste from the placenta through the umbilical cord. The fetal bladder initially lies at the level of the umbilicus. Later, during the fourth and fifth months of gestation as the bladder descends towards the pelvis the urachus gets stretched. In the course of time, the lumen gets completely obliterated to form a fibromuscular cord connecting the anterior bladder to the umbilicus. This completely obliterated urachus is now known as MUL. The MUL is a vestigial structure with no known function. Improper or incomplete obliteration of the urachus can occur and this leads to the development of various urachal anomalies as some or the whole of the channel remains patent .Four types of anomalies have been described by Bauer and Retik , dependiMorphologically the urachus is between 3-10 cm long and 8-10 mm in diameter and is composed of three layers. The innermost layer is transitional epithelium in 70% and columnar epithelium in the remaining 30%. A submucosal middle layer surrounds this. The outermost layer is muscular and continuous with the detrusor muscle of the bladder. All these layers are converted to fibrous tissue once the lumen is obliterated -10.Owing to the lack of specific symptoms, arriving at an accurate diagnosis necessitates a thorough history as well as a complete physical examination coupled with radiological evaluation. Ultrasonography and CT scans usually are the investigations of choice for UCs. A CT scan can be helpful to detect the presence of a malignancy within the cyst .The definitive treatment option for UCs is surgical excision. Initial non-operative treatment for infected UCs includes aspiration and antibiotic therapy before a definitive excision, however, this may be associated with a 30% recurrence rate . An openIn our patient, we found that the laparoscopic procedure provided an excellent view of the operative field and the UC which could be dissected off the undersurface of the umbilicus thus helping to preserve it.The clinical diagnosis of UCs in adults is based on a high index of clinical suspicion. Ultrasonography and CT are often the investigations of choice. Laparoscopic excision can be considered a safe and effective option for the complete excision of UCs.


This case report demonstrates the efficacy of total neoadjuvant therapy (TNT) based on pathological complete response (PCR). We also discuss the surgical approach to preserving the anus and its perioperative management.The patient was a 26-year-old woman, with blood in the stool and stool thinning for over two months. Preoperative examination revealed locally advanced rectal cancer invading the left anal raphe and enlarged lymph nodes adjacent to the left internal iliac vessels. The lesion was preoperatively classified as T4bN1bM0 IIIC. Considering the size and depth of the tumor, it was difficult to have sufficient margins for radical resection, and the tumor was too close to the anal orifice. Considering the patient's youth and strong desire to preserve the anus, it was decided to use TNT combined with a camrelizumab regimen. After the entire course of neoadjuvant radiotherapy, the tumor size significantly reduced in fibrotic manifestations, and no enlargement of the lymph nodes adjacent to the left internal iliac vessels was observed. She underwent robotic laparoscopic ultra-low anterior rectal resection, left lateral lymph node dissection, and temporary ileostomy, and no significant residue was observed after all bowel tubes were taken for examination, nor was there cancerous involvement at the distal or radial cut edges, or metastasis. The patient was discharged nine days postoperatively, and no major complications were detected. Follow-up was performed without adjuvant chemotherapy.TNT may be a better surgical option for preserving the anus and for complete radical resection in patients with LARC for whom Miles’ resection is indicated. Local rIn this case report, we demonstrate the apparent effectiveness of TNT + immunotherapy and the advantages of organ preservation through TNT, including a short course of radiotherapy + XELOX + camrelizumab, and radical surgery, as shown by pCR and anus preservation. In addition, we review the relevant literature and cases to discuss the surgical approach (with anus preservation) and perioperative management.2.Our patient was a 26-year-old woman with blood in the stool and thinning for 2 months, with a feeling of urgency and heaviness. No family history of cancer. Laboratory findings revealed a hemoglobin concentration of 101 g/L. Serum carcinoembryonic antigen and carbohydrate antigen 19–9 levels were 2.2 ng/ml and 7.8 U/ml, respectively. Colonoscopy revealed a cauliflower-like neoplasm in the lower part of the intestine, with necrosis and hemorrhage on the surface, hard and poorly mobile, and the lower margin adjacent to the anal dentate line, invading most of the perimeter of the intestinal lumen . Magneti2 bid for 14 days and L-OHP 130 mg/m2 on day 1))+ camrelizumab was administered every 3 weeks for 3 cycles. Review after three cycles suggested that the lesions were significantly smaller and the left internal iliac vessel parietal lymph nodes were smaller than before the treatment  , 18, butreatment . Howeverreatment . We concreatment .After completion of TNT, the review CT suggested that the original tumor was only seen as a few low-signal foci of fibrosis, MRI suggested that the stage was Tx N1a, CRM (-), EMVI (NA), and the primary tumor MR TRG grading (standard) was about grade 1  , rectal 3.We have described a rare case of a patient with surgically resected locally advanced rectal cancer who showed impressive PCR results after TNT, with preservation of the anus as a vital organ.In the current treatment strategy for LARC, we are increasingly focusing on the role of TME and neoadjuvant therapy –21, partA multicenter phase II trial of NAC with XELOX plus bevacizumab for LARC reported satisfactory short-term outcomes, with a completion rate of 84.4% and pCR rate of 13.3% . Cercek Difficulties with TNT + camrelizumab in the treatment of locally advanced rectal cancer must be addressed. First, although immunotherapy improves outcomes in CRC patients, it also leads to an increase in unique immune-related adverse events (irAEs) , 27, as Second, there are difficulties associated with long-course radiotherapy and chemotherapy during surgery. During surgery, the anatomy of the patient's surgical area is confusing because of prolonged radiotherapy, chemotherapy, and traumatic bleeds, which greatly increase the difficulty of radical resection. Therefore, careful differentiation of anatomical structures to complete TME requires a surgeon with excellent clinical surgical skills. Third, anal function must recover after radical resection. One of the most important concerns of ultralow anal preservation surgery is the ability to continence , 32. TheIn conclusion, a patient with LARC was treated with TNT + camrelizumab and underwent PCR and complete radical resection with preservation of the anus. She remains alive 9 months after surgery without recurrence. TNT + camrelizumab may be a better surgical option for anal preservation and complete radical resection in patients with LARC who have indications for Miles' surgery.