While conventional lipomas represent the most commonly seen benign mesenchymal tumor in adults, their occurrence in the bladder wall is exceptionally rare. This report details a rare case of a bladder lipoma, a benign tumor primarily composed of mature adipocytes, presenting as gross hematuria in a 68-year-old male. Despite the patient's previous history of left nephrectomy, no significant pathological findings were initially observed. The bladder lipoma was detected via cystoscopy as a polypoid mass on the posterior bladder wall and confirmed through transurethral resection of the bladder tumor (TUR-BT). Histopathological analysis verified the mass as a bladder lipoma composed of mature adipocytes. Following a specific postoperative follow-up period, no recurrence of the tumor was observed, suggesting successful treatment. This case underscores the clinical significance of considering bladder lipoma in differential diagnoses of bladder tumors, especially in patients presenting with gross hematuria, given its exceptional rarity. Lipomas, well-encapsulated benign tumors primarily composed of mature adipocytes, are the most frequently seen soft-tissue tumors in adults . Their mA 68-year-old male patient arrived at the Department of Urology, expressing concerns about gross hematuria. His medical history revealed a radical left nephrectomy conducted five years prior due to renal cell carcinoma, with no subsequent signs of recurrence. Notably, the patient was not receiving any form of anticoagulant or antiplatelet therapy.To evaluate the cause of hematuria, initial laboratory tests were conducted. These included a complete blood count, liver function tests, kidney function tests, and a coagulation profile. All test results fell within the normal range, offering no immediate clues to the hematuria's source. An ultrasound examination was performed as part of the initial diagnostic process. However, the ultrasound also did not reveal any significant pathological findings.The next step in the diagnostic workup was a cystoscopy. This procedure uncovered a smooth, whitish, well-differentiated polypoid mass on the posterior bladder wall Figure .Given this finding, a computerized tomography (CT) scan was performed to gain more insight into the nature of the mass and to exclude other potential etiologies of the hematuria. The CT scan showed mild thickening of the bladder wall and a fatty density, indicative of an intravesical extension of the mass, while, importantly, no other potential causes for the patient's hematuria were identified. Considering the patient's age, it was crucial to rule out potential gastrointestinal involvement as well. The patient underwent a colonoscopy following the CT scan, which produced no abnormal findings, thereby ruling out the gastrointestinal origins of the tumor.Following the discovery of the mass during the cystoscopy and CT scan, the patient underwent transurethral resection of the bladder tumor (TUR-BT). During the operation, the tumor exhibited a homogeneous, yellowish color, lending further support to the suspicion of a benign etiology Figure .Subsequent histopathological examination of the resected tissue revealed a well-encapsulated mass of mature adipocytes located within the lamina propria of the mucosa layer, a diagnosis consistent with a bladder lipoma Figure .There was no evidence of malignancy or bladder wall invasion, with the lesion encased by a thin rim of urothelial mucosa and no involvement of the muscularis propria. The absence of hyperchromasia or multinucleated stromal cells further ruled out a liposarcoma.Postoperatively, the patient had an uneventful recovery and was hospitalized briefly before discharge. Regular follow-up examinations, including periodic cystoscopies and ultrasound evaluations, were scheduled. These follow-ups confirmed no recurrence of the bladder lipoma, marking the successful treatment of this rare condition.A bladder lipoma is an extremely unusual tumor. Lipomas are a kind of benign tumor that develops from mature adipose tissue. Adult benign mesenchymal neoplasms are quite prevalent. Lipomas of the bladder are quite rare and make up a tiny fraction of all bladder tumors. In addition to the bladder, it's worth noting that lipomas have also been identified in the upper urinary tract, further indicating the rarity and wide-ranging occurrence of these tumors . LipomasThe size and location of a bladder lipoma tumor may affect how the disease manifests clinically. In most cases, imaging or cystoscopy will uncover an asymptomatic bladder lipoma. Blood in the urine, urinary frequency, urgency, or dysuria (painful urination) are not always indications of a bladder lipoma, although they might be. These symptoms are not exclusive to bladder lipoma and may be present in a variety of bladder diseases ,10.Imaging examinations like ultrasonography, CT, or magnetic resonance imaging (MRI) are often utilized to diagnose and assess bladder lipomas. These imaging techniques may shed light on the tumor's extent, location, and phenotype. Typical imaging findings for bladder lipomas include hyperintense lesions on T1-weighted MRI images and well-defined, homogeneous, low-density masses on CT scans. However, in cases presenting with unusual characteristics, such as large size, necrosis, extension through the entire bladder wall, concerning features on imaging, or a personal or family history suggestive of a predisposition to sarcomas, a histopathological examination may be necessary. This examination provides a definitive diagnosis of bladder lipoma and helps exclude other mesenchymal neoplasms containing components of or resembling mature adipose tissue .Lipomas of the bladder are often removed surgically. For lipomas that are small and close to the skin's surface, endoscopic excision is often the treatment of choice. Open surgical excision may be required if the lipoma is very large or deeply infiltrating. Importantly, lipomas of the bladder have an excellent prognosis given their benign nature, and it is worth highlighting that, contrary to the text's previous suggestion of low risk, they actually carry no risk of metastasis .While the present case involves a bladder lipoma, it's worth noting that other rare benign tumors like bladder leiomyomas can also manifest with similar symptoms, warranting careful differential diagnosis to ensure appropriate treatment, as evidenced in a reported case of a 52-year-old man with a bladder trigone leiomyoma . Well-diIn light of these findings, the key message we wish to convey is the necessity for urologists to maintain a high level of vigilance and a strong index of clinical suspicion for any bladder mass . Even inThis case emphasizes the need to consider bladder lipomas in the differential diagnosis of bladder tumors, especially in patients presenting with gross hematuria. Early recognition and management can lead to excellent outcomes with no recurrence, as shown in this case. In conclusion, bladder lipoma is a very unusual benign bladder tumor. It has no noticeable symptoms and is generally discovered incidentally. Bladder lipomas may be evaluated using imaging investigations such as ultrasound, CT, or MRI, but a histological study is necessary for a definite diagnosis. The main therapy is surgical excision, and the prognosis is usually quite good. To better understand the clinical features, diagnosis, and therapy of bladder lipomas, further research and case reports are required.


Ectopic twin gestation involving a complete hydatidiform mole (CHM) and coexisting embryo is an exceedingly rare occurrence.In this report, we present the case of a 22-year-old female  who was in her 8th week of gestation and presented with abdominal pain. Due to the detection of active bleeding and a ruptured right fallopian tube, the patient underwent a salpingectomy on the right side.The patient was diagnosed with an ectopic twin gestation involving a CHM and coexisting embryo.The patient was treated with right-side salpingectomy.The operation was successful and her recuperation was satisfactory.In the management of ectopic pregnancy involving CHM, it is crucial to enhance the accuracy of preoperative diagnosis. Additionally, histopathological examination of the salpingectomy specimen and conceptus is definitely essential for accurate diagnosis and appropriate follow-up management of tubal pregnancies. As preoperative diagnosis can be difficult, postoperative histopathological diagnosis remains the primary diagnostic tool. Even rarer are cases of tubal complete hydatidiform moles (CHMs). In this report, we describe the case of a 22-year-old female who experienced an ectopic twin gestation of CHM and coexisting embryo in the same fallopian tube, which is an extremely uncommon event. To the best of our knowledge, no other cases of an ectopic twin gestation of CHM and coexisting embryo in the same fallopian tube have been reported. We believe that our case is unique, given that the gestation coexisted with a CHM mass on the same side of the fallopian tube. Herein, we provide a detailed description of the clinical and histologic findings relevant to this rare presentation. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. Also, patient anonymity is preserved.Ectopic molar pregnancy is a rare occurrence, with an estimated incidence of approximately 1.5 per 1 million conceptions.A 22-year-old female  who conceived naturally, presented with abdominal pain in her 8th week of pregnancy. The patient had previously delivered a live infant 7 months earlier and was currently breastfeeding. Physical examination revealed tenderness in the right lower quadrant. Serum human chorionic gonadotropin (hCG) levels were measured and found to be 13,996 IU/L. Pelvic ultrasound revealed a heterogenous mass in the right adnexa measuring 22 × 21 mm, which contained a 14 × 9 × 11mm gestational sac (GS) and a 6mm embryo showing active heartbeats. Notably, no intrauterine GS was visualized on the ultrasound image , it is an extremely rare condition that occurs from 1 in 20,000 to 1 in 100,000 pregnancies. A PUBMED search was conducted using the keywords “hydatidiform mole,” “ectopic molar pregnancy,” and “completely hydatidiform mole coexistent with a normal fetus.” However, our search did not reveal any cases of tubal pregnancy involving CHMCF. Therefore, we believe that this case represents the first report of such a presentation.Tubal molar pregnancy is an extremely rare event, with an estimated incidence of approximately 1.5 per 1 million conceptions. However, it is well-known that tubal ectopic pregnancies should be diagnosed and treated as early as possible. Ultrasonography and β-hCG levels are not very helpful in differentiating between CHMCF and other ectopic pregnancies in the first trimester, due to the absence of the classic features previously described in the second trimester. Postoperative histopathological diagnosis remains the primary tool for diagnosing CHMCF. However, identifying early molar pregnancy can be challenging for many histopathologists.–7 Early ectopic gestation sometimes presents florid trophoblastic proliferation so some pathologists may consider molar disease. The morphologic features of hydrops, scalloped villi, and stromal karyorrhexis can aid in diagnosing ectopic mole. Additionally, ancillary studies like IHC and molecular genotyping can significantly improve diagnostic accuracy. A negative result of p57 IHC supports the diagnosis of CHM by confirming the absence of a maternal allele. Banet et al demonstrated that p57 is almost always negative in the cytotrophoblastic cells and villous stromal cells of CHMs, while a positive p57 expression is found in almost all partial moles and nonmolar pregnancies. Ki-67 is also supposed as a useful adjunct for refining the diagnosis of CHM. Karyotype analysis is also of great importance in distinguishing between partial and complete molar pregnancies. It is important to note that CHMs are diploid and androgenetic in origin, with all 46 chromosomes derived from the father,,13 while in partial hydatidiform mole, the paternal to maternal chromosome ratio is 2:1. In our case, the absence of p57 signal, high Ki-67 proliferative index, and diploid karyotype, confirmed the diagnosis of a CHM.CHMCF is usually diagnosed in the second trimester of pregnancy when the molar placenta is well-documented by ultrasonography examination. have suggested that salpingotomy should be the preferred surgical treatment option for most patients with unruptured tubal pregnancies. However, this approach may have hidden issues that could impact both short-term and long-term outcomes. In view of this situation, intraoperative rapid pathological diagnosis might be a breakthrough to avoid unnecessary injury.Owning to the scarcity of tubal CHM pregnancy cases, there are currently no established guidelines or expert consensus on diagnosis and treatment. Laparoscopy is typically utilized to treat ectopic pregnancies. Studies have shown that ruptured fallopian tubes are common in cases of tubal CHM pregnancy, thus salpingectomy is often the preferred treatment approach. When it comes to unruptured tubal pregnancies, without a preoperative diagnosis of tubal CHM pregnancy, salpingotomy may be considered as an alternative option. Pasic et alIn conclusion, we report a rare case of tubal pregnancy involving CHMCF. This serves as a reminder of the importance of improving preoperative diagnosis for effective and appropriate management of CHM ectopic pregnancy. Ongoing efforts are being made to enhance preoperative diagnostic capabilities. It cannot be overemphasized that histopathological examination of salpingectomy specimens and concepti in tubal pregnancies is essential for accurate diagnosis and appropriate follow-up management.The authors gratefully acknowledge the work of past and present members of our department.Conceptualization: Jianing Wang.Data curation: Yun Shen, Chanchan Gong.Funding acquisition: Jianing Wang.Investigation: Yawei Shao.Project administration: Ruiheng Zhao.Writing – review & editing: Jianing Wang.Writing – original draft: Yun Shen.


Sacrococcygeal teratoma (SCT) is an uncommon infantile tumor. It has a female preponderance with malignant variants being more common in males. These usually manifest as palpable masses over the sacral region in infancy which may or may not be associated with neural tube defects. An initial radiological investigation is warranted to analyze the extent and components of the mass to guide an approach for surgical excision. We present a classic case of an SCT in a female infant born as a twin. This mass was evaluated radiologically by X-ray and ultrasound followed by histopathological correlation. This is a case of Altman Type-I lesion and was confirmed as a mature teratoma on histopathological examination. Sacrococcygeal teratoma (SCT) is an uncommon infantile tumor. It has a female preponderance with a male-to-female ratio of 1:4. However, malignant variants of sacrococcygeal teratomas are more common in males. It has an incidence of one in 35,000-40,000 live births . SurprisA two-month-old female born out of a twin pregnancy presented with a mass at the sacral region. The mass was present since birth and slightly increased in size over the past two months. It measured approximately 10 x 8 cm on presentation (Figure The patient had no bowel or bladder complaints. On examination, the mass was well-defined in shape and soft in consistency. It showed irregular margins and was mobile in nature. It showed a positive fluctuation test and was displacing the anal opening anteriorly. The infant was advised X-ray infantogram including the lumbosacral spine followed by an ultrasound examination of the mass. On X-ray, a well-defined soft tissue density lesion was visible at the sacrococcygeal region, also showing tiny calcifications and few lucent areas within indicating fat. No underlying bony erosion or destruction was noted Figure .On ultrasound, a well-defined lesion with solid and cystic components was noted with fatty tissue within the solid component. Few of the cystic components were anechoic and few showed debris within. A small extension of the lesion was seen internally posterior to the urinary bladder, which was multi-cystic in appearance Figure .The patient underwent surgical excision followed by histopathological evaluation of the specimen. On histopathology, it had areas of stratified squamous epithelium, ciliated and mucin secretion columnar epithelium, and transitional epithelium. It also had fibro adipose tissue as well as muscle bundles at places along with cartilage and adnexal structures like sebaceous glands and sweat glands Figure . These fSCTs are solid tumors mainly seen in newborns. The most typical location for a teratoma in infants is the sacrococcygeal region. Adult SCTs are rare . MeningoThe mainstays in the diagnosis of SCT antenatally are fetal ultrasonography and MRI. MRI describes the intrapelvic and abdominal extent of the tumors more precisely than ultrasound and it also offers more details on the compression of adjacent organs .Altman et al. conducted a study and established a classification system for SCTs based on the location of tumors. In Type I, the tumor is predominantly external with a minor presacral component. Tumors having a large intrapelvic extension but a minor external component are classified as Type II. Tumors externally visible as a small lump, with the major component located internally in the pelvis and abdomen are classified as Type III. Type IV only has a presacral component with no external component. This classification helps in deciding the surgical approach and its prognosis .According to Altman, our case falls in the Type I category since it has a major external component and a minor presacral component. Histopathological examination revealed that it is a mature teratoma, which was benign in nature. Although histological examination plays a crucial role in the diagnosis of SCT, a correlation of both the radiological imaging findings and the pathological examination provides a more holistic approach to diagnosis by considerably identifying the nature of teratoma as benign .Standard surgical management of SCTs includes a wide excision of the tumor without rupture or spillage and a minimal amount of gluteal muscle resection with no injury to the bowel, bladder, or other pelvic organs .SCT is a relatively rare tumor that occurs in newborns and infants. Fortunately, with early diagnosis and proper treatment, the prognosis of SCT is generally good. The treatment approach involves complete surgical removal of the tumor, which may be challenging because of the tumor location. Altman classification is highly useful in surgical management; hence, preoperative assessment is crucial to facilitate complete excision. Overall, SCT requires a multidisciplinary approach involving pediatric surgeons, oncologists, and radiologists. With continued research and advancements in treatment, the prognosis of SCT will improve further.


Splenic cyst is a rare disease, with reported incidences ranging from 0.07 to 0.3 %. A splenic cyst is typically discovered inadvertently and may not cause any symptoms until it grows to a significant size. In some cases, complications such as acute abdomen may be brought on by an intracystic hemorrhage, rupture, or infection. As a rare disease, diagnosing a splenic cyst is still precarious because only a few cases have been reported.The first case is a 23-year-old Asian man without a significant history of illness who complains of a left upper quadrant mass that he discovered 10 years prior. Since then, the mass had been gradually growing and had been accompanied by severe pain. Walking made the pain worse; lying down made it lessen. A computed tomography (CT) scan of the abdomen showed a 20.05 × 15.95 × 26.71 cm splenic cyst. Surgery for a peri-cystic splenectomy was done. A primary splenic cyst was identified in the specimen after microscopic and macroscopic examination. After 10 days, the patient was released from the hospital without complications. The second case is that of a 28-year-old Asian man who complained of a mass in their abdomen that was getting bigger in size. Four years prior to the complaint, the patient had fallen while driving a motorcycle, and the left side of his abdomen collided with the sidewalk. In this patient, a splenectomy—the complete removal of all spleen parts—was done. The specimen's macroscopic and microscopic examination revealed a splenic pseudocyst. The patient was discharged after three days without complications.Splenic cysts are considered rare and challenging to diagnose, as there have been only a limited number of reports. Nevertheless, proper management is still needed, as it carries the risk of rupturing and causing complications such as peritonitis and anaphylactic reactions. Considering the risk of overwhelming post-splenectomy infection (OPSI), conservative treatment can be the gold standard for splenic cysts. However, considering the risk from the size of the cyst, splenectomy or peri-cystic splenectomy is an appropriate surgery option for a splenic cyst.Splenectomy, or peri-cystic splenectomy, is a surgery option for a splenic cyst with significant size and rupture risk. •Splenic cyst is rare.•Partial splenectomy can result in recurrence and post-operative hemorrhage.•Total splenectomy should be avoided due to the risk of sepsis.•Conservative treatment is one of the gold standards for splenic cysts. Splenectomy used to be the standard treatment, but it is now being called into question, owing to the current trend toward conservative surgery, particularly for benign pathologies, as well as increased awareness of postoperative complications As a rare disease, diagnosing a splenic cyst is still challenging because only a few cases have been reported. However, a splenic cyst must be diagnosed given the risk of spontaneous rupture or infection, which can result in acute abdomen 22.1A 23-year-old Asian man with no major medical history complained about a mass he found 10 years ago in the upper left abdominal quadrant, but he seemed reluctant to undergo surgery and decided to seek conservative treatment. The mass was the size of an orange and had been slowly enlarging since then until it was as large as a football and was associated with sharp pain, so he sought medication. The pain was exacerbated by walking and relieved by lying down. He also suffered from early satiety and constipation. There were no signs of rectal bleeding, hematochezia, nausea, or vomiting. The patient had no prior history of abdominal surgeries, pancreatitis, alcohol abuse, gallstone disease, or trauma. Physical examination revealed a visible asymmetry in the bowel contour in the left upper quadrant. A well-defined mass was palpable below the left costal margin. There were no signs of abdominal tenderness or rebound tenderness on palpation. The contrast abdominal computed tomography (CT) scan revealed a 20.05 × 15.95 × 26.71 cm homogenous intraabdominal mass that was partially septated with well-defined regular edges in almost the entire abdomen, from the left upper abdomen to the middle, which pressed the surrounding organs . He was One consultant gastrointestinal surgeon, one gastrointestinal fellow, and one surgical resident at a tertiary general hospital carried out the operation. Intraoperative findings showed that the cyst originated from the spleen. The cysts pushed against the left side of the stomach wall and the left lobe of the liver. An 5 cm incision was made in the cyst capsule using the monopolar cautery, and the cystic fluid was gently aspirated to keep leaking out into the abdominal space and so that the cystic capsule could be seen . After tPostoperative care included maintenance of the fluid, antibiotics, a soft diet, and early mobilization. He was hospitalized for ten days for the observation of abdominal drain production, which was around 100 cc in the first week after surgery and diminished in the second week. One month after surgery, he went for a follow-up visit and was doing well, and there were no signs of complications such as abdominal pain, recurrence, or infection at the surgical site Cyst fluid analysis was not performed as standard for a benign lesion, and the splenic cyst capsule was sent for histological examination. Anatomical pathology results in this patient showed a cyst wall structure coated by erosive mesothelial cells with a normal cell nucleus. Under those structures, there are fibro-collagenous connective tissue stroma, which has undergone hyalinization, lymphocyte cells, and histiocytes, accompanied by blood vessel dilatation and bleeding. There is also a normal white pulp. There is no sign of malignancy. The diagnosis for this patient's pathological condition is a primary splenic cyst .Fig. 4Th2.2This case was taken from the medical record in 2016, where radiologic imaging and intraoperative images were not available for this case. A 28-year-old Asian man arrived at the hospital's polyclinic for digestive surgery, complaining of a growing mass in his abdomen. He had a history of motorcycle accidents in which the left side of his abdomen collided with the sidewalk four years prior. The patient did not seek treatment from the hospital at the time and instead went to a traditional clinic. There were no reports of defecation difficulties or changes in defecation pattern, diarrhea, or bloody stools, and no reports of nausea or vomiting. An abdominal ultrasound was performed, which indicated a splenic cyst with a diameter of 12.7 cm. The abdominal CT scan data were not available in the medical record. A laparotomy for splenic cyst removal was scheduled. One consultant gastrointestinal surgeon, one gastrointestinal fellow, and one surgical resident at a tertiary general hospital carried out the operation. Intraoperative findings showed that the cyst originated from the spleen, was located deep within the spleen, and was surrounded by splenic parenchyma. An attempt for marsupialization and removal of the cystic capsule were not possible considering the possibility of bleeding, and a complete splenectomy was decided. An abdominal drain was inserted. He was hospitalized for three days before being discharged. An edematous fibro-collagenous connective tissue stroma with lymphocyte cells was revealed by histological examination. There were a few cystic cavities between those tissues, with no epithelial cells on the surface. There is no evidence of malignancy. The anatomical pathology result suggested a splenic pseudocyst. According to the medical record, the patient visited the clinic four times for post-operative control. Despite receiving the vaccines (Haemophilus influenza and Streptococcus pneumonia) prior to the splenectomy procedure, the patient frequently complained of fever.3A rare disease with an incidence rate of 0.07–3 % is splenic cyst, which is more common in women. Typically, splenic cysts are categorized as parasitic or non-parasitic based on their etiology. Echinoccocal parasitic cysts account for 50–80 % of splenic parasitic cysts. In rare cases, 0.5–4 % of cases of hydatid disease can result in a parasitic cyst on the spleen Of all splenic cysts, false ones (secondary) make up about 80 % of the total. The most frequent causes of secondary splenic cysts are trauma, splenic infarction, disorganized hematoma, splenic abscess, and intrasplenic pancreatic pseudocyst. Secondary splenic cysts that are caused by infection, most often mononucleosis or tuberculosis Spleen cysts appear to be a coincidental finding and are usually asymptomatic unless they grow to a significant size and cause symptoms such as abdominal discomfort, splenomegaly, or fever. When a cyst grows larger than 5 cm, it becomes symptomatic, and symptoms worsen when it grows larger than 8 cm The majority of splenic cysts are symptomatic, making diagnosis challenging. Imaging in conjunction with immunological tests may be able to solve diagnostic issues. Radiological findings ranging from cystic to solid, unilocular to multivesicular cyst. Calcification of the cyst wall is possible. Immunological tests like hemagglutination inhibition (HAI), enzyme-linked immunosorbent assay (ELISA), and Western blot can help confirm a diagnosis. If the cyst is intact, calcified, or sterile, an immunological test may be negative or insufficient for a definitive diagnosis A splenic cyst can cause a life-threatening situation due to a spontaneous or traumatic rupture, infection, and bleeding of the spleen, which may lead to anaphylaxis Only two patients have been recorded in the medical record and treated in our tertiary general hospital's digestive surgery division in the last 22 years, which is the referral center in West Java, a province in Indonesia with a population of 49.94 million. This condition shows that a splenic cyst is a very rare occurrence. The difference between those two patients in this case is the surgical procedure. A partial splenectomy, or peri-cystic splenectomy, was performed on the first patient because the cyst was single and located in the superficial surface of the spleen. Whereas a total splenectomy was performed on the second patient because the cysts were multiple, located deep in the spleen, and covered with dense parenchyma of the spleen. The distinction between these two procedures also has an impact on the length of stay in the hospital. The first case has a longer length of stay than the second. This condition is caused by the production of drainage fluid, which contains more product than the second for the first few days following surgery. Another distinction is the risk of infection. When compared to the first patient, the second patient has a higher risk of infection. In this case, the second patient had already been vaccinated to avoid the occurrence of OPSI (overwhelming post-splenectomy infection), but the second patient complained that the patient had more fever and flu than the first patient, who did not receive the vaccine after the surgery. This case demonstrated that conservative treatment is more favorable for splenic cysts if possible.4Splenic cysts are uncommon. As a rare disease, diagnosing a splenic cyst is still challenging because only a few cases have been reported. Nonetheless, proper management is still required because there is a risk of rupture, which can lead to complications such as peritonitis and anaphylactic reactions. Splenectomy was once considered the gold standard for splenic cysts, but it is now being called into question, given the contemporary preference for conservative surgery, especially for a benign pathology, and awareness of postoperative risks.Before this case report and the accompanying images could be published, the patient's written informed consent had to be obtained. Upon request, a copy of the written consent may be reviewed by the journal's editor-in-chief.Not commissioned, externally peer-reviewed.No ethical clearance was required.The author(s) received no funding for this case report.The guarantor of this report is Kiki Lukman.Not applicable.Kiki Lukman: Conceptualization, Visualization, Supervision, Funding acquisition. Bambang Am Am Setya Sulthana: Investigation, Data curation, Resources. Deny Budiman: Investigation, Data curation, Resources. Prapanca Nugraha: Writing – original draft, Writing – review & editing, Project administration.The authors affirm that they have no known financial or interpersonal conflicts that would have appeared to have an impact on the case report presented.


Malignant peripheral nerve sheath tumors (MPNSTs) are commonly associated with poor prognosis and are primarily caused by germline mutations in the SMARCB1/INI-1 gene. However, these tumors are rarely found in the spine. This case report presents the case of a 3-year-old boy diagnosed with a lumbosacral dumbbell-shaped epithelioid MPNST, an extremely uncommon manifestation. Immunohistochemistry revealed the complete absence of the SMARCB1/INI-1 protein, and genetic testing identified a novel germline mutation in the SMARCB1/INI-1 gene in both the patient and his father, suggesting a “second-hit loss.” One year of follow-up after the tumor's radical resection revealed no suspected metastasis. This case report offers novel genetic research results regarding spinal dumbbell-shaped MPNSTs. Six studies, including 13 cases associated with spinal dumbbell MPNST, were included in the literature. The range of age of these patients varied from 2 to 71 years. Of the 12 known patients diagnosed with spinal dumbbell MPNST, only one received radiation therapy, while the rest underwent surgery. Two patients who underwent partial resection had metastases after surgery, while one of the five patients who underwent complete surgical resection alone had no distant metastases and a good prognosis, indicating that radical resection is more likely to be effective in inhibiting distant metastasis and improving the prognosis. Epithelioid malignant peripheral nerve sheath tumors (EMPNSTs) are a highly malignant and extremely rare variant of malignant peripheral nerve sheath tumors (MPNSTs), accounting for only 5% of all MPNST variants –4. PrimaThe study of EMPNSTs has been significantly enhanced by advances in gene-sequencing technology. In this case report, we present the genetic research findings of a spinal dumbbell-shaped EMPNST and provide new insights into the surgical strategy and exploration of EMPNSTs in children. Furthermore, we reviewed all reported spinal dumbbell-shaped EMPNSTs and evaluated the effectiveness of radical resection for recurrence and metastasis.A 3-year-old boy presented with a 3-month history of limping and intermittent pain in the right plantar. He became unwell and was reluctant to walk for 2 months before being admitted to the hospital. Pelvic computed tomography (CT) scanning revealed a mass with a heterogeneous signal arising through the foramina at the right-sided Lumbar 5 (L5) and Sacral 1 (S1) . T2-weigRadical tumor resection with the microscope was performed, and bilateral pedicle screws were implanted at L5 and S1. The patient's muscle strength improved after the operation, and he could walk independently. Systemic postoperative chemotherapy (vincristine + cyclophosphamide + doxorubicin/ifosfamide + etoposide) and 160 cGy single pelvic irradiation were administered for 28 days. Follow-up CT , b and MImmunohistochemistry revealed diffuse growth of spindle cells and polygonal cells visible in the low-power view . Under t*7)] in exon 5 of the SMARCB1 gene, which was considered a “second-hit loss” . Germline copy number loss of heterozygosity in the q11.21-q11.23 region of chromosome 22 (~3.018 Mb) was found in the patient, which was inherited from his father. Panel sequencing  was performed on the tumor after the operation. A frameshift mutation was detected [c.606del  are rare and high-grade neurogenic tumors with an incidence of approximately 0.001%, accounting for 3%–10% of malignant soft tissue neoplasms. When the spine is involved, a dumbbell-shaped mass with bone erosion can be observed. MPNSTs seldom arise in the vertebral body. A variant of MPNSTs called epithelioid MPNSTs (EMPNSTs) accounts for approximately 5% of all MPNSTs cases. EMPNSTs occur in other organs, such as superficial and deep soft tissue, and have been previously reported in the kidney, bladder, ovary, trachea, lung, ileum, prostate, pleura, mediastinum, and retroperitoneum . The patIn general, sarcomas arising from schwannomas often exhibit an epithelioid morphology, including epithelioid malignant peripheral schwannomas and epithelioid angiosarcomas, whereas most neurofibromas cause conventional spindle cell EMPNSTs , 17. T1-Loss of SMARCB1/INI-1 copy number is widespread in more than 90% of malignant rhabdoid tumors and epithelioid sarcomas , 19, sucInterestingly, they found no significant morphological differences in EMPNST with or without combined SMARCB1 mutations . SchaefeThe pathological differential diagnosis of EMPNSTs includes malignant melanoma, myoepithelial carcinoma, proximal epithelioid sarcoma, epithelioid myxofibrosarcoma, and extraosseous myxoid chondrosarcoma (EMCS). EMPNSTs are characterized by nodules, oval cells, and cords with prominent nucleoli and usually manifest a focal striated morphology or clear cytoplasm. Unlike conventional MPNSTs, EMPNSTs typically show diffuse and strong staining of the S100 protein. The loss of expression of the melanoma-associated antigens can be observed, such as Melan-A/Mart-1, HMB-45, and MiTF, which can differentiate melanoma.Currently, the mainstay of treatment for EMPNSTs involves radical surgical resection combined with postoperative chemoradiotherapy and neoadjuvant therapy . From thWe report a case of a child diagnosed with paravertebral EMPNST who was confirmed to have inherited the germline SMARCB1 mutation from his father. The genetic evaluation of the tumor revealed a novel frameshift mutation in exon 5 of SMARCB1. Surgical radical resection combined with postoperative radiotherapy and chemotherapy suppressed the progression of the tumor. A literature review also highlighted that radical resection may be necessary to achieve local control to avoid recurrence.The datasets presented in this article are not readily available because of ethical and privacy restrictions. Requests to access the datasets should be directed to the corresponding authors.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.MQ participated in all aspects of this report, including patient management, and draft writing. NJ managed the patient and reviewed the manuscript. WD and ZC managed the patient and supervised the study. All authors have read and approved the final manuscript and agree to be held accountable for all aspects of the report.


Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare obstetric emergency that may have an adverse outcome for the mother and baby. This case report describes a unique SHiP case initially diagnosed as acute appendicitis in a patient with severe endometriosis before conception. A woman in her 30s, a primigravida, was admitted with abdominal pain at 32+5 weeks gestational age. Following a surgical review, she was initially diagnosed with acute appendicitis and commenced on intravenous antibiotics. She experienced a dramatic deterioration in her health in the form of clinical shock and fetal distress. She had an emergency laparotomy, a hysterectomy, and a left salpingo-oophorectomy for uncontrollable bleeding. The baby was born in good health, and the mother had an uneventful recovery. Spontaneous hemoperitoneum during pregnancy is rare ,2. It isA primigravida woman in her 30s presented at 32+5 weeks of gestation with a sudden onset of continuous abdominal pain. The pain was dull and most pronounced in the left lower abdomen. There was no vaginal loss, fever, nausea, vomiting, or urinary tract symptoms. The pain was exacerbated by physical activity and relieved temporarily by analgesia. On presentation, her vital signs were within the normal range, and a urinalysis showed no abnormalities. Abdominal examination revealed diffuse tenderness with guarding. There was no palpable uterine contraction. Fetal monitoring with a cardiotocograph (CTG) was normal. She was admitted and given regular pain relief. The patient initiated antenatal care at our facility at 27 weeks of gestation. She had a significant medical history of severe endometriosis and had undergone laparoscopic cystectomy for a ruptured left endometrioma before conceiving while being worked up for in-vitro fertilization.Her blood investigations revealed a hemoglobin level of 111g/L, a white blood cell count of 20.1 x 10^9 /L, and neutrophilia at 18.1 x 10^9 /L. The C-reactive protein was 11mg/L. The venous lactate was 1.2mmol/L. Renal and liver function tests were within the normal range. An urgent abdominopelvic ultrasound revealed a bilateral hydronephrosis and a small pelvic fluid collection, but the appendix was not visualized. Without an obstetric cause for her pain, the acute surgical team was invited to review the patient. Upon review by the surgical team, a provisional diagnosis of acute appendicitis was made. Intravenous antibiotics and fluid management were initiated. A pelvic magnetic resonance imaging (MRI) scan was ordered; it found a left complex tubo-ovarian lesion measuring approximately 5.0 x 3.5 cm, displaying characteristics consistent with a hemorrhagic ovarian cyst, possibly of endometriotic origin Figures ; and theThe patient subsequently made an uncomplicated recovery and was discharged on the fifth day after surgery. After a few weeks of neonatal care, the baby was discharged from the neonatal unit. During her six-week postnatal follow-up visit, repeat magnetic resonance imaging (MRI) indicated the persistent presence of left hydronephrosis and cortical thinning resulting from distal ureteric obstruction caused by endometriosis.The exact incidence of this condition in patients with severe endometriosis remains unknown, but an estimate of one in 10,000 has been reported . The incSHiP typically presents with acute-onset abdominal pain -20, ofteDiagnosing spontaneous hemoperitoneum in pregnancy presents a significant challenge due to the nonspecific clinical presentation -20 and sThe decision regarding fetal delivery should be based on the clinical situation. Among the cases reviewed in the literature Table , only onThis case report sheds light on a challenging clinical scenario: spontaneous hemoperitoneum during pregnancy at 32 weeks of gestational age, compounded by severe endometriosis. This rare and high-risk combination presented a complex clinical picture, leading to massive intraperitoneal bleeding and necessitating an emergency premature delivery. The case underscores the importance of recognizing and closely monitoring pregnant patients with known severe endometriosis, as they are at an increased risk for such complications. Early diagnosis and swift intervention are paramount in preventing maternal and fetal morbidity and mortality. We further emphasize the significance of a multidisciplinary approach involving obstetricians, surgeons, and specialists in endometriosis management. Collaboration and timely decision-making were essential to achieving a successful outcome in this case. It also highlights the need for further research to understand the intricate relationship between the pathogenesis of endometriosis and spontaneous hemoperitoneum during pregnancy, aiming to improve prevention and management strategies to achieve good maternal and fetal outcomes. Ultimately, successful outcomes in such cases rely on the collaborative efforts of the healthcare team and the ability to adapt swiftly to emergent situations, ensuring the well-being of both mother and child.


Ewing's sarcoma (ES) is a malignant small round cell neuroectodermal tumour primarily affecting children in the first and second decade of life.Since ES is difficult to control, early diagnosis is crucial, and the treatment requires a multimodality approach constituting chemotherapy, surgery and radiotherapy.Here, we present a case of ES of orbit in a 17-year-old female diagnosed in 2021. This case report focuses on the clinicopathological presentation and management principles of this rare manifestation of the disease that unilaterally infiltrated into the extraconal space of the orbit as well as the I/L frontal sinus. The patient underwent chemotherapy and radiation, and she is on follow-up. Ewing's sarcoma (ES) is a malignant small round cell neuroectodermal tumour which primarily affects children in the first and second decade of life, classically involving long bones of lower limbs, ribs and the pelvis . PrimaryThis tumour has similar morphological aspects of tiny round blue cell tumours, including membrane CD99 protein expression, cytogenetic features of t translocation or t rearrangement, and molecular features of hybrid transcripts of the EWS gene with FL1 or ERG gene . It is aA 17-year-old girl presented to a local hospital with swelling around the left eye, watering of the eye and blurred vision for three months. MRI showed an extraconal lesion in the left superior and medial orbit, up to the apex, infiltrating the superior rectus, superior oblique and middle rectus muscle approximately 4.6 x 3.9 x 3 cm, with compression of the optic nerve and erosion of the medial wall and the roof of the left orbit  done for EWSR1 translocation  was positive, confirming the diagnosis of ES. Bone marrow aspirate showed reactive marrow, and bone marrow biopsy showed no evidence of malignancy. She was then referred to our hospital for further management.The institutional multidisciplinary tumour board decided to treat her further with systemic chemotherapy followed by local radiotherapy. Chemotherapy was started as per the Ewing Family Tumor-EFT 2001 protocol. At week 11 of chemotherapy, the patient was started on local treatment with radiation. A contrast-enhanced MRI of the orbit done before the start of radiation showed an infiltrating lesion in the left orbit involving the superomedial compartment, left frontal sinus and left lateral ethmoidal air cells. The necrotic component (25 x 27mm) was seen along the inferior wall of the left frontal sinus. Posteriorly, on the left side, there was a loss of interface with the optic nerve. The contralateral right eye and right optic nerve were normal.Baseline visual acuity and perimetry were within normal limits. The patient was immobilised in a supine position with a head and neck thermoplastic mould, and a CT simulation was done with a 3 mm slice thickness. A custom wax bolus of 5 mm was used over the target area during the simulation and treatment. The simulation CT was fused with the pre-chemotherapy MRI, and the gross pre-chemotherapy disease was contoured as gross tumour volume (GTV). The clinical target volume (CTV) comprised the residual tumour with the entire left orbit limited by the normal anatomical barriers. The CTV was given a margin of 5 mm to create the planning target volume (PTV). Radiotherapy was planned using 06 MV photons by Volumetric Modulated Arc Technique-RapidArc technique consisting of two partial arcs in the Eclipse treatment planning system  and the prescription dose was 54 Gy in 30 fractions to the PTV. A total of 95% of the PTV volume received 99.3% of the prescribed dose, i.e. V95 was 99.3% . She tolerated radiation well, developing only grade 1 dermatitis (Radiation Therapy Oncology Group-RTOG Acute Radiation Morbidity) during treatment. However, after the completion of treatment, the patient did not turn up for a follow-up visit but on a telephone interview, she informed that she is doing her normal day-to-day activities and attending her regular college classes without difficulty.A female patient of 17 years with primary ES of the orbit was disease-free with no evidence of disease at the last follow-up, highlighting the reasonably good outcomes expected with multimodality management that included surgery, chemotherapy, and radiation therapy. A previous report by Koka et al. reported the mean age at presentation to be 17.50 years . So far,In our case, the patient presented with unilateral proptosis, swelling around the eye, watering of the left eye and gradually progressive loss of vision. Woodruff et al. reported about a six-year-old boy whose sole complaints were headache and profound loss of vision, which was acute in onset due to a tumour in the orbit and ethmoid sinus that had spread into the anterior and middle cranial fossa and caused optic nerve injury . The ES The osseous component of orbital ES is more common (85%) than the extraosseous (15%) component. Osseous ES has a bony origin and can spread into soft tissue spaces, while the extraosseous ES arises from soft tissue in the orbit . In our On CT imaging, ES appears as an infiltrative lytic lesion causing severe bone damage and a mottled look of the bone.They present heterogeneous masses on MRI that are isointense to hypointense on T1-weighted images, isointense to hyperintense on T2-weighted imaging, and exhibit contrast enhancement with gadolinium . In our When diagnosing a histopathological picture of a small round blue cell tumour, the differentials will be rhabdomyosarcoma, neuroblastoma, lymphoma and osteogenic sarcoma .ES is a unique neoplasm that arises from undifferentiated small round cells in the bone. This tumour represents 8-10% of all primary malignant bone tumours. Patients under 30 account for 90% of cases, while those under 20 account for 75%. Its frequency is highest in 5 to 13 years of age [ES has an unclear histogenesis. Because vascular pathways were frequently present, Ewing hypothesized that this tumour had a vascular origin and called it endothelial myeloma of bone . Most caExtraskeletal sarcomas are clinically and pathologically indistinguishable from bony ES and have been described most commonly in young adults. They may degrade neighbouring bone, making the precise location of origin challenging to establish. Extraosseous tumours are more uncommon than bone tumours, and they may represent numerous histologic tumour types rather than a single entity. Although these lesions have prominent amounts of cytoplasmic glycogen and poorly formed cell junctions, electron microscopy, immunohistochemistry, and chromosomal analyses suggest that at least some of these lesions are other tumours, such as peripheral neuroepithelioma or other primitive soft-tissue tumours ,17.Until recently, the outlook for ES at all sites was similarly bleak. The five-year survival rates with surgery and radiation alone were only 8% and 10%, respectively . AccordiIn summary, ES is a bone tumour that seldom affects the orbit. Most youngsters, with a small male predominance, are affected in their second decade. The instances manifest with distinct symptoms, and local trauma may predispose to the diagnosis of an asymptomatic cancer that was previously present. Neuroblastoma, rhabdomyosarcoma, and lymphoma are all possible diagnoses. Histopathological and immunohistochemical studies are used to confirm the diagnosis. Follow-up for cases with orbital involvement is insufficient in the current literature. Local excision or radiotherapy, as well as systemic chemotherapy, is used to treat the condition.


Furthermore, intraoperative frozen section examination should have been part of the management armamentarium in this case, leading to enhanced testicular preservation.Leiomyomas are benign, slow-growing, mesenchymal neoplasms that originate from smooth muscle. We report a case of a 44-year-old man presented with an asymptomatic left scrotal mass. Scrotal ultrasonography (US) showed a 3.9 cm well-limited, hypoechoic intratesticular mass. The patient underwent a radical left orchiectomy and histologic findings revealed an intratesticular leiomyoma. To our best knowledge, so far, this is the 19 Neoplasms of the testis are most often primary testicular tumors of germ cell origin, occurring most frequently between the ages of 25 and 35 years and are almost always malignant. Less commonly, non-testicular malignancies may involve the testis, including leukemia, lymphoma, and metastatic disease . In the A 44-year-old white man was referred by his general practitioner because of a clinical finding of a painless left scrotal mass. The patient had noticed a progressive, painless swelling in the left hemiscrotum over the past six months. He had two children, and denied any history of undescended testis, development sex disorders (DSD), trauma, weight loss or appetite disturbance. No family history of testicular malignancies was also noticed.On physical examination, he had a firm and painless mass measuring 4 cm × 3 cm covering the whole left testis, while his right testis was unremarkable. Serum tumors markers  showed no elevated levels. Scrotal ultrasonography (US) showed a well-limited heterogeneous hypoechoic intratesticular mass measuring 3.9 x 2.7 cm on the left testis, the rest of the testicular parenchyma appeared homogeneous and no hydrocele was mentioned Figure .The patient consented to undergo a radical inguinal left orchiectomy, whereupon the left testis was found to be enlarged with a palpable and firm intra-parenchymal mass. The patient’s postoperative recovery was uneventful.Pathologically, the gross specimen showed a whitish nodular mass that measured 4.2 cm in diameter, with a fasciculated aspect on section and well demarcation from the remainder testicular parenchyma  and desmin Figure .These histopathological findings were consistent with the diagnosis of leiomyoma without any sign of malignancy. At his four-year follow-up, the patient showed no signs of local recurrence nor distant metastasis.Leiomyoma of the testis is an uncommon condition . To our However, a benign disease should have been considered in our patient who had presented with a long duration of symptoms and did not have any history of well-established risk factors for testis cancer , and infertility), especially in the absence of disseminated GCT or elevated serum tumor markers. Indeed, the existence of a testicular mass should not be considered a sign of malignancy, and frozen section evaluation should be part of the treatment arsenal, which may lead to enhanced testicular preservation in particular cases . The facIn the setting of an indeterminate intratesticular mass, a benign lesion should be considered. However, leiomyoma is a rare benign testicular neoplasm that is diagnosed based on histopathological confirmation almost on a radical orchiectomy specimen. By reporting this case, we aim to stress the importance and reliability of FSE in the correct diagnosis of an indeterminate testicular mass. Perhaps a surgical management strategy for testicular masses based on FSE diagnosis can be implemented with the goal of increasing organ preservation surgery.


Leukemia is the most frequently occurring cancer in children, and lymphoblastic lymphoma (LBL) is a rare subtype. LBL are lymphoid neoplasms of B or T cell origin and are primarily treated with chemotherapy. Although cure rates among children are excellent, these patients must be monitored for relapse. Cutaneous lesions involving B-cell LBL (B-LBL) are extremely rare and here we present a patient with a worsening B-LBL scalp mass who required radical surgical excision.A 6-year-old female patient with a history of a nontender scalp mass discovered at approximately 2-3 years of age was evaluated for resection of the nodule due to its size and treatment history. The patient was originally diagnosed with follicular lymphoma by punch biopsy; excision was successfully performed on this 4 cm lesion and upon examination of the skin biopsy did we get a diagnosis of B-LBL. Reconstruction of the scalp was done through the rotation flap method. The patient’s scalp healed well, and adjuvant chemotherapy was continued. There has been no reoccurrence.Here we report the rarity of B-LBL cases involving extranodal involvement in the scalp. The most common reconstruction of scalp lesions has been using free flap from the anterolateral thigh (ALT) and latissimus dorsi (LD). Our case used the rotation flap, which has its functional and cosmetic benefits. The importance of monitoring this patient is emphasized due to the dangerous consequences of B-LBL relapse. Ultimately, our successful treatment and care of this rare case can be used as guidance for similar patients in the future. The most frequently occurring cancer in children is leukemia, which comprises 30-40% of childhood malignancies. The symptoms can be mild or progress to further complications including death , 2. TherOne subtype of leukemia is acute lymphoblastic leukemia (ALL)/lymphoblastic lymphoma (LBL). ALL and LBL are commonly classified together due to overlapping characteristics, as they are lymphoid neoplasms of B or T cell origin occurring mostly in children . TreatmeAlthough cure rates are excellent in this population, these patients must be monitored for long-term toxicities and relapse. This monitoring is especially critical, since only half of children with first relapse of ALL survive long term and this number decreases even more with later relapses .LBL is already a relatively uncommon neoplasm of precursor lymphocytes, comprising only 5% of non-Hodgkin’s Lymphoma . CutaneoA 6-year-old female presented with a history of a nontender scalp mass that was first noticed as a single nodule at approximately 2-3 years of age. She was initially being monitored by her pediatrician, and was noted to have waxing and waning erythema and enlargement. She was thus referred to the pediatric hematology/oncology clinic for further workup. An ultrasound (US) of the scalp obtained in May 2021 showed a hypervascular lesion measuring 2.7 x 0.5 cm x 2.1 cm that was consistent with a hemangioma. Multidisciplinary referral to dermatology was done for clinical monitoring and the case was discussed in vascular tumor board. Upon frequent follow up and repeat US the lesion continued to enlarge, which was unusual for a hemangioma. Thus, a punch biopsy was obtained which demonstrated a mature B cell lymphoma of follicular germinal center origin; atypical cells were positive for CD10, CD20, BCL2, and negative for CD3, CD4, CD5, CD8, CD30, CD56, MUM1, TIA1, BCL-1, and BCL6. She had no other systemic symptoms and denied fever, weight loss, night sweats, or other lymphadenopathy. Staging was subsequently done which included MRI of the disease site, PET/CT, and CXR to evaluate for mediastinal mass. MRI showed 4.0 cm x 2.7 cm x 2.9 cm soft issue scalp mass overlying the left frontal lobe, inseparable from the outer table and replacing the subcutaneous fat. The lesion enhanced, showed restricted diffusion, and had areas of susceptibility representing calcification and punctate hemorrhage possibly secondary to a recent biopsy Figure 1At the time of our evaluation, the lesion was about 4 cm, eroding the scalp with a firm consistency and minimal mobility over the skull. Given the large size of the lesion and the expected defect which would result from complete removal, we planned to coordinate care with our plastic surgery team. The excision of the left frontal scalp lesion was performed under general anesthesia. The skin was opened circumferentially around the tumor, and it elevated without issue with clean bone underneath. All skin edges were hemostased without issue and no palpable tumor remained. This excision left an approximate 4 cm diameter circular defect in the left anterior scalp with no bony defect Figure 2The excision specimen was a 5.5 x 4.3 cm, unoriented skin with the underlying lesion Figure 2Unexpectedly, pathology revealed the lesion to be consistent with B-cell lymphoblastic lymphoma. The biopsy showed that the neoplastic cells were positive for CD10, CD19, CD22, CD34, CD99, TdT, and Bcl-2, and negative for Bcl-1, Bcl-6, cMYC, MUM-1, CD30, or P53. CD21 highlighted a residual follicular dendritic cell meshwork. Ki-67 was about 70-90%. A lumbar puncture (LP) and bone marrow evaluation was performed, which was negative for CNC or marrow disease. The patient underwent placement of a central venous access device (left subclavian vein subcutaneous port placement) and was initiated on treatment for Low Risk B-lymphoblastic lymphoma with a 2-year course of chemotherapy including vincristine, dexamethasone, pegasparaganese, doxorubicin and cytarabine per standard of care Children’s Oncology Group trials. She completed induction chemotherapy with minimal complications. At the end of induction, PET/CT was negative for residual disease, and she was considered in remission. Currently, she continues treatment and is clinically doing well. Cosmetically, her scalp healed well without any wound healing issues. She has a few areas of alopecia; however, the appearance of the scalp overall is excellent given her preoperative appearance Figure 4B-LBL is a non-Hodgkin’s lymphoma that originates in lymphoblasts and appears in about only 10% of the LBL cases . Unlike This patient was initially diagnosed with Stage 1 Follicular Lymphoma based on punch biopsy of the skin. Curative therapy for these lesions in pediatrics includes gross total resection. However, pathology from our resection resulted as B-LBL, making this case unusual and mandating intensification of therapy. B-LBL lesions do not need to be surgically resected as they are extremely chemoresponsive, and treatment for LBL is similar to acute lymphoblastic leukemia. Given the risk of recurrence and relapse, systemic chemotherapy and preventative CNS therapy is required in all cases.In general, malignant scalp masses need careful attention and treatment due to their aggressive nature . MultimoIn a similar B-LBL case, there was a 5x5 cm excised lesion that was treated using an anterolateral thigh (ALT) flap . Free flOur case used a rotational flap, commonly known as the O-Z flap, for reconstruction of the scalp. In general, rotation flaps are most used for lesions on the lateral face, cheeks, chin, and scalp and when other simpler types of closure fail to provide adequate functional or cosmetic results . It has Alternative treatment for scalp coverage has been tested for full-thickness scalp defects. Integra bilayer wound matrix is a technique that has a high success rate. A study showed that the patients had no wound breakdown or wound-healing issues before radiotherapy. It provides an alternative to local flaps because the scalp’s poor mobility can make it difficult to use local flaps for larger defects, even if the treatment is effective for small lesions .We report a unique case of a six-year-old girl with a history of a nontender scalp mass that was first noticed as a singular nodule. She was monitored for several years with insidious lesional growth, necessitating further workup. After resection of this scalp lesion, her biopsy indicated a LBL diagnosis. There are only 38 other cases in literature of patients diagnosed with B-LBL presenting with scalp lesions. Following resection, our patient did not receive a free flap reconstruction of this site, which has been the conventional method for wound repair after scalp tumor resection. Instead, we performed a rotational flap on the patient, which has substantial benefits for post-operative recovery. Our patient has been healing well and, besides a few areas of alopecia, her overall scalp cosmesis is excellent. Moving forward, in cases of scalp tumor resection, rotation flaps should be considered first when feasible before traditional free flaps, as they provide clear cosmetic and functional benefits. Finally, more work should be supported to better understand the behavior and response to systemic therapy of B-LBL scalp lesions, given the rarity of these cases and the poor survival rates with recurrence.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the patients for the publication of any potentially identifiable images or data included in this article.TK, GJ, EB-W, RF were involved in the composition of this manuscript and GL, AT, YW, OT, and AK were involved in revision and review of this manuscript. TK and AK developed the concept for this report. All authors contributed to the article and approved the submitted version.


Surgical resection is the mainstay for management of splenic flexure cancers, with the aim of achieving adequate lymphadenectomy. Left-sided bowel resections often require ligation of the inferior mesenteric vein (IMV) for mesocolic dissection or lymphadenectomy which can result in congestive colitis on the anal side of the anastomosis secondary to poor venous outflow. Preserving the IMV may mitigate this risk but is technically difficult and can compromise oncological resection. This case report is a rare example of high left segmental resection of the splenic flexure with preservation of the IMV in a patient with splenic flexure melanoma.A non-obstructing lesion was discovered in a 73-year-old male who underwent colonoscopy following a positive faecal occult blood test. Biopsy of the lesion confirmed a melanoma. This patient had a history of cutaneous melanoma which was excised 20 years prior. A laparoscopic high left segmental colectomy was performed, and metastatic melanoma was identified in 3 of 12 regional lymph nodes. The patient recovered with no complications.This patient underwent high left segmental colectomy to achieve oncological clearance while resecting minimal bowel and preserving bowel function. The IMV was spared in this surgery to prevent venous congestion. Reports of colitis following left sided colectomy have been described, whereby colitis is thought to result from a mismatch in arterial perfusion and venous drainage following IMV resection.This case highlights the potential role of preservation of the inferior mesenteric vein in a rare case of splenic flexure melanoma. •Preservation of inferior mesenteric vein in left-sided colectomy is rare and adequate lymph node retrieval is important.•Preservation of inferior mesenteric vein in left-sided colectomy allows to prevent congestion and colitis.•Multi-disciplinary discussion for splenic flexure carcinomas are indicated. Although there is literature available on the management of SFCs, there is no worldwide consensus on optimal surgical management Left-sided colectomy typically resects the inferior mesenteric vein  which re2A 73 year old male underwent a colonoscopy for a positive faecal occult blood test. His past medical history includes melanoma (Clark level 4) of the back which was completely excised 20 years prior, and hypertension. A non-obstructing lesion was found at the splenic flexure  and tattFollowing surgical resection, the patient recovered without complications was content with the management and was discharged home four days post operatively after regaining bowel function. Following a discussion at a multi-disciplinary meeting, the patient opted for surveillance as an alternative to adjuvant immunotherapy based on the potential risk profile of the treatment and unknown benefits. The initial plan for surveillance included a clinical review and 3 monthly PET and MRI scan, however the patient was unable to maintain ongoing imaging after 6 months due to the high burden of appointments and travel time required. Colonoscopy at 12 months post-operatively showed a single benign polyp. At 18 months post-operatively no signs of recurrence were observed, and clinical surveillance is ongoing.2.1The procedure took place in a modified Lloyd-Davis position with the right arm tucked in. Infraumbilical 10 mm Hasson port was placed and 14 mmHg pneumoperitoneum was established. Three 5 mm working ports were inserted in the RUQ, LUQ, and LLQ. Following the identification of the IMV we utilised a sub-IMV approach with medial to lateral dissection to enter the plane between the mesocolon and Gerotas fascia. This was performed using a combination of blunt dissection and Ligasure. The gonadal vessels lie deep to the plane of dissection. The ascending branch of the left colic artery was ligated as skeletonization of the IMV continued towards the inferior border of the pancreas.A window into the lesser sac was created with an infra-colic approach through the transverse mesocolon to the right of middle colic artery. The left branch of the middle colic artery was ligated with Ligasure while the remaining colon and sigmoid colon were further mobilised medially to allow for tension-free extra-corporeal anastomosis (side to side stapled). 3The splenic flexure is situated at a watershed area between the mid-gut and hindgut. The splenic flexure receives vascular tributaries from the superior mesenteric artery  and infeSurgical resection must incorporate resection of the malignancy with a margin of healthy tissue, in addition to that necessitated by arterial ligation and adequate lymphadenectomy. A recent meta-analysis of non-randomised studies indicated no significant difference in short term surgical complications or oncological outcomes between common surgical resection options Multiple reports of colitis following left sided colectomy have been published The patient in this case has a history of cutaneous melanoma Clarke level IV. Histopathology of the operative specimen indicated a 30 mm ulcerated melanoma  penetrating through bowel wall and present in 3/12 lymph nodes. It is not known whether this lesion represents a primary mucosal melanoma or a recurrence of his previous cutaneous melanoma. Regardless, operative intervention is recommended for metastatic melanoma to the GI tract for both symptom management and to prolong survival 4This case report demonstrates a rare case of melanoma of indeterminate origin in the colon, and considers the technical difficulty and potential role of IMV preservation in colectomy. Furthermore, this case report highlights the paucity of literature on the surgical management of splenic flexure carcinomas and emphasizes that worldwide consensus is needed for optimal management.IMVinferior mesenteric veinIMAinferior mesenteric arterySMAsuperior mesenteric arteryColonic melanoma.Supplementary Video 1The following are the supplementary data related to this article.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.None.https://www.bendigohealth.org.au/Ethicsapplications/).The ethics was exempt from ethical approved due to being a case report, aligned with institutional values , MD.N/A.None declared.


Chondrosarcoma, although rare in the distal radius, poses significant challenges. Early diagnosis through incisional biopsy is essential. Surgical resection with margin control and fibular grafting can be effective, but vigilant surveillance is crucial due to its aggressive nature. Metastasis demands consideration of additional interventions or palliative care.Chondrosarcomas constitute a rarity in the upper limbs, and their occurrence in the distal radius is even rarer with only one case previously documented. We report a case of distal radius chondrosarcoma in a 35‐year‐old female patient who presented with pain and swelling in her left wrist. Following an initial examination, an incisional biopsy was performed, confirming the diagnosis of dedifferentiated chondrosarcoma. The patient underwent a marginal resection of the distal radius and first carpal with ipsilateral fibular and locking compression plate fixation. Unfortunately, despite the interventions, the patient experienced recurrent swelling and ultimately required below‐elbow amputation, followed by above elbow amputation due to metastasis. Unfortunately, the patient passed away due to recurrence and metastasis. Radiological progression of dedifferentiated chondrosarcoma in the distal radius. The pain was characterized as mild to moderate in intensity, dull in nature, and worsened with hand movement. Concurrently, there was noticeable swelling in the left wrist, which rapidly increased in size over a period of 3 months. There were no other instances of swelling in the body, and the condition was not associated with weight loss. The patient has an unremarkable medical history and is married with two children. Upon examination, a 13 × 10 cm swelling extending from the forearm to the hand was observed in the left wrist. Dilated veins were visible on the anterior aspect of the wrist, while distal neurovascular function remained intact. X‐ray of the wrist AP and lateral view showed a mixed‐density lesion involving the distal radius, which extended densely into the soft tissue. The osteolytic lesion extended to the proximal carpal row , while second biopsy report after the below‐elbow amputation showed skin covered tissue exhibiting a spindle cell neoplastic lesion arranged in fascicles and herring bone pattern. The cells were monomorphic spindle shaped with moderate atypia. Scattered dilated blood vessels were seen. Approximately 10/31 high‐power field (hpf) mitoses were identified with foci of necrosis. Areas of chondroid differentiation were not seen. Skin was tumor free. Immunohistochemical stains showed Negative ASMA, Desmin, S‐100, CD34, EMTLE‐1, STAT6, and focal positive CD99. The second biopsy in comparison with the first represented dedifferentiated chondrosarcoma.2.2The plan was to do a marginal resection of the distal radius and fast carpal with ipsilateral fibular and LCP plate fixation. The patient was counseled about the procedure and potential complications, including nerve and vascular injury and recurrence. Under general anesthesia, the skin and subcutaneous tissue were incised through a dorsal approach. The tendon involved in the tumor was cut, the radial artery was ligated, and the median nerve was spared. The tumor with the distal radius in the proximal carpal row was marginally excised. The margins were negative.Midshaft ipsilateral non‐vascularized fibular graft was taken through the lateral approach. The graft was placed at the distal radius, and the plate was fixed with a 20–30‐degree perpendicular bend using a recon plate  was introduced by Dahlin and Beabout in 1971 and is applied to a high‐grade sarcoma present next to a low‐grade malignant cartilage‐forming tumor.Dedifferentiated chondrosarcoma has an aggressive nature and results in higher mortality rates compared to conventional chondrosarcoma or non‐cartilaginous sarcomatous components alone. The 5‐year survival rates for these are <20%.Diagnosing chondrosarcoma can be challenging due to its potential resemblance to other benign or malignant bone lesions. In our case, the diagnosis was confirmed through an incisional biopsy, considered the gold standard for diagnosing bone tumors.Surgery remains the primary treatment modality, ranging from curettage and bone grafting to wide excision or amputation, depending on the specific circumstances. Radiation therapy and chemotherapy are less commonly employed and are typically reserved for high‐grade or recurrent tumors.Unfortunately, despite the diligent efforts of the surgical team, this patient experienced a tumor recurrence shortly after the initial surgery, necessitating the amputation of the affected limb. This emphasizes the aggressive nature of chondrosarcoma and underscores the importance of vigilant surveillance and follow‐up care. The presence of metastasis in the chest indicates a poor prognosis for the patient, warranting consideration for additional treatment options or palliative care. During this challenging period, it is crucial to provide the patient and her family with thorough emotional and psychological support.Our case underscores the importance of early detection and prompt medical intervention when dealing with rare and aggressive conditions like dedifferentiated chondrosarcoma. It is essential for healthcare providers to consider the possibility of such conditions in patients presenting with unusual or persistent symptoms. Advancements in imaging modalities, such as MRI, CT scans, and PET scans, may aid in early diagnosis. Research into novel therapies, including targeted therapies and immunotherapies, may offer hope for better outcomes in the future.4We report a case of recurrent chondrosarcoma of the distal radius in a 35‐year‐old female patient. The patient presented with diffuse swelling and pain in the left wrist, progressing rapidly. A bone scan revealed focal areas of heightened tracer uptake in the lower region of the left radius. Chondrosarcoma was suspected, with a giant cell tumor considered a differential diagnosis. The diagnosis of chondrosarcoma was ultimately confirmed through histopathology.Badaruddin Sahito: Conceptualization; writing – original draft; writing – review and editing. Hussain Haider Shah: Data curation; writing – original draft; writing – review and editing. Syeda Alishah Zehra: Writing – original draft; writing – review and editing. Javeria Saquib: Writing – original draft; writing – review and editing. Farea Ahmed: Writing – original draft; writing – review and editing. Muhammad Sheheryar Hussain: Writing – original draft; writing – review and editing. Tirth Dave: Supervision; writing – original draft; writing – review and editing.This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.None declared.The ethical approval was not required for the case report as per the country's guidelines.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


This case report describes a rare occurrence of ectopic adrenal cortical tissue (EACT) in the undescended testis (UDT) of an adult male patient. The patient presented with an empty left scrotum since birth, and a magnetic resonance imaging (MRI) confirmed the diagnosis of left-side UDT. Orchidectomy was performed, and a microscopic examination revealed a UDT with EACT. The patient had no significant medical or surgical history and had a normal preoperative hormonal profile. EACT is usually found incidentally during surgical procedures and is more common in children than adults. This case emphasizes the importance of investigating adrenal rests due to the potential of neoplastic transformation or hormonal activity. The case report concludes that EACT of the UDT is still a possibility in the adult patient population. Discovering heterotopic adrenal tissue along the spermatic cord is a rare medical condition. During embryological development, many structures would migrate from their initial position in the vicinity of the adrenal gland to their final position in the abdomen or the pelvis. Such structures can harbor heterotopic adrenal glandular tissue. Retroperitoneal adipose tissue and the kidneys are the usual recipients of ectopic adrenal tissue. In comparison, the ovary, testis, spermatic cord, liver, colon transversum, and gastric wall are rarely reported with adrenal heterotopia .Our case presented with an empty left scrotum since birth. On clinical examination, the testis was absent in the left scrotal sac, which was confirmed with magnetic resonance imaging (MRI). The clinical diagnosis was a left-side undescended testis (UDT). Orchidectomy was conducted, and on microscopic examination, it was consistent with a UDT with ectopic adrenal cortical tissue (EACT). We present this case that illustrates the unusual and rare occurrence at this age and site.A 21-year-old male, with no significant medical or surgical history, presented to our clinic with an empty left scrotum since birth. The patient reported noticing a 2 cm x 2 cm bulge in his left inguinal area that can sometimes be palpated. Upon examination, the left hemiscrotum was noted to be atrophic, exhibiting minimal rugae in comparison to the opposite side. The left inguinal region was smooth with no obvious lump, which can be consistent with a UDT. The right testis was hypertrophic with normal epididymis and palpable vas but no varicocele. A preoperative hormonal profile was conducted to rule out testicular malignancy. Lactate dehydrogenase, human chorionic gonadotropin, and alpha-fetoprotein were all within normal limits. To confirm the testicular position, an MRI was ordered Figure .UDT is a prevalent congenital anomaly observed among pediatric patients. Anomalies of the epididymis have been documented in connection with undescended testicles. While it's acknowledged that the adrenal cortex can sometimes develop in atypical locations, instances of adrenal tissue developing outside its usual location near the adrenal gland are infrequent. Only a handful of cases of ectopic adrenal tissue in the para-testicular and inguinal regions have been reported, and this occurrence is even rarer in adults .Heterotopic adrenal cortical tissue or EACT can be located in the upper abdominal region or along the trajectory of the gonads' descent. The connection between the developing adrenal cortex and the genital ridge during embryonic development clarifies the correlation with the gonads. Ectopic adrenal tissue is believed to arise when cells detach from the primary body of the adrenal cortex or emerge outside of it, subsequently attaching to or becoming associated with the gonads or nearby tissues . FollowiThe discovery of ectopic adrenal tissue within the spermatic cord has primarily occurred as an unintended finding during surgical interventions, such as herniotomy or orchiopexy, in the inguinoscrotal region . These rThese heterotopic rests are more common in children than in adults. In their study of 13 cases, Mendez et al. discovered that the median age of diagnosis was 5.8 years. They found that ectopic rests are ten times more common in children than in adults. However, in our case, the patient was an adult male who presented with a UDT .To summarize, EACT represents a rare form of pathology, often only detected accidentally during surgical interventions. There is, however, a notable surge in its occurrence in conjunction with UDT. This escalation may be attributed to the embryological activities involved in the development of the adrenal and gonadal systems. The correlation between EACT and UDT might also provide insights into theories concerning testicular descent, particularly focusing on the formation of the gonadal ridge and the migration of primordial germ cells.In a surgical approach to a patient, further investigations are critical of these adrenal rests due to the possibility of these ectopic adrenal tissues undergoing neoplastic transformation or becoming functional. The significance of our case is that despite its rare occurrence, the EACT of the UDT is still a possibility in the adult patient population.


A 49-year-old female patient was referred to a tertiary care hospital with a history of postmenopausal bleeding and abdominal pain that had persisted for the last two months. An abdominal examination revealed a huge mass that had been present for 12 weeks. A fibroid uterus was suggested by USG. A biopsy was done and sent to histopathology which revealed myxoid leiomyoma. Subsequently, the patient underwent total abdominal hysterectomy without bilateral salpingo-oophorectomy. Histopathological examination confirmed the diagnosis of myxoid leiomyosarcoma (MLMS) of the uterus. Less than 1% of malignant female genital tract tumors are uterine sarcomas, which account for roughly 3% of all uterine tumors. The four most prevalent uterine sarcomas are carcinosarcoma, leiomyosarcoma (LMS), endometrial stromal sarcoma, and adenosarcoma, listed in decreasing frequency . Myxoid A 49-year-old female patient presented with complaints of postmenopausal bleeding for the last two months associated with abdominal and pelvic pain. Blood tests performed prior to admission revealed the following results: hemoglobin 10.8 g/dl, iron 31 g/dl, red blood cells 4.280,000/L, white blood cells 7.400/L, and platelets 243.000/L. Cancer antigen (CA) 125, serum lactate dehydrogenase, and CA 19-9 were in the normal ranges.On examination, the patient had a clinically pale appearance, but her vital signs were stable. A lump was felt in the mesogastric and hypogastric areas during an abdominal examination. It reached the umbilicus and had a firm consistency. The uterus measured 18 weeks in size and had a lump that was palpable on the anterior wall during a vaginal examination. Bilateral ovaries and fallopian tubes were both healthy. Trans-abdominal ultrasound examination revealed an increased size of the uterus , an endometrial thickness of 2 mm, and a large fibroid localized to the myometrium. A provisional diagnosis of fibroid uterus was given, and a biopsy was sent to the histopathology department. Histopathological examination of the biopsy specimen revealed leiomyoma with myxoid changes as no associated atypia, and no mitotic figures could be identified. The patient next underwent a total abdominal hysterectomy without bilateral salpingo-oophorectomy. During surgery, a large fibroid measuring 4.8 x 3.5 x 2.6 cm was found. It lateralized to the isthmus and broad ligament. Ovaries and fallopian tubes on both sides were in good condition. In our surgical pathology section, the resected specimen was received for histopathological analysis.The specimen received consisted of a distorted uterus with a separate piece of the cervix and a separate tissue mass. Distorted uterus with cervix measured 11.2 x 10.4 x 5.6 cm. Separate cervix measured 3 x 3 x 2 cm. A tissue mass that was sent separately was 4.8 x 3.5 x 2.6 cm in size. Endometrial thickness and myometrial thickness were 0.2 cm and 3 cm, respectively. The external surface of the uterus was bulky. On the cut section, the endometrial cavity was patent, and the myometrium showed a fleshy mass with grey-white to yellowish areas. The external surface of the separately sent tissue mass was grey-brown and congested. The cut section of the separately sent tissue mass was grey-brown, fleshy, gelatinous, and friable. Areas of necrosis were also seen . They were arranged in fascicles, interlacing patterns, sheets, and nests. Few multinucleated giant cells were seen. Stroma showed myxoid changes. Areas of coagulative necrosis were also noted. Lymphovascular invasion was absent Figures . HistopaA proliferation of malignant smooth muscle cells with a lot of myxoid matrix is known as MLMS. Low cellularity and low mitotic index serve as distinguishing characteristics . A very It is challenging to establish the preoperative diagnosis of uterine LMS. Vardi and Tovell  and GallThe majority of research that has been published concurs that the number of mitoses per 10 high-power fields is a helpful diagnostic and prognostic factor in LMS. Burch and Tavassoli  claimed Our patient was a postmenopausal woman who was experiencing unusual vaginal bleeding. With minimal opportunity for error, the first tissue diagnosis of myxoid leiomyoma was given which was based on clear-cut microscopic results of histopathological examination of the initial biopsy specimen. Despite the experience in diagnosis, it is unclear if the sarcomatous change took place later or if the initial microscopic look was deceiving. The absence of cellular atypia in the biopsy specimen must be emphasized, though. This example has been reported to emphasize the need to distinguish MLMS from a uterine leiomyoma with myxomatous alterations. There have been reports of an incidence of up to 15% for myxoid degeneration in benign leiomyomas, while myxoid transformation in LMS is extremely uncommon . Due to We reported a case of MLMS of the uterus. Menopausal state, pelvic symptoms, and the gross morphology of the tumor with fleshy, soft features all supported a malignant pathology. The uneven myometrial invasion, infrequent mitosis, cell pleomorphism, necrosis, and predominant myxoid component on histopathology provided the framework for the diagnosis of MLMS. On histopathological examination, we confirmed the diagnosis of MLMS of the uterus. Our experience supports the need for prudence in indicated clinical contexts and the requirement to be alert to the possibility of MLMS in such situations.


Inguinal hernia is amongst the most common acute abdominal disease that presents in the Emergency Department (ED). Pathologically, it involves the displacement and herniation of abdominal, pelvic, or groin tissue through weaknesses in the abdominal wall. Many inguinal hernias are simple and asymptomatic, managed conservatively without the need for surgical intervention. However, under rare circumstances, hernias are susceptible to significant complications requiring emergent surgery. This report follows the case of a 61-year-old Hispanic-American male presenting to the ED with signs of a complex strangulated inguinal hernia and consequent infarction of the testis with Fournier’s Gangrene. Clinical evaluation elucidated a one-week worsening abdominal pain, non-reducible painful inguinal hernia, nausea, vomiting, constipation, groin discoloration, dysuria, and a history of failed primary hernia repair during childhood. The patient underwent emergent surgery to excise ischemic-necrotic portions of the sigmoid colon, creation of end-colostomy, non-mesh repair of inguinal hernia, and right-sided complete orchiectomy with the removal of adjacent scrotal-Dartos tissues and spermatic cord due to Fournier’s Gangrene. This report provides both a report for a potentially preventable consequence in one of the most common surgical presentations and a review of the multi-disciplinary expertise that is required in the surgical management of complex inguinal hernias. Inguinal hernias are among the most common acute abdominal diseases that present in the Emergency Department (ED) ,2. ClassComplicated strangulated inguinal hernias present acutely with non-specific symptoms indicative of abdominal obstruction: lower abdominal pain, nausea and vomiting, erythematous and tender areas of the overlying skin, and possible signs of septic shock ,6. HowevIn this report, we review the case of a complicated strangulated inguinal hernia of the sigmoid colon with consequent vascular compromise of the ipsilateral scrotum and dartos tissue. This case required an emergent multi-disciplinary exploratory laparotomy to repair the hernia, debridement of necrotic tissue in the abdomen and scrotum, excision of necrotic tissue within the colon and scrotum, and revascularization with preservation of salvageable tissue.This is the case of a 61-year-old Hispanic-American male with a past medical history of obesity and recurrent inguinal hernia. Previous surgical history included a pediatric repair of an inguinal hernia at age eight, without mesh. The patient presented to the ED with a one-week history of lower-right abdominal pain that worsened in the past three days, prompting him to seek treatment. The patient also reported a three-day history of nausea, two episodes of vomiting, two days of constipation, a one-day discoloration of the groin, and a one-day history of dysuria.On presentation to the ED, the patient was in generalized discomfort, feverish (100.5°F/38.06°C), hypertensive (133/78mmHg), and tachycardic (104 beats per minute). Examination of the abdomen revealed an erythematous lower-right abdominal hernia, measuring 15x10cm, extending to the right scrotum  identified an elevated White Blood Cell (WBC) count at 23,500/ul with neutrophilic shift, 93.7%. Inflammatory markers were also elevated; Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) were 68.0 mm/hr and >350 mg/L respectively. The serum sodium level was 135 mEq/L, with an estimated Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score of 6. Additional preliminary blood tests revealed an elevated Lactic Acid, 2.6 mmol/L. This composition of patient history, clinical symptoms, and laboratory results were indicative of strangulated inguinal hernia with possible ischemic extension to the right scrotum. The patient was referred for intravenous (IV) contrast-enhanced CT-imaging of the abdomen and pelvis, ultrasound of the right scrotum, and urology consult due to concerns for ischemic-necrosis consequent to a strangulated inguinal hernia with possible ischemia of the right scrotum.CT imaging Figure  revealedUltrasound Figure  of the rThe patient underwent emergent exploratory laparotomy; during the inspection, a right-sided inguinal hernia containing a sigmoid colon was visualized. Utilizing a bowel grasper, the herniated sigmoid colon was partially reduced, revealing significant ischemic portions and copious amounts of feculent murky free fluid. On examination, 10 cm of sigmoid colon was found to be ischemic and non-viable Figure , with thThe patient was discharged on postoperative day 10, following an uneventful hospital course, and transferred to short-term rehabilitation with pelvic drain, temporizing end-colostomy, and negative-pressure wound vacuum-assisted closure (VAC) on the open surgical site of the right groin. Upon discharge, the patient was afebrile, with a normalized WBC count of 9,500/ul, negative wound culture, and steady vancomycin-trough levels. The patient followed up with the outpatient clinic on postoperative day 18 for removal of pelvic drain, switch of negative-pressure wound VAC to regular sterile-dressing changes, switch to topical bacitracin, and planning for six-month ostomy-reversal. Outpatient appointment with urology for closure of open surgical wound in right groin occurred on postoperative day 21 with no further complications noted to date.The lifetime prevalence of groin hernia is estimated between 27-43% in males, with inguinal hernia being the most common -3. NatioCharacteristically, an inguinal hernia presents with a reducible unilateral lower-abdominal/pelvic mass . The diaAs reflected in this case, an obese male with failed primary hernia repair during childhood and longstanding recurrent inguinal hernia presented with a complex strangulated hernia associated with multiple associated complications: ischemia of a portion of the distal sigmoid colon, necrosis of the abdominal wall hernia sac and adjacent omentum, and right-sided testicular infarction resulting in complete orchiectomy of the right testicle. Albeit asymptomatic, the clinical circumstances surrounding this case raise the question of whether early-preventative surgical intervention in longstanding recurrent inguinal hernias may provide a favorable risk-benefit profile in certain patients. With the advancement and resource-optimization of minimally invasive abdominal surgery, the question of surgical repair vs watchful waiting may require re-evaluation ,12. The Systematic reviews of asymptomatic inguinal hernia estimated an average of 79% (range 48-91%) of patient-crossover rate from watchful waiting to surgical repair for worsening of hernia symptoms, 24% experiencing complex hernia complications, including ischemia, necrosis, septic shock, bowel perforation, and urinary complications ,16. ThisInguinal hernias are among the most prevalent acute abdominal diseases. Surgical intervention is usually reserved for symptomatic, complicated, or complex hernias. Asymptomatic inguinal hernias are usually managed with watchful waiting, without adequate consideration of contributing comorbidities that would increase the risk for progressively worsening disease or hernia-associated complications. With the rapid evolution, optimization, and popularization of minimally invasive surgical repair, preventative early surgical intervention may provide a favorable clinical course and reduce the development of significant clinical consequences. This report provides both a report for a potentially preventable consequence in one of the most common surgical presentations and a review of the multi-disciplinary expertise required in the surgical management of complex inguinal hernias.