Midgut malrotation has a noticeable frequency among congenital anomalies and presents mostly as vomiting. We report a case of a five-year-old boy with recurrent attacks of bilious vomiting and mild epigastric colicky abdominal pain for a year. Midgut malrotation with Ladd's band and superior mesenteric vein (SMV) dilatation causing partial intestinal obstruction were diagnosed based on the clinical presentation, upper gastrointestinal (GI) barium follow-through study, computed tomography (CT) scan with and without IV contrast, and intraoperative findings. In the upper GI barium study, the duodenum was passing anteriorly, and the second and proximal third portions were persistently dilated with recurring to-and-fro type peristalsis, resulting in delayed passage through the third portion. In the abdomen and pelvis CT scan with and without IV contrast, the SMV was dilated, forming a venous collar around the third portion of the duodenum and causing partial obstruction. Exploratory laparotomy revealed a hugely dilated SMV trapped in the Ladd’s band. Ladd’s procedure was done besides releasing the SMV and widening the root of the mesentery. The postoperative follow-up was smooth, without any relapse of the previous symptoms. Midgut malrotation in the older age group is rare in itself because there are relatively few cases documented in this age range. We determined to present this case to raise awareness of knowledge concerning the diagnosis and timely management of this condition in order to prevent comorbidity. In addition, we realise that SMV dilatation is an uncommon correlation of the known condition, midgut malrotation, and hope to contribute to the literature. Intestinal malrotation is a congenital anomaly in which the midgut fails to spin entirely or partially during the early embryological developmental period, and approximately 75-85% of such patients are detected in early infancy with more specific and typical symptoms, while the minority of cases may be missed until childhood, as in our case, or perhaps even adulthood, caused by a broad variety of atypical mild small bowel obstruction symptoms . The incA five-year-old boy was referred to the paediatric surgery department electively with recurrent attacks of vomiting for a year. The vomitus was moderate, yellowish-greenish, bilious, non-bloody, and non-projectile, with three episodes per day. The first episode lasted for four days and was then alleviated for a six-month symptom-free period. The second episode had the same clinical scenario that lasted for a week, then was alleviated for two months. Once there, the third episode began, repeating every month with an increasing frequency of attacks. The vomitus was associated with nausea and intermittent mild epigastric colicky abdominal pain with no radiation, provoked by eating and relieved by vomiting. There was no change in bowel or bladder habits, signs of dehydration, or a significant change in weight. There was no history of fever, cough, yellowish discoloration, headache, seizure, or blurred vision. He had a free medical and surgical history.The patient was cooperative and oriented, with no jaundice, cyanosis, or pallor. His vital signs were within normal limits, and his recent weight was 18 kg. The abdomen was flat, with an inverted umbilicus at the midline. Bowel sounds were normal. The abdomen was soft and lax without tenderness, masses, or organomegaly. There were normal tympanic sounds on abdominal percussion.Electrolytes and the complete blood count were both within normal limits. There were no significant findings on the standing abdominal X-ray. There were no notable findings other than mild distal esophagitis and unremarkable biopsy results on the upper gastrointestinal (GI) endoscopy report that the patient had. An abdominal ultrasound was performed; there are some reported findings of malrotation, but further investigations were recommended. In an upper GI barium study, at the level of the third portion of the duodenum to the right side of the spine, there was persistent dilatation of the second and proximal third portions of the duodenum with a recurrent to-and-fro type of peristalsis with delayed passage through the third portion Figure . The fouThere was a high suspicion of SMAS; therefore, an abdomen and a pelvis computerised tomography (CT) scan with and without IV contrast were performed. This revealed an ectopic left kidney in the pelvis with anterior malrotation and a dilated extra-renal pelvis, superior mesenteric vein (SMV) dilatation forming a venous collar around the third portion of the duodenum, which was superiorly compressed by the portal vein, an abnormal course and ring-like formation around the proximal jejunum causing partial obstruction, and the bowel - due to non-optimal filling - looks normal without evidence of wall thickening or dilatation.Exploratory laparotomy was done and revealed a narrow mesenteric root, a cecum in the mid-upper abdomen with Ladd’s band crossing the third portion of the duodenum, a significantly dilated superior mesenteric vein whose diameter was around 1.5 cm, which was trapped in these bands Figure , and a cLadd’s procedure, along with appendectomy, was done, the superior mesenteric vein was released, and the root of mesentery was widened Figure .The postoperative period passed uneventfully, and the patient was discharged on the third day after resuming oral feeding and passing normal bowel motions. The follow-up during the next five months was smooth, without any relapse.Midgut malrotation is a congenital anomaly of fixation, internal rotation, and the bowel failing to rotate a total of 270° counterclockwise around the axis of the superior mesenteric artery (SMA) . Midgut Intestinal malrotation can be present with a midgut volvulus accompanied by ischemia and necrosis, which is mostly associated with a pathognomic pattern called the "whirlpool sign," which corresponds to a clockwise wrapping of the SMV and the mesentery around the SMA. The SMV can be found to be collapsed or dilated. Pracros et al. examined six patients with Ladd’s band and without volvulus, none of whom presented the "whirlpool sign" in ultrasound imaging . In our According to Stringer’s classification, there are three main types of midgut malrotations based on the embryological state of development: type 1 non-rotation, in which the DJ junction lies on the right and the colon on the left; type 2 incomplete rotation, also known as duodenal malrotation, in which the cecum in the epigastric region overlies the third part of the duodenum; and type 3 reverse rotation, also known as combined duodenal and cecal malrotation, in which the DJ loop is anterior to SMA and the transverse colon is posterior to SMA . An uppeThe upper GI barium study in our case showed a duodenum passing anteriorly, a DJ junction on the left side of the spine, the fourth portion of the duodenum ending at the ligament of Treitz, and a cecum in the mid-upper abdomen with Ladd’s band crossing the third portion. Hence, it seems that it contains features of both type 2 'incomplete rotation' and type 3 'reverse rotation'. It also showed findings corresponding with the SMAS, a cause of vomiting resulting from the compression of the third part of the duodenum between the SMA and the aorta . After pLaparoscopic or open Ladd’s procedure is the standard surgical management for intestinal malrotation . Timely We remark that SMV dilatation is a rare association of the known disease, midgut malrotation, and hope to contribute to the literature.Since there are few reported cases of midgut malrotation in this age range, we determined to present this case to raise awareness of knowledge concerning the diagnosis and timely management of this condition in order to prevent comorbidity. Furthermore, we recognise that SMV dilatation is a rare association with the well-known condition, midgut malrotation, and we hope to contribute to the literature.


Meningioma is a common non-glial tumor of the brain. Extracranial meningiomas in the parapharyngeal space are especially rare. Herein we report a case of extracranial meningioma in the parapharyngeal space and give a comprehensive description of its complete clinical course and radiological findings, which may provide helpful information in the diagnosis and treatment of extracranial meningiomas in the parapharyngeal space.A 61-year-old man presented a slowly increased mass under the left ear without pain and numbness over one year. Ultrasound examination detected a hypoechoic uneven mass behind the left parotid gland with a clear boundary, and color Doppler flow imaging revealed blood flow signals within the mass. Unenhanced computed tomography (CT) of the craniofacial region revealed a homogenous soft tissue mass in the parapharyngeal space without calcification. Magnetic resonance imaging (MRI) showed that a homogenous soft tissue mass was hyperintense on T2-weighted image, hypointense on T1-weighted image, and obviously enhanced after contrast enhancement in the parapharyngeal space. Coronal MRI showed that the lesion originated from basicranial dura extending into parapharyngeal space through the left foramen ovale at the skull base. Finally, histopathological and immunohistochemical analyses confirmed the final diagnosis of extracranial meningiomas in the parapharyngeal space.Extracranial meningiomas of the parapharyngeal space are rare and often pose a diagnostic challenge. Preoperative imaging examinations, especially CT and MRI, can aid in the accurate preoperative diagnosis, especially when intracranial extensions and dural tail signs are observed. Meningioma is a common non-glial tumor of the brain, accounting for 15% of all intracranial tumors , such asThis study followed the tenets of the Declaration of Helsinki and was performed according to the guidelines of the Second Affiliated Hospital of Zhejiang University School of Medicine. Written informed consent was obtained from the patient. A 61-year-old man presented a slowly increased mass under the left ear without pain and numbness over one year. In addition, the patient bit the cheek with his left posterior teeth when he consciously ate over four months. The distension of the left lateral pharyngeal wall was visible in the mouth. Ultrasound examination detected a hypoechoic uneven mass (8.2*5.6cm in size) behind the left parotid gland with a clear boundary (Extracranial meningiomas are very rare, comprising only 2% of all meningiomas. Due to the lack of prevalence and specific symptoms, extracranial meningiomas are often misdiagnosed . The mosThe parapharyngeal space is enclosed superiorly by the skull base, posteriorly by the vertebral column, anteriorly by the mandible and parotid glands, and inferiorly by the submandibular glands. Parapharyngeal meningiomas present without specific symptoms. The mass often goes undetected for a long time because local symptoms do not exist until the mass reaches a significant size. This was the case with our patient who had a slowly increased mass under the left ear for more than one year without pain or numbness. When symptoms do occur, they can vary greatly depending on the site involved. The tumor may present as a mass in the neck, a bulge in the mouth, or a mass around the ear . PossiblCT and MRI examinations are essential diagnostic tools for parapharyngeal lesions and are very useful in preoperative surgical planning. The imaging diagnosis of parapharyngeal meningiomas is challenging because of the similarities among lymph node tumors, paragangliomas, and neurogenic tumors of the cranial nerves . NeverthAlthough most extracranial meningiomas in the parapharyngeal space are benign, surgical excision is the primary treatment. Pathological examination is essential in confirming a definite diagnosis. Histologically, extracranial meningiomas are similar to other classic meningiomas. Immunohistochemical pathology is a critical tool for confirming the diagnosis of an extracranial meningioma . In the In summary, extracranial meningiomas in the parapharyngeal space are rare and often pose a diagnostic challenge. Preoperative imaging examinations, especially CT and MRI, can evaluate the tumor’s extent. These imaging modalities can aid in the accurate preoperative diagnosis, especially when intracranial extensions and dural tail signs are observed. Although the parapharyngeal region is a rare location, parapharyngeal meningioma should receive diagnostic consideration for the lesion that is a mass originating from the basicranial dura extending through the foramen at the skull base and showing a dural tail sign.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.The studies involving human participants were conducted according to the guidelines of the Declaration of Helsinki and were reviewed and approved by the Medical Research Ethics Review Committee of The Second Affiliated Hospital, Zhejiang University School of Medicine. The patients/participants provided their written informed consent to participate in this study. Written informed consent has been obtained from the patient to publish this paper.Conceptualization, CW and LH. Methodology, JM and KW. Software, JM and KW. Investigation, JM and KW. Resources, SY and CW. Writing—original draft preparation, SY and CW. Writing—review and editing, LH and CW. Visualization, CW. Supervision, CW. Project administration, CW. All authors contributed to the article and approved the submitted version.


The occurrence of diffuse large B-cell lymphoma (DLBCL) of the appendix presenting as acute appendicitis is rare, constituting only a minuscule portion (0.015%) of gastrointestinal lymphoma cases. We present a case of a 55-year-old woman that was admitted to the emergency department with symptoms of acute appendicitis and underwent an interval laparoscopic appendectomy with a right hemicolectomy and lymph node resection. Pathological examination revealed the presence of DLBCL in the appendix. The patient is undergoing chemotherapy. Diffuse large B-cell lymphoma (DLBCL) of the appendix presenting as acute appendicitis is rare, representing only 0.015% of all gastrointestinal lymphoma cases .This type of cancer can metastasize to other body parts if left untreated, following an aggressive path of dissemination and organ invasion . The staEarly detection and prompt treatment can significantly improve the prognosis for patients with appendiceal DLBCL . RegularA 55-year-old woman with a previous surgical history of cholecystectomy and myomectomy was admitted to the digestive surgery service after experiencing 2 months of pain in the right lower quadrant. She denied fever, weight loss or change in defecation.On physical examination, the patient reported mild tenderness in the right iliac fossa upon palpation but denied irradiation of the pain or other sign of peritonism. The cardiorespiratory examination showed no abnormal findings.The abdominal computed tomograCT scan showed an enlargement of the cecal appendix with a maximum diameter of 2.8 cm. Irregularities were identified in the lower contour of the appendix, with liquid accumulation and thickened wall measuring 1.6 × 1.4 × 1.1 cm . LaboratThe patient underwent a laparoscopic exploration. During the operation, at the level of the right iliac fossa, a sizeable appendicular mass measuring 9.2 cm × 3.4 cm × 3.0 cm was noted with a contiguous invasion of the right colon and two segments of the small bowel. Because of multiple adhesions at the right iliac fossa, the procedure was converted into a laparotomy through a midline incision.The two loops of the small bowel involved in the lesion had >90% of their circumference compromised, resulting in intestinal obstruction. Surgery proceeded with a right hemicolectomy sent for transoperative freezing examination, demonstrating atypical lymphocytosis. Pelvic lymphadenectomy of the internal iliac chain was performed, and the material was sent for histopathologic analysis with a pre-diagnosis of lymphoproliferative neoplasia.The anatomopathological examination of the colon demonstrated a lymphoproliferative lesion of large and atypical cells with necrosis and hemorrhage, suggesting a high-grade non-Hodgkin’s lymphoma  and b. IMucocele of the appendix is a condition with symptoms that can mimic other illnesses. Thus, it is crucial to perform a differential diagnosis to eliminate other possible causes of the patient’s symptoms. Possible differential diagnoses for mucocele of the appendix include appendicitis, ovarian cyst, diverticulitis, Crohn’s disease and gastrointestinal tumors. A comprehensive evaluation that incorporates the patient’s medical history, physical examination, imaging studies and laboratory tests may be required to make an accurate diagnosis. Performing a precise diagnosis is essential to achieve optimal treatment outcomes and minimize the likelihood of complications.Primary appendiceal lymphoma (PAL) is a rare form of gastrointestinal lymphoma, accounting for just 0.015% of all diagnoses [Symptoms of appendiceal lymphoma may include abdominal pain, bloating, constipation or diarrhea, but some patients may be asymptomatic, and the condition may be discovered incidentally. Depending on the stage and type of cancer, patient health and personal preferences, treatment options may include surgery, chemotherapy, radiation therapy or a combination of treatments .Available treatment options are limited. However, recent studies have shown that combining surgical resection and postoperative chemotherapy can offer promising outcomes for patients with localized intestinal DLBCL . The suret al. [The prognosis for PAL varies based on the type and stage of the disease and the patient’s health. Patients with early-stage disease tend to have a better prognosis than those with advanced disease. A retrospective analysis of 116 patients with PAL by Ayub et al.  revealedDespite these promising results, it is essential to note that each patient’s case is unique. Close monitoring and follow-up are essential to address potential complications or recurrences  promptlyLymphoma of the appendix is a rare type of cancer that requires prompt diagnosis and treatment. Patients should seek medical attention if they experience symptoms and undergo regular medical check-ups to monitor their health and catch any potential issues early.None declared.Informed consent was obtained from the patient to be included in the study.


Mesenteric cysts are detected in all age groups with almost equal incidence in both genders. Although a rare abdominal growth, it is commonly found in the fifth to seventh decades of life. These are mostly small (asymptomatic) with a 3% chance of malignant transformation. With the increase in the size of the cyst, nonspecific complaints of abdominal pain, distention, discomfort, nausea, vomiting, flatulence, constipation, or diarrhea may develop. Owing to the varied presentation and lack of pathognomonic clinical, laboratory, or imaging findings, these are difficult to diagnose. The subtype mesenteric pseudocyst is even rarer with a reported incidence of less than 1 out of 250,000 hospital admissions and can be found anywhere along the mesentery from the duodenum to the rectum. Etiology is either traumatic or infectious. Incidental diagnosis during abdominal imaging or laparotomy is common. However, it warrants immediate surgical intervention when infected or ruptured. Complete excision of the cyst is the treatment of choice. Here, we report an interesting case of a middle-aged gentleman who had been repeatedly evaluated for a tense abdomen with exudative ascites. Following decompression, he presented to us with a large obliquely mobile mass in the abdomen. The diagnosis was made by clinical and radiological findings and confirmed by histopathological examination of the intact, excised specimen post-laparotomy. Mesenteric pseudocysts are rare abdominal tumors that can arise from mesenteric tissues. They are typically benign, fluid-filled cysts that can cause abdominal pain, nausea, vomiting, and other nonspecific abdominal symptoms . The diaSurgical excision is the preferred treatment for mesenteric pseudocysts, but the optimal approach to surgery remains controversial. There are various techniques for cyst excision, including partial or complete cystectomy, marsupialization, and simple drainage. Laparoscopic methods are recently better accepted than laparotomy . HoweverAlthough the pseudocyst by definition lacks a true wall, which makes intact excision practically impossible, we report a case of mesenteric pseudocyst where intact removal could be achieved.A 52-year-old gentleman, a resident of Gorakhpur, Uttar Pradesh, presented to the surgery outpatient department with a complaint of low-grade intermittent fever and a gradually increasing abdominal distention for the past nine months. The fever was insidious in onset and relieved after taking oral medications. The patient also reported a cough for two weeks initially, nine months ago. He had been receiving empirical treatment for abdominal tuberculosis for the past nine months and was on anti-tubercular therapy (ATT).On examination, his general physical examination was unremarkable. The abdomen was distended, and a 15x12 cm mass was palpable in the umbilical, right lumbar, and iliac fossa region , and peritoneal hydatid cyst.The routine blood tests were normal. The imaging studies, including contrast-enhanced computed tomography (CECT) whole abdomen Figure , showed The patient was given the albendazole regimen for hydatid disease and planned for surgery. He underwent exploratory laparotomy with all due precautions for intra-op spillage and anaphylaxis. An intact excision of the cyst was performed, which was arising from the terminal ileal mesentery with the least disruption of other intra-abdominal contents as shown in Figure The specimen measured 15 cm x 12 cm Figure  and weigThe histopathology showed a collagenous cyst wall infiltrated by a few lymphocytes with the presence of hemosiderin-laden histocytes in the luminal surface of the cyst wall Figure . The cysA mesenteric cyst is a rare type of abdominal cyst that arises from the mesentery, a fold of the peritoneum that attaches the intestines to the back of the abdominal wall. These cysts can be classified as true cysts or pseudocysts based on their histological features . True mePseudocysts are thought to arise from a variety of etiologies, including trauma, inflammation, and pancreatitis. Pancreatic pseudocysts are well-known complications of acute or chronic pancreatitis, which result from pancreatic duct disruption with the accumulation of pancreatic juice in the peripancreatic space. Over time, the fluid within the pseudocyst can become encapsulated by a fibrous wall, creating a pseudocyst .Mesenteric pseudocysts, on the other hand, are a relatively rare condition, and their etiology is not entirely clear. Some case reports suggest that mesenteric pseudocysts may arise from trauma while others suggest they may be caused by inflammatory or neoplastic processes. A case report by Micković S et al. (2014) described a mesenteric pseudocyst in a patient with a history of abdominal trauma .The diagnosis of mesenteric pseudocysts is challenging, as they may be asymptomatic and reported incidentally on imaging studies. The symptoms, when occur, include abdominal pain, nausea, vomiting, and bowel obstruction . ConditiThe management of mesenteric pseudocysts depends on the size and location of the cyst, as well as the presence or absence of symptoms. Small, asymptomatic cysts may be monitored with periodic imaging studies while larger or symptomatic cysts require surgery. Cyst rupture, torsion, or hemorrhage requires urgent intervention. Complete surgical excision is the gold standard treatment for mesenteric cysts and pseudocysts . The patIn our case, preoperatively, we were in a diagnostic dilemma with both a peritoneal hydatid cyst and a mesenteric cyst in consideration in a middle-aged gentleman. Optimizing the safety of our patient, we opted for a laparotomy incision in view of minimizing spillage and achieving intact excision of the cyst. Better mobilization of the cyst and meticulous adhesiolysis helped our objective with the open technique. The postoperative diagnosis was of a mesenteric pseudocyst. Echinococcus IgG could be falsely elevated in cases of past hydatid infection or due to other helminthic infections, which probably happened in this case .However, laparoscopic excision is the preferred surgical approach, as shown by Kurnicki J et al. 2011) and Bhandarwar AH et al. (2013) ,10. Bhul and BhanThis case highlights the importance of considering mesenteric pseudocysts in the differential diagnosis of abdominal masses and optimizing the surgical approach on a case-to-case basis. The definitive treatment of mesenteric pseudocysts is surgical excision, which was successfully performed in this case. The prognosis is generally good, with a low risk of recurrence, if the cyst is completely removed.


Wait and see is considered a reasonable option, but the diagnosis should be certain. Diagnosis can be based on morphological and cytological data, but the sensitivity of the fine needle aspiration cytology (FNAC) is not absolute, with a high rate of non-diagnostic findings in the event of a Warthin tumor, hindering the counseling and therapeutic decisions. The aim of the study is to evaluate the reliability of FNAC and its combination with anamnestic, clinical, and ultrasonographic data in diagnosing Warthin tumors. (2) Methods: A total of 413 patients affected by masses within the major salivary gland and managed between 2017 and 2022 at our institution have been included in the present retrospective study. Each patient underwent fine needle aspiration biopsy (FNAB) with a subsequent cytological diagnosis; successively, for each patient, the clinician (otolaryngologist) and the histopathologist discussed the combination of cytological (even non-diagnostic), clinical, and ultrasonographic data in order to make a “multiparametric” diagnosis. A total of 214 cases were subsequently submitted to surgical resection and had a final histopathology report, to which the cytological and the multiparametric diagnoses can be compared. We extracted all the patients with a cytological, multiparametric, and/or histological diagnosis of Warthin tumors in order to assess the sensitivity and specificity of FNAC and of multiparametric analysis in diagnosing Warthin tumors in case of a major salivary gland mass. (3) Results: One hundred thirty-two cases had a cytological, multiparametric, and/or histological diagnosis of Warthin tumors. FNAC displays a sensitivity of 68.4% and a specificity of 98.7% in diagnosing Warthin tumors. The multiparametric evaluation allowed a considerable improvement in sensitivity (92.9% vs. 68.4%), minimizing the number of non-diagnostic results and preserving at the same time a similar value of specificity (95.5% vs. 98.7%). Notably, none of the patients with a cytological or multiparametric diagnosis of Warthin were affected by a malignant lesion in the final histopathological report. (4) Conclusions: In the case of Warthin tumors, a multiparametric evaluation encompassing anamnestic, clinical, and cytological data is effective in reducing the number of non-diagnostic reports and can safely guide the management of a tumor  which is absolutely benign and can be associated with no clinically relevant issues. A huge variety of neoplastic and non-neoplastic swellings can be detected within the major salivary glands in humans. Salivary gland tumors (SGTs) are the most common primary neoplasms in these areas, with a wide range of histopathological subtypes that account for approximately 2 to 3% of all tumors of the head and neck region . Most SGSmoking, obesity, metabolic syndromes, and HIV infection are known risk factors for WTs . An incrMagnetic resonance imaging (MRI) is considered by some authors the imaging modality of choice in patients with salivary gland neoplasms, and the presence of certain imaging findings at routine contrast-enhanced MRI may help to differentiate between malignant and benign salivary tumors. However, the imaging findings are often nonspecific . DiffusiCytological evaluation of samples obtained by fine needle aspiration biopsy (FNAB) is a well-established and reliable tool in the diagnostic work-up of head and neck masses without an obvious origin from mucous and/or cutaneous surface, with very low morbidity and no significant risk of tumor seeding ,23. It iWe evaluated an institutional database including all patients that underwent a FNAB of head and neck lesions at the Lump Clinic of the Otolaryngology Division of the University Hospital of Sassari, Italy, from September 2017 to December 2022. The study has been conducted according to the principles of the Declaration of Helsinki. Data were analyzed with an observational retrospective design, and in this case, mandatory ethical approval is not requested by Italian law .Before each FNAB procedure, all previous relevant clinical documentation , the clinical history, and the other relevant information are routinely recorded: time of onset; growth pattern; initial signs and symptoms; personal history of neoplasms or infectious/inflammatory systemic diseases; family history of neoplastic diseases; other clinical conditions; history of smoking habit or alcohol consumption; current medication list. Anamnestic data collection was followed by a physical examination and neck ultrasonography (US) by a Nemio SSA-550A echograph  until January 2021 and then by an Acuson NX3 Elite  coupled with a 12 MHz 30 mm linear probe. The physical examination always included inspection and palpation of the neck surface (including the skin) and the assessment of the characteristics of the neck mass, including approximative location, size, shape, mobility, consistency (soft vs. firm), and ulceration of overlying skin. Upper airway endoscopy and palpation of the mucosal surfaces were also performed as needed and indicated. The ultrasonographic parameters of the lesions routinely recorded included: side of the lesion; anatomical region ; site ; largest diameter/s; overall echogenicity ; contour ; margins (well-/ill-defined); texture ; cystic component ; distal phenomena (posterior acoustic enhancement or shadowing); vascularity ; sonographic palpation (compressible or not); and presumable possible origin.A team of otolaryngologists and histopathologists performed all the FNA procedures as previously described . In brieFor the aim of the present work, we selectively analyzed cases with a cytological, multiparametric, and/or histological diagnosis of WTs in order to assess the reliability of the two assays in diagnosing WTs by computing their specificity and sensitivity. Statistical analysis was performed using JMP software, release 7.0.1, from the SAS Institute.Data collection from our database retrieved a total of 633 FNAB reports. A total of 413/633 (65.2%) FNAB were performed on major salivary gland lesions. In 128 out of 413 (31%) FNAB on major salivary glands, the multiparametric analysis suggested a diagnosis of WT, while 92/413 (22.2%) cytology reports were consistent with WTs. In 214/413 (51.8%) major salivary gland cases, surgery was performed, and a definitive histological report was available. Among 214 histopathology reports, 57 (26.6%) were consistent with a diagnosis of WT, while 41 FNAB (19.16%) and 60 multiparametric analyses (28%) were positive in the same subgroup. Contingency tables showing the results of FNACs and multiparametric analysis compared to histology reports are shown in Therefore, the negative predictive value (NPV) was noticeably improved with multiparametric analysis compared to that of cytology alone (97.4% vs. 89.6%), while the positive predictive value (PPV) was worse with multiparametric (88.3% vs. 95.1%), mainly because of the increased number of false positive results (seven vs. two cases). Nevertheless, none of these patients had a final diagnosis of malignancy . Diagnostic accuracy was 90.6% for FNAB cytology and 94.9% for multiparametric analysis.Overall, WT cases suggested by FNAC, multiparametric analysis, or histopathology were 132, and 64 of these (48.5%) had a histologic specimen coming from surgical treatment, consistent with WTs in 57 cases .The main US features of these 132 cases are reported in p = 0.1 at t-test), and the operated lesions were significantly larger than the non-operated ones according to the US performed by the surgeon before the FNAB . Most of the tumors  were located within the superficial lobe of the parotid gland, except two (1.5%) located within the submandibular gland.In total, 92/132 (69.7%) of these cases had a cytology report consistent with WTs, while 128/132 (97%) were consistent with WTs, according to the multiparametric analysis. Complete FNAB and multiparametric analysis results for these cases are shown in Growth, usually above 2 cm, as smaller lesions are clinically barely detectable also because of their soft consistency;Recurrent infections, usually associated with an enlargement of the mass . In someOccasional finding  after a head and neck region imaging , often fWTs are benign lesions with a negligible rate of malignant transformation. The reasons why they are first noticed as neck masses and studied according to international guidelines ,25,26 arResection of these lesions has a lower priority than most of the other neoplasms arising within major salivary glands, and active surveillance would be a valuable option under certain conditions. Among such conditions, there is an elderly age, a low performance status, comorbidities, substantial absence of growth, no clear acute infections, no cosmetic relevance, patient preference, but most of all, a reliable diagnosis of WTs. Conversely, relevant tumor growth, clinical problems, and above all, an uncertain diagnosis are clear surgical indications .In the present series, none of the lesions diagnosed as a WT at FNAB or multiparametric diagnosis turned out to be malignant, thus supporting the described diagnostic approach, which appears safe.Out of the 132 lesions with a diagnosis of WT, 68  were not surgically treated in the present series, with a considerable reduction in morbidity mainly allowed by a reliable diagnosis. Notably, the non-operated patients were older, and the non-resected lesions were significantly smaller, consistently with the above-cited criteria considered when defining the recommendation.However, a non-diagnostic result, as it was in 25% of the cytopathology reports of the non-operated lesions, would not have allowed to safely recommend active surveillance with avoidance of surgery, and consequent risks, morbidities, and costs. In these cases, our multiparametric approach has proven to be very useful. Multiparametric diagnosis is ultimately a consensus between the cytopathologist and surgeon based upon the combination of cytological findings, non-diagnostic ones in particular, and clinical and ultrasonographic parameters. Cytological findings in the smear not pathognomonic but compatible with WTs are abundant histiocytes and/or neutrophils and/or the presence of normal lymphocytes . AnotherIn the present analysis, we decided to group the non-diagnostic reports together with the negative ones, as in both cases, there was not a cytological diagnosis of WT, with the aim to obtain a realistic estimate of the diagnostic power. With this premise, our board, evaluating clinical, cytological, and US data, performed better than FNAC alone, reaching a specificity and sensitivity, respectively, of 95.5% and 92.9% as compared to FNAC’s 98.7% and 68.4%. Notably, other authors reported issues concerning the sensitivity of FNAC in the diagnosis of WTs, with figures often below 70%, even when non-diagnostic reports were not considered in the estimate ,32,33,34Although benign, WTs represent a challenge for the surgeon and for the patient, inherently and precisely because of their benign nature and the undesirable potential complications resulting from an unnecessary sialoadenectomy. While one could be tempted to rely on FNAB’s results alone or prevalently to characterize the lesion and counsel the patient, such an attitude could lead to a certain amount of misdiagnosed WTs and sometimes to unnecessary surgical treatments. Our approach, albeit still simple and not organized in an objective score, is able to correctly identify WTs as such even when the FNAB misses the diagnosis, leading to more precise and efficient counseling to the patients, especially those unwilling or not fit for a surgical treatment.


Brain metastasis from Ewing sarcoma is rare and can present with various symptoms. We present a 21-year-old female who underwent surgery for Ewing sarcoma of the knee joint and, after six months, was reported with complaints of headache and vomiting. Considering recommended investigations, metastatic Ewing sarcoma of the brain was diagnosed, and a treatment protocol, such as a combination of surgery, chemotherapy, and radiation, was given. Our observation shows this is the first case reported with a solitary metastatic brain lesion associated with Ewing sarcoma. Ewing sarcoma is an aggressive malignancy that affects bones and soft tissue, with a higher incidence in young adults and children. It is usually found in the diaphysis of long bones of the arms and legs but can also occur in the spine, pelvis, chest wall, ribs, and skull. It usually spreads to the lungs and other bones and rarely metastasizes to the brain. Metastatic brain tumor associated with Ewing sarcoma is rare. A few cases have been studied in the existing literature . The mosWe present a 21-year-old female who complained of difficulty walking and swelling on the medial side left knee for two months. Her left knee joint examination revealed a limited range of motion. On investigation, the hematological profile, renal function test, and liver function test were within normal limits. The abdominal ultrasound report, however, showed two inguinal lymph nodes. The X-ray and magnetic resonance imaging report revealed well-defined lobulated approximately measuring 7 x 10 cm mixed intensity mass in the medial compartment of the left distal thigh with mild perilesional edema, while tissue biopsy from the left knee joint showed grossly necrotic and hemorrhagic areas and histologically malignant small round blue cells with the possibility of Ewing sarcoma of the left knee joint. The diagnosis was further confirmed by immunohistochemistry. The tumor was positive for cluster of differentiation 99 (CD99) and transducer-like enhancer of split 1 (TLE1). The post-surgery patient commenced chemotherapy with six cycles of the VAC regime  and 30 sessions of Cobalt-60 external beam radiation therapy and was kept on follow-up. After six months, the patient was hospitalized with complaints of severe headaches and multiple episodes of vomiting for one month. On examination, she was alert and conscious. Her vital signs were within normal limits. Her neurological examination exhibited left-sided weakness; however, cranial and sensory findings were normal. Her vital signs showed that her temperature was 98.8 F, pulse rate was 80 per minute, respiratory rate was 16 per minute, blood pressure was 110/90, and body mass index was 18. While her pupils were reactive to light, Babinski's sign was positive, and her Glasgow Coma Scale (GCS) score was 15/15. However, there were no findings on other systematic examinations. Brain magnetic resonance imaging with intravenous Gadolinium contrast in axial view showed ring enhancing hyperdense mass lesion in the right frontal lobe associated with significant perilesional edema causing mass effect on adjacent brain parenchyma, and frontal horn and body horn of ipsilateral lateral ventricle, and midline shift   is found in more than 90% of Ewing sarcomas, resulting in the formation of the EWSR1-FLI1 fusion gene (Ewing sarcoma breakpoint region1-Friend Leukemia integration 1 transcription factor), and its detection helps in confirming the diagnosis [2 (q24; qEwing sarcoma spreads to other body parts, such as the lungs, bones, and lymph nodes. Ewing sarcoma is most likely prone to metastasis from its primary site due to several risk factors, such as larger tumor size, advanced age, specific genetic mutations, certain treatments such as radiation therapy, and specific locations of the body such as the chest or abdomen. However, metastases to the central nervous system have most recently been estimated to occur in less than 5% of cases . They arTreatment of metastatic Ewing sarcoma of the brain depends on several factors. The treatment options available for patients with CNS-EES are similar to those for EES elsewhere in the body. For localized Ewing sarcoma, multiagent chemotherapy regimens, including cyclophosphamide, ifosfamide, doxorubicin, dactinomycin, and etoposide, have been proven to be effective. However, multimodality treatment, including surgery, chemotherapy, and radiation, is utilized for metastatic tumors . The diaThe treatment plan for metastatic brain Ewing sarcoma includes surgery followed by chemotherapy and radiation. Also, it involves collaborating with a multidisciplinary team of specialists to determine the best course of action according to the patient's needs. As in our case, a surgical treatment plan via a modified coronal approach was utilized after a common consensus among a multidisciplinary team of specialists. This surgical approach is well suited for the tumor located in the frontal and parietal lobes of the brain. Other surgical treatment approaches, such as craniotomy and endoscopic and stereotactic surgery, could be considered for metastatic brain tumors . These sThis case report is crucial for neurosurgeons and oncologists in terms of the fact that metastatic Ewing sarcoma of the brain should be taken into account as one of the differential diagnoses of a brain tumor with its varying presentation from single to multiple lesions so that earlier identification of the tumor based on its specific confirmatory investigation such as immunohistochemistry and histopathological examination can be made. The required treatment modality could be utilized. In addition, it is also encouraged that more research on this rare metastatic brain tumor is needed for a better understanding of these tumors in terms of diagnosis and treatment protocols.The presence of a metastatic brain tumor secondary to a knee joint Ewing sarcoma is concerning and requires prompt medical attention. Our case report highlights the significance of considering Ewing sarcoma as a potential diagnosis in patients with a history of bone cancer who present with neurological symptoms. Early diagnosis and prompt treatment are critical for improving outcomes in this rare and aggressive malignancy.


Actinomycosis is caused by actinomyces israelii, a gram positive nonacid fast, anaerobic, commensal bacterium within the oral cavity. Though it is a commensal in oral cavity, it seldom presents as cervicofacial actinomycosis. But there is limited access to literature proving cervicofacial actinomycosis existence so far. We report a case of 35 year old gentleman who presented with painless progressive neck swelling associated with pain while chewing food. On examination, 3.5*2.5 swelling was noted in right submandibular gland area, radiologically a foreign body was detected in the right submandibular gland. Mass was excised in toto and sent for HPE which revealed submandibular gland actinomycosis. Post operatively, patient was managed with long-term broad-spectrum beta lactams and was on regular follow-up. No evidence of recurrence/ fresh complaints noted till date. Although cervicofacial actinomycosis is rare and dangerous with debilitating complications, timely diagnosis and early intervention with broad spectrum antibiotics and surgical excision (if required) shows promising results with complete eradication of disease leaving no residues.The online version contains supplementary material available at 10.1007/s12070-023-03498-7. Actinomycosis is caused by actinomyces Israeli, a gram-positive nonacid fast, anaerobic, commensal bacterium within the oral cavity . It is nA 35-year-old well-built gentleman presented to us with complaints of painless progressive swelling on the right side of neck for 1.5 months. He also had complaints of pain while chewing food for 15 days with no h/o difficulty in swallowing/hoarseness of voice/weight loss. Patient consulted local hospital for similar complaints one month back. An ultrasonography of neck was performed which revealed a foreign body within right submandibular gland as shown in Fig. Actinomycosis is an opportunistic infection of oral cavity most common sites being tonsils & carious teeth. Three major areas where actinomycosis can occur are Cervicofacial, Pulmonary and Gastrointestinal. Cervicofacial actinomycosis has been reported quite a few times in literature , howeverInjury to healthy tissue has been mentioned as one of the predisposing factors for this rare condition to occur which was also seen in our case. Usually, actinomycosis cases present with discharging sinuses, hyperemia, febrile, tender mass . To our Radiologically ultrasound fails to differentiate it from malignancy. However, contrast enhanced CT might help us bring close to diagnosis . This diThe characteristic finding of this infection is presence of ‘Sulphur granules’ from the aspirate. Patients usually present with abscess leading to discharging sinuses and fistulas. Although cervicofacial actinomycosis is infrequent, it is always ideal to rule this out from other pathologies like malignant or benign tumors to various granulomatous and mycotic infections .The interesting aspect we noticed was the presence of a foreign body (grass root) within the gland substance on ultrasonography, which the patient had used frequently before for tooth cleaning. The patient presented with symptoms of swelling post injury. A possible explanation for its occurrence could be that the root of grass accidentally injured the mucosa of floor of mouth and gained its entry via the duct into the gland substance cultivating later into a florid suppuration. Foreign body induced reaction and suppuration with actinomycosis is itself an extremely rare phenomenon in submandibular region and has not been reported till date.Medical management includes penicillin as treatment of choice , 5 for aBone permeation has also been noted in few cases  and is aActinomycosis of submandibular gland is an extremely rare disease and often forms a diagnosis of exclusion. The unusual presentation as seen in our case creates a diagnostic dilemma and leads to treatment delay. Although cervicofacial actinomycosis is rare, dangerous with debilitating complications, thus early diagnosis and prompt treatment with surgical excision followed by long course of broad-spectrum antibiotics shows promising results with complete eradication of disease leaving no residues.Below is the link to the electronic supplementary material.Supplementary Material 1


Shoulder pain is a common complaint seen in the orthopedic clinic. Here, we report a rare case of primary extranodal ileocecal with exceedingly rare right shoulder deltoid non-Hodgkin’s lymphoma (NHL). A 67-year-old female presented with abdominal swelling for four months associated with loss of appetite, loss of weight, and night sweats. Abdominal contrast-enhanced CT and cecal biopsy confirmed the diagnosis of ileocecal NHL. A right hemicolectomy was performed, and the patient completed six cycles of chemotherapy. The patient developed right shoulder pain with swelling three months later and was diagnosed with a relapse ileocecal lymphoma with dissemination to the right deltoid muscle after a repeat positron emission tomography scan. Clinicians need to consider NHL as a differential diagnosis in evaluating shoulder pain or swelling even though it is exceedingly rare. A partial or non-response to chemotherapy with dissemination to skeletal muscle carries a poor prognosis. Shoulder pain is a common complaint in elderly patients presenting to the orthopedic clinic. They commonly present with shoulder impingement, rotator cuff tendinopathy or tear, frozen shoulder, or glenohumeral osteoarthritis. Here, we report a rare case of primary extranodal ileocecal with rare right shoulder deltoid non-Hodgkin’s lymphoma (NHL).A 67-year-old female with a history of type 2 diabetes mellitus on oral metformin 500 mg daily presented with right lower quadrant abdominal swelling for four months associated with loss of appetite, loss of weight of 10 kg, and night sweats. Abdominal contrast-enhanced CT was performed which showed a massive right-sided bowel mass involving the cecum and ascending colon with necrotic mesenteric, para-aortic, and aortocaval lymphadenopathy with local infiltration. Colonoscopy was performed and a cecal biopsy showed a high-grade diffuse large B-cell lymphoma (DLBCL) of the cecum. Bone marrow trephine biopsy showed no evidence of infiltration by the primary disease. A right hemicolectomy was done because of suspected intestinal obstruction and the patient completed six cycles of R-CHOP  chemotherapy. A positron emission tomography (PET) scan was performed subsequently Figures , 2A. ThrLymphoma is a liquid malignant tumor that arises from lymphocytes and is classified as either Hodgkin’s lymphoma or NHL. NHL commonly involves the gastrointestinal tract, Waldeyer’s ring, skin, lung, bone, and the central nervous system. Gastrointestinal NHL accounts for 4-12% of all NHLs [Our patient was at the modified Ann Arbor stage IIE2, Paris TNMB system T2, N1, M0, B0, and Lugano stage 2B based on the abdominal contrast-enhanced CT and cecal biopsy. Post-chemotherapy PET scan showed disease progression with evidence of active lymphoma in the cecum, abdomen, and pelvic nodes but the patient chose to watch and wait as she was clinically asymptomatic.Auger et al. reported a longer survival for patients entering complete remission than those who had a partial or no response with a survival of 34 months versus four months . Three mSamuel et al. reported that the presenting history is short, usually of limb swelling developing rapidly over a few weeks . This coHistologically, diffuse large cell NHL is the most common histological subtype for extranodal lymphoma affecting the skeletal muscle . A PET sA PET scan is usually performed for staging purposes as well as to monitor response to chemotherapy. Although a PET scan cannot establish the diagnosis, it is a useful adjunctive tool. In our case, the patient had a pre-existing ileocecal lymphoma, therefore, chemotherapy was immediately started for the relapse and skeletal muscle lymphoma after the repeat PET scan. We did not perform a tissue biopsy for the deltoid muscle as the patient had a relapse and the treatment would not differ for both the relapse and the skeletal muscle lymphoma.This case report highlights the need for clinicians to consider secondary skeletal muscle NHL as a differential diagnosis while evaluating shoulder pain or swelling even though it is rare. A partial or non-response to chemotherapy with distant metastasis in the elderly will lead to a poorer prognosis.


We report the clinicopathological characteristics, immunohistochemical features, ultrastructure, tissue source, differential diagnosis, treatment, and prognosis of a patient with a uterine tumor resembling ovarian sex-cord tumor (UTROSCT).A 40-year-old woman had a uterine myoma with enlargement for 2.5 years. An ultrasound examination showed a mixed echogenic mass at the posterior wall of the uterus and a dark cyst in the right adnexal area, which suggested a suspected uterine myoma with liquefaction and a suspected chocolate cyst. The patient underwent transabdominal tumor resection with removal of the right adnexal mass. Through postoperative pathological examination, the patient was diagnosed with UTROSCT. No recurrence was observed after a follow-up of 1 year.Although UTROSCT is usually benign, it can relapse or metastasize, and patients with UTROSCT need comprehensive diagnosis and treatment. Uterine tumor resembling ovarian sex-cord tumor (UTROSCT) is an extremely rare gynecological tumor with low malignant potential. To our knowledge, Clement and Scully  in 1976 A 40-year-old woman underwent a physical examination at our hospital in October 2019, and the gynecological ultrasound examination suggested a right adnexal mass (5.9 cm diameter) and uterine myoma (5.8 cm diameter) with partial liquefaction. She did not have abnormal symptoms, such as hypermenorrhea or a history of abnormal uterine bleeding, and denied a previous medical history of gynecological diseases, family history of malignancy, or history of hereditary syndromes or disorders.Figure 1). A pelvic magnetic resonance imaging examination suggested a suspected myoma cyst with malignant potential in the uterus and a suspected cystadenoma in the right adnexal area .No regular ultrasound reexamination was performed until April 2021, and the results showed an enlarged and morphologically abnormal uterus, a mixed uneven echogenic mass at the posterior wall of the uterus , and a dark cyst (109 mm × 93 mm) in the right adnexal area with dense punctate echo, suggesting suspected uterine myoma with liquefaction and a suspected chocolate cyst. Abdominal computed tomography showed lesions in the pelvis and uterus . Immunohistochemical results  showed calretinin  (−), CD10 (2+), CD117 (−), CD34 (blood vessel+), CD99 (3+), D2-40 (M2A antigen) (lymph vessel+), desmin (3+), estrogen receptor (ER) (3+), Ki67  (15%+), progesterone receptor (PR) (3+) α smooth muscle actin (α-SMA) also known as actin α-2 (ACTA2) (3+), α-inhibin (−), and cytokeratin (−). A differential diagnosis suggested UTROSCT or uterine leiomyoma, which needed to be confirmed through immunohistochemistry and molecular pathology results. Pathological sections were sent to a higher level hospital, and the results showed a mesenchymal tumor in the uterus, the morphological and immunohistochemical features of which were consistent with those of UTROSCT. Immunohistochemical reports from that hospital showed caldesmon (−), CD10 (−) , cyclin D1 (−) , FOXL2 (+) , and a-inhibin (−) . Additionally, a molecular pathological examination did not detect breakpoints in JAZF1 (7p15) or NCOA2. The patient was discharged, and subsequent follow-up showed no abnormal symptoms or disease recurrence for at least 1 year after surgery. The present report was approved by the Scientific and Ethical Committee of Nanjing Lishui People's Hospital. Documented informed consent was obtained from the patient for publication of this case report and any accompanying images on a specified patient privacy and confidentiality form. This case report was prepared following the CARE Guidelines [Total hysterectomy and right adnexectomy were discussed based on the pathological conditions and examination results. However, the patient had a fertility requirement, and; therefore, was treated by transabdominal tumor total resection with the removal of the right adnexal mass 1 month later. The tumor was located at the left fundus of the uterus, with no clear boundaries. A little yellow liquid flowed during the resection of the tumor. No. 1 absorbable sutures were used for the interrupted suture of the uterus. The postoperative pathological examination suggested an endometrioid cyst in the right ovary, a uterine stroma–originated tumor with cystic degeneration, and negative margins of the resected specimens , and FOXL2 . The posNCOA2/3 fusion is a characteristic of UTROSCT [ESR1-NCOA3 fusion gene and the other 2 had ESR1-NCOA2 and GREB1-NCOA2 fusion genes. Some studies have also detected other gene fusions in cases of UTROSCT, such as the GREB1-NCOA1 and GREB1-CTNNB1 fusion genes [NCOA1-3 fusion genes [NCOA encodes a series of nuclear hormone receptor coactivators like NCOA1-3, which stimulates transcription in a hormone-dependent manner after binding to nuclear receptors. Their hormone-dependent uterine function and dysfunction have been validated in a mouse model of p160/steroid receptor coactivator (SRC) expression and endometrial biology and pathobiology [The molecular pathogenesis of UTROSCT remains unclear. Studies have shown that  UTROSCT , 15, seron genes . UTROSCTon genes . NCOA enobiology . Severalobiology .While total hysterectomy with bilateral adnexectomy is the most common treatment for UTROSCT, the treatment needed should be considered specifically on a case-by-case basis, because age and fertility requirements play an important role in determining whether these surgeries are appropriate. Zhang et al.  had repoUTROSCT is a very rare gynecological tumor. The diagnosis and differential diagnosis of UTROSCT rely mainly on pathological examinations. Therefore, it is necessary to investigate further the histological characteristics, immunophenotypes, and long-term biological behaviors of UTROSCT to improve our understanding of this rare tumor.


Objective In this report we present a rare case of a large cyst of Skene gland in a female patient with a palpable vaginal mass persisting for at least 2 years.Case Report A 67-year-old female admitted to the department of urology due to the presence of “a vaginal mass” for the past 2 years. A cyst of Skene's duct was suspected based on clinical manifestation and findings of magnetic resonance imaging showing an extensive cyst formation in the upper vaginal area and anterior to the urethra. Based on these findings, a decision for surgical removement of the cyst was made. The cyst was incised, drained, and marsupialized. The postoperative recovery was uneventful, and the patient was discharged on the second postoperative day.Conclusion High clinical suspicion is important to reach this rare diagnosis. Partial excision and marsupialization of the cyst is a simple procedure with low morbidity, without recurrence, and excellent results. Dutch histologist Reinier de Graaf was the first to describe the presence of the female prostate formed by the glands and ducts located around the female urethra.These glands are homologous to the male prostate that are developed from the same embryological tissues, being associated with various pathologies.Infections, cystic and solid, benign, or malignant tumors are typical disorders of these glands.In the present report, we aim to present an interesting case of a female patient with a large and symptomatic Skene's gland cyst, underlining the importance of high clinical suspicion to reach the rare diagnosis and present the current literature.A 67-year-old female admitted to the department of urology due to the presence of “a vaginal mass” for the past 2 years. Her symptoms included dyspareunia, frequency and urgency of urination, interruption, and distortion of urinary flow as well as episodes of vaginal bleeding. Her past medical history was insignificant.On vaginal examination, a cystic mass of 5 cm in diameter with ulceration covering the urethral meatus was observed . A cystBased on these findings, a decision for surgical removement of the cyst was made. The cyst was incised, drained, and marsupialized with interrupted 4–0 Vicryl sutures. The excised tissue was sent for histological examination while the posterior wall of the cyst remained in place avoiding the complete excision of the cyst to minimize the risk of urethral lesions. The postoperative recovery was uneventful, and the patient was discharged on the second postoperative day.The histopathology examination confirmed the diagnosis by reporting a cyst covered with stratified squamous epithelium. Patient remained asymptomatic, with no signs of recurrence during the next 6 months.Most common pathologies associated with Skene's glands are infections, such as gonorrhea, tuberculosis, and trichomoniasis, and can be present both in the glands and other parts of the reproductive system.Obstruction of the ducts of these glands leads to the formation of cysts that present as benign cystic masses inferolateral to the urethral meatus, typically affecting in women in the third or fourth decade of their life.According to Lucioni et al, Skene's gland is thought to be the female homologue of the male prostate.Since Skene's ducts arise from the urogenital sinus, these cysts are usually lined with stratified squamous epithelium.The history, physical examination, and urethrocystoscopy are often sufficient to set the diagnosis of the simple cyst or Skene's gland abscess. Transperineal ultrasound and MRI can be useful tools for a more detailed examination with the use of MRI as the gold standard examination of female urethra.21in a case series of 25 patients, found no recurrence of Skene's gland cysts after partial excision with marsupialization.When conservative treatments fail, surgical options include needle aspiration, partial excision, marsupialization, or complete excision of the cyst.Large Skene's cysts are very rare benign lesions. History, clinical examination, and endoscopy are often sufficient for a definitive diagnosis. High clinical suspicion is important to reach this rare diagnosis. Partial excision and marsupialization of the cyst is a simple procedure with low morbidity, no recurrence, and excellent results.


Renal cell cancer (RCC) is at times associated with intravascular tumour thrombus (TT), which in rare cases can extend to the right atrium. The management of RCC with intravascular tumour thrombus is complex and requires a multidisciplinary approach involving urologists, vascular surgeons, and cardiologists. The pre-operative workup is extensive and includes imaging studies to determine the extent of the tumour thrombus and assess the patient's overall health status. Here, we present a case report detailing the operative and perioperative management of a patient presenting with renal cell cancer and intravascular TT. In Australia, renal cell cancer is the seventh most diagnosed cancer, with an estimated 4552 new cases expected in 2020. The incidence rate of renal cancer in Australia is relatively low compared to other types of cancer, with around 15 new cases diagnosed per 100,000 people each year. The majority of renal cancers are diagnosed in people around the age of 70-74 years, and they are more common in men than in women .A 55-year-old female with a background history of asthma, hypertension and gastroesophageal reflux disease presented to the emergency department at a regional hospital with symptoms of frank haematuria with clots. She had complaints of nausea and lethargy with intermittent right upper quadrant pain for the past few months as well. Examination was unremarkable, with her observations being stable. Abdominal examination revealed a large, non-ballotable mass in the right upper quadrant that was minimally tender. The mass did not have regular borders and appeared to move with respiration. Her blood tests are detailed in Table A computerised tomography (CT) scan of the abdomen revealed a large heterogeneous mass sized 19.1 × 9.7 × 19.6 cm with intrahepatic extension to segments 4b, 6 and 7 as well as perinephric extension Figure . The masThe patient was admitted to our hospital under the urology and cardiothoracic team for observation and further investigations to help with surgical intervention. She underwent an magnetic resonance imaging (MRI) that revealed an invasion of the mass in the hepatic segments V and VI and clarified the vascular anatomy Figure . The TT On her next admission, she was taken to the operating room for an open right radical nephrectomy with IVC thrombectomy and retrieval of atrial thrombus under cardiac bypass, which has been described here.Once the patient was intubated in a supine position, invasive monitoring was placed with an arterial line, a central line, and a transesophageal echocardiogram probe. A midline laparotomy was performed for mobilisation of the mass and exposure of the IVC, which was achieved after the falciform ligament, ascending colon and hepatic flexure were mobilised.The cardiothoracic team then extended the midline laparotomy and entered the chest via a sternotomy. The renal vein and IVC were then isolated and separated from the perinephric tissue. Once the patient was heparinised, the aorta was clamped, and the patient’s core temperature was lowered to 20.5°C, after which cardioplegia was attained. The kidney was then mobilised and excised. The right atrial TT was retrieved via a right atriotomy. Inspection of the caudal IVC showed no obvious thrombus, but a further tumour was palpated at the level of the hepatic veins, which was mobilised digitally and retrieved via the right atrium. There was tumour invading the caval wall and hepatic vein as well, which could not be safely retrieved. There was significant bleeding from the liver bed after the mass was resected, and a hepatobiliary surgeon was consulted intraoperatively with the advice to use deep hepatic parenchymal sutures, packing and haemostatic adjuncts to manage the bleeding. The patient’s abdomen was packed, and an open abdominal vacuum-assisted closure (VAC) dressing was applied. She returned to the operation room two days later after an uneventful stay in the intensive care unit (ICU), where she remained intubated for an uncomplicated abdominal closure.During her recovery on the ICU, she required continuous renal replacement therapy (CRRT) for oliguria and acute kidney injury (AKI), likely due to acute tubular necrosis (ATN) secondary to hypovolemia. She was gradually changed to intermittent haemodialysis (IHD) and started producing urine with an improvement of kidney function, after which her IHD was ceased 18 days postoperatively. She was also diagnosed with extensive bilateral deep vein thrombosis (DVTs), for which she was put on a heparin infusion and discharged home on a daily dose of clexane and a follow-up with haematology in six months. The patient also had to undergo review by speech pathology and ENT for a left vocal cord palsy secondary to intubation. She is due to follow-up with the ENT team in the clinics later next year and to continue with vocal function exercises to aid in swallowing.Her histology was reviewed at our multidisciplinary team (MDT) meeting, which showed clear cell renal cell carcinoma, 220 mm, International Society of Urologic Pathologists (ISUP) Grade 2, pT3b, N0 and the TT showed clear cell renal carcinoma as well. She is due to get a repeat CT scan to assess the residual tumour and will then receive adjuvant radiotherapy as appropriate.Intravenous neoplastic extension of TT has been classified according to the Mayo staging system into four levels namely, level 0 ; level I ; level II ; level III (thrombus extending to the intrahepatic IVC); and level IV (thrombus extends above the diaphragm or into the right atrium) . AlthougIntravascular TT, if completely resected along with a nephrectomy, has been shown to have a survival rate of around 47-62% at five years. This number drastically drops if the tumour has been incompletely resected or is associated with metastatic disease ,6. The lThe best imaging modality for diagnosing a TT has historically been venacavography, but this has recently fallen out of favour due to its inability to demonstrate caval wall invasion and the associated risk of kidney injury due to contrast . UltrasoManagement for renal cell carcinoma with a level IV thrombus involves complete resection of the parenchymal tumour and the TT while preventing tumour embolism and avoiding vital organ ischaemia. Most of the centres use cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) to treat tumours with intracardiac extension ,12. OtheAt present, there is a lack of a universally recognised follow-up strategy and adjuvant therapy that is for patients with renal-cell carcinoma post-surgery that is supported by evidence. Current treatment protocols advocate for patient participation in a clinical trial or the implementation of active surveillance .Surgical intervention is the standard of care for renal cell cancer with intravascular tumour thrombus. Careful surgical planning and expertise are required to manage the tumour thrombus and its associated complications. This case report highlights the need for multidisciplinary management and close monitoring of postoperative complications in patients with complex renal cell cancer.


Mechanical small-bowel obstruction can occur due to various reasons, including the impaction of a gallstone in the ileum after it has passed through a cholecystoenteric fistula. Gallstone ileus is an infrequent yet significant cause of this condition. This case report documents an instance of gallstone ileus, which accounts for less than 1% of patients with mechanical small bowel obstruction. We report a 75-year-old female patient who presented with colicky pain in both upper quadrants, hyporexia, and constipation that worsened during a period of nine days, which subsequently was accompanied by nausea and vomiting of bilious appearance in the next three days. Abdominal CT reported a dilated common bile duct (1.7 cm) with multiple stones inside measuring between 5 and 8 mm associated with pneumobilia of intrahepatic bile ducts and dilatation of small intestinal loops produced by a high-density image of approximately 2.5 cm. Laparoscopic exploration showed an obstructive mass measuring 15 cm from the ileocecal valve corresponding to a 2.54 x 2.35 cm gallstone, which was removed and enterorrhaphy was performed. The sine qua non condition for gallstone ileus to occur is the presence of a fistula between the gallbladder and the gastrointestinal tract. The treatment is mainly surgical and should be aimed primarily at the intestinal obstruction and secondarily at the cholecystoenteric fistula. This condition tends to have a high rate of complications and consequently long hospital stays. Making a timely diagnosis provides us with the tools for a surgical approach aimed at intestinal obstruction and subsequently in the management of the biliary fistula. Mechanical small bowel obstruction can occur due to various reasons, including the impaction of a gallstone in the ileum after it has passed through a cholecystoenteric fistula. It is defined as a mechanical intestinal obstruction due to impaction within the gastrointestinal tract of one or more gallstones. Gallstone ileus occurs in fewer than 0.5% of patients who present with mechanical small bowel obstruction and it is most frequent in elderly patients and females .Since this pathology is associated with relatively high rates of morbidity and mortality, a reflection of the advanced age of the patients, deteriorated clinical conditions, as well as the high incidence of concomitant diseases, an early and accurate diagnosis is very important .In this report, we present a case of a 75-year-old female diagnosed with a bowel obstruction due to a gallstone that passed through a cholecystoenteric fistula. The patient was admitted and operated on in an academic hospital.A 75-year-old Latin female with a morbid history of arterial hypertension, arthritis, cholelithiasis, and obesity came to the emergency room due to colicky abdominal pain of 7/10 on a Numeric Rating Scale (NRS), with 0 being no pain and 10 being the worst pain imaginable. Additionally, she reported hyporexia and constipation that worsened during a period of nine days, which subsequently was accompanied by nausea and vomiting of bilious appearance in the next three days every time she ingested any food. During the initial assessment, the patient reported urinating only once all day, suggesting a decreased urine output and indicating that she was experiencing oliguria. The patient reported being compliant with her medications, which included atenolol, chlorthalidone, aspirin, and celecoxib. The patient denied any recent changes to her medications or diet. On physical examination, the patient looked critically ill, with a depressible abdomen, tenderness on superficial and deep palpation in all the abdomen diffusely, a negative Murphy's sign, no peritoneal irritation, and no masses or visceromegalies. The patient's vital signs were recorded as follows: blood pressure of 130/80 mmHg, heart rate of 78 beats per minute, respiratory rate of 16 breaths per minute, and body temperature of 37.1°C. Oxygen saturation was measured at 100%.The initial laboratory test results were obtained and are presented in Table An abdominal X-ray was done showing dilation of intestinal loops associated with air-fluid levels, absence of distal intracolonic air, and well-defined radiopacity projected in the right hypochondrium Figure .Abdominal CT reported a dilated common bile duct (1.7 cm) with multiple stones inside that measure between 5 and 8 mm associated with pneumobilia of intrahepatic bile ducts. Dilatation of small intestinal loops produced by a high-density image of approximately 2.5 cm, identified in the hypogastrium topography. Also, few diverticula in the ascending and sigmoid colon and free fluid in the pelvic cavity were noted Figures .The patient was admitted by the general surgery department with a diagnosis of intestinal obstruction and surgical treatment was decided. The patient was properly hydrated with 0.9% saline via IV. The surgical approach was by exploratory laparoscopy, finding an obstructive mass 15 cm from the ileocecal valve corresponding to a 2.54 x 2.35 cm gallstone. The surgical technique used in this case involved an initial incision made on the right iliac fossa (RIF), followed by an exploration of the intestinal loops until the obstructive mass was located. Once the mass was identified, a longitudinal incision was made on the segment of the obstruction. The gallstone causing the obstruction was then carefully removed, and the segment was repaired using a technique called enterorrhaphy. This involved suturing the incision made on the bowel segment, thereby restoring the continuity of the intestinal lumen  was performed on the third day after surgery, where choledocholithiasis and an image suggestive of a gallbladder-dependent bilioenteric fistulous tract were observed, and approximately 11 stones were extracted Figure . On the Seven months later, the patient underwent cholecystectomy by laparotomy with the closure of the cholecystoenteric fistula without any complications. The surgical technique involved making a right subcostal incision to access the abdominal cavity. The surgeon carefully evaluated the extent of the fistula and located the site of the cholecystoenteric fistula. The adjacent tissues were then meticulously dissected to expose the opening. The borders of the fistula were trimmed, and the opening was sutured shut with care. The surgeon then proceeded to locate the gallbladder, identified the cystic duct and artery, and dissected them meticulously. The gallbladder was detached from the liver bed with caution to avoid any damage to surrounding structures. The site was checked for any signs of bleeding or leakage before closing the right subcostal incision with sutures. The patient was kept under observation in the recovery room before being transferred to a hospital room for postoperative monitoring. No complications were reported.Gallstone ileus is a rare complication of biliary pathology and occurs in 0.3% to 4% of patients with cholelithiasis . Its preThe sine qua non condition for gallstone ileus to occur is the presence of a fistula between the gallbladder and the gastrointestinal tract . The patIn a 32-year retrospective review of 24 cases, 90% of obstructing stones were greater than 2 cm in diameter, with the majority measuring over 2.5 cm . The minClinical symptoms vary, depending on the site of the obstruction. The most common presenting clinical picture is a mechanical intestinal obstruction with abdominal distention and pain, vomiting, constipation or obstipation, and fluid imbalance. The patient may also have jaundice. In cases of chronic evolution, there will be recurrent episodes of pain caused by the passage of gallstones through the intestine, along with a period of asymptomatic time, reaching complete obstruction in several stages. During the abdominal exploration, signs include distension and increased bowel sounds. Physical examination and laboratory tests do not point to a particular cause of intestinal obstruction. Laboratory studies may show an elevated white blood cell count, which was the case in this patient with a slightly elevated count of 11.5 x 10³U/L, an abnormal liver function test, which was also the case, with elevated levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) of 73 U/L and 75 U/L, respectively [Plain abdominal radiography frequently demonstrates a nonspecific pattern of intestinal obstruction and its diagnostic utility in the identification of gallstones is limited. Ultrasonography is most helpful in demonstrating the impacted stone as well as in confirming residual cholelithiasis or choledocholithiasis. A CT scan can objectify intestinal obstruction by identifying the stone and the level of obstruction, having a sensitivity greater than 90% . Rigler'The treatment is mainly surgical and should be aimed primarily at the intestinal obstruction and secondarily at the cholecystoenteric fistula and may be performed simultaneously or not depending on the patient's condition ,11. InteGallstone ileus is a rare entity that can cause intestinal obstruction mainly in elderly women, with a high rate of complications and consequently long hospital stays. This case report highlights the importance of considering gallstone ileus as a potential diagnosis in patients with a history of cholecystitis and symptoms of bowel obstruction. It also emphasizes the value of utilizing imaging studies to confirm the diagnosis and identify any potential underlying causes. Furthermore, our report underscores the need for timely surgical intervention to prevent complications and improve patient outcomes. Making a timely diagnosis provides us with the tools for a surgical approach aimed at intestinal obstruction and subsequently in the management of the biliary fistula.


Congenital giant orbital tumors in infancy are relatively rare, especially when the tumors are associated with significant intracranial extension. We describe the use of a transorbital neuroendoscopy-assisted resection of such a lesion. While this approach is increasingly gaining popularity for certain anterior and middle skullbase lesions in adults, this report represents the youngest patient reported on where this minimally invasive approach has been successfully used to resect the intracranial tumor. This surgical approach obviated the need for a separate craniotomy, with the additional benefit of minimizing blood loss. Optic pathway glioma (OPG) is a benign low-grade neoplasm of the optic pathway and is the commonest optic nerve tumour comprising 4% of orbital tumours in children . The neoTransorbital neuroendoscopic surgery (TONES) as a novel minimally invasive skullbase surgical corridor was described in 2007 . The benefits of improved visualization and minimally invasive, endoscopy-assisted surgery have made this corridor attractive for selective conditions affecting the anterior and middle skullbase region.This report describes a case of histologically confirmed pilocytic astrocytoma in a neonate which presented to our unit as a giant orbital tumor with intracranial extension and also the unique multi-disciplinary team approach and minimally invasive surgical management of the neonate.A new-born boy was referred to our service with the presentation of marked proptosis of the left eye. Magnetic resonance imaging (MRI) revealed an extensive left orbital mass with intracranial extension. A combined, multidisciplinary team approach, including ophthalmology, pediatric neurosurgery, and interventional radiology contributed to optimizing the clinical and surgical outcome in this patient.The patient was born to a 23-year-old mother with an obstetric history of two previous live births and otherwise no medical history of relevance. The prenatal ultrasound performed at another centre did not apparently reveal any gross abnormalities. A male patient was born at 39-week gestation, delivered by normal vaginal delivery with good Apgar scores and a birth weight of 2.8 kg. On physical examination, a large left eye proptosis was noted at birth, and the patient was then referred to our tertiary level institution for further assessment and management.Following transfer to our hospital, an ophthalmologist examined the patient on day 2 of life where an assessment of massive left eye proptosis secondary to a retrobulbar mass was made. The globe seen anterior to the mass was deformed with complete corneal melt and uveal prolapse Fig. . The proMRI of the head demonstrated a large, well-circumscribed mass in the left orbit Fig. a which eA presurgical computerized tomography (CT) scan was included to better delineate the bony anatomy and canals, which also confirmed the MRI findings. Digital subtraction angiography (DSA) was performed pre-operatively, which demonstrated that the tumor was supplied mainly through the intra-orbital and intra-ocular branches of the ipsilateral ophthalmic artery Fig. a.Fig. 3aThe initial histological report from an incisional biopsy was inconclusive. A pre-resection embolization of the lesion was then performed co-axially through a microcatheter in the left ophthalmic artery. Onyx material was used to embolize and completely obliterate the left ophthalmic artery and its branches. This was confirmed post-embolization as there was no supply or tumor blush demonstrated in the tumor area Fig. b.Surgical resection was performed by a multidisciplinary team, including ophthalmology and pediatric neurosurgery. An orbital lid-sparing exenteration of the tumor was initially performed by the ophthalmologist Fig. a, b. TheFollowing on the resection of the large intra-orbital component of the tumor, the pediatric neurosurgery team then dissected and removed tumor that was exposed through the expanded left optic canal. The intracranial cavity exposure and tumor dissection were performed initially using the 30-degree angled lens on the endoscope  present. These are nonspecific degenerative changes. In addition, there were foci of intense mucinous degeneration with tumor cells in pools of mucin.Immunohistochemical stains showed focal-positive immunoreactivity for glial fibrillary acid protein (GFAP) with glial cells Fig. b.The image is a whole slide scan showing cross-sections through the optic nerve that has been expanded by the tumor .Optic nerve glioma may exhibit unusual microscopic features such as extensive arachnoid proliferation, chordoid and chondroid metaplasia, thus mimicking chondrosarcoma or chordoid meningioma. Immunohistochemical staining with GFAP is crucial to exclude these other entities .The child remained well throughout the hospital stay and was discharged after a week. One month postoperatively, the patient was seen in the neurosurgery outpatient department and was doing really well with complete healing of the incision site with no signs of orbital tumour regrowth or infection.The patient was lost to follow-up for a period, and then re-presented to the neurosurgery outpatient department 8 months post-surgery, still clinically well with no features of recurrence. A repeat MRI was done at this stage, which demonstrated no typical orbital structures in keeping with left ocular exenteration. The residual mass was demonstrated, comprising of a small intra-canalicular 8 × 5 mm) and intracranial (13 × 8 mm) component, markedly decreased compared to the initial MRI (Fig.  mm and iOPG can broadly be categorized into three subtypes, namely childhood syndromic, childhood sporadic and the adult form. Childhood syndromic is associated with neurofibromatosis in about 50% of glioma patients, and their association has been well documented . The feaOn imaging findings, the OPG has two primary forms. The more common form causes a fusiform enlargement of the optic pathway, producing an enlarged optic nerve with effacement of the surrounding subarachnoid space. The less common imaging presentation is that of eccentric expansion .Most patients with OPG present between the ages of 2 and 6 years with unilateral loss of vision and axial proptosis, with a mean age of diagnosis at 4–5 years of life. A high index of suspicion is imperative, especially with abnormalities such as optic disc oedema, pallor, atrophy and abnormal pupillary light reflex on clinical examination. Children without neurofibromatosis are likely to present with abnormally increased intracranial pressure, nystagmus and strabismus , 7.The transorbital endoscopic approach provides minimally invasive access to several anatomical regions in the anterior and even middle skullbase regions. This approach may be used as a standalone procedure or in combination with other approaches –13. A unGiven the benign profile of this tumor and the location, no adjuvant therapy was given to this child.A high index of suspicion and low threshold for further investigation should always be utilised in a child who presents with proptosis, especially as in this case, at birth. The appropriate management of orbital tumors especially in young children requires a multidisciplinary team approach, including obstetricians, paediatricians, ophthalmologists, neurosurgeons, radiologists and pathologists.Advances in minimally invasive surgical approaches, such as the transorbital endoscopic approach in this case, will continue to enhance the ability of the surgeon to safely access complex lesions through less invasive approaches.


The current literature suggests that serious complications after intrauterine contraceptive device (IUCD) insertion are rare. We present a rare case of a migrated IUCD into the rectosigmoid colon.A 33-year-old woman (parity one) presented to the emergency department with a three-day history of flank pain, upper urinary tract infection symptoms, and a low-grade fever. Differentials initially included renal colic or pyelonephritis. However, subsequent computed tomography of the kidneys, ureters, and bladder (CT-KUB) and magnetic resonance imaging of the pelvis (MRI-pelvis) showed a migrated IUCD posterior to the uterine body, with both ends closely abutting onto the adjacent proximal rectum. During further history-taking, she reported a past surgical history of an emergency caesarean section five years ago and the insertion of a copper-IUCD six weeks postnatally. She was subsequently referred to the gynaecologists. In view of the involvement of the bowels, the colorectal surgeons were consulted, and the patient was managed by a multidisciplinary team. The patient subsequently underwent diagnostic hysteroscopy, flexible sigmoidoscopy, diagnostic laparoscopy, removal of impacted IUCD, and repair of the rectum. Intraoperatively, her hysteroscopy noted a normal uterus with an intact cavity. Flexible sigmoidoscopy noted the horizontal arm of the IUCD abutting into the lumen of the rectosigmoid region; however, attempted removal with traction was unsuccessful. A partial rectotomy was done eventually to remove the IUCD.Migration of an IUCD is rare, with uterine perforation rates ranging from 0.04% to 0.2%. Albeit a rare complication, this case highlights the need for clinicians to be cognizant of complications arising from IUCD insertion, as symptoms are often non-specific and mild. This case also highlights the importance of a multidisciplinary discussion in the management of a migrated IUCD, which may include gynaecologists, colorectal surgeons, radiologists, and more. Many innovative ways were also discussed regarding the assessment of it, which includes preoperative imaging or endoscopic evaluation. Novel methods of removal of migrated IUCD in the rectosigmoid colon have also been proposed, including manual traction, proctoscopy, rigid sigmoidoscopy, and removal via a snare. They provide an alternative to the traditional diagnostic laparoscopy or laparotomy, thus reducing the need for general anaesthesia or operative intervention. Looking forward, long-term studies can be done to evaluate the need for intervention for asymptomatic patients where the risk of surgery may outweigh the benefits. According to the Centers for Disease Control and Prevention (CDC), family planning is one of the 10 great public health achievements of the 20th century. In 2019, among women of reproductive age, 922 million people used some form of contraception-either traditional or modern methods of contraception. It is estimated that 159 million of them use the intrauterine contraceptive device (IUCD) [Migration of an IUCD is rare, with uterine perforation rates ranging from 0.04% to 0.2% . Most peHere, we present the case of an unusual presentation of a migrated copper IUCD into the rectosigmoid junction.A 33-year-old woman (parity one) presented to the emergency department with a three-day history of right loin-to-groin pain associated with a low-grade temperature of 37.6 degrees Celsius and dysuria. She denied any bowel-related symptoms. She had presented to her general practitioner with urinary symptoms two days prior and was started on oral antibiotics for a presumed lower urinary tract infection. As her symptoms persisted and compounded with right loin-to-groin pain and fever, she presented to the emergency department. On examination in the emergency department, she had tenderness over the right hypochondrium and right flank with no signs of peritonitis. An X-ray of the kidney, ureter, and bladder done in the emergency department showed no renal stones, and an intrauterine device was noted within the midline of the pelvis Figure .Her investigations demonstrated a raised total white cell count of 11.3 x 109/L, and she was subsequently commenced on intravenous antibiotics and analgesia.Despite treatment, her symptoms persisted, and thus further imaging tests were performed. A subsequent computed tomography of the kidneys, ureters, and bladder (CT-KUB) performed reported a migrated intrauterine device located between the body of the uterus and the adjacent rectosigmoid colon. There were small pockets of gas surrounding it with no fluid collection, and no calculus was seen in the urinary tract. Figure -3.Magnetic resonance imaging of the pelvis (MRI-pelvis) subsequently confirmed a migrated IUCD posterior to the uterine body, with the horizontal arms of the IUCD closely abutting the adjacent proximal rectum.On further history, the patient reported having had a copper intrauterine device inserted five years ago postnatally after an emergency caesarean section for failure to progress. During her fourth-week postnatal visit, she had a Papanicolaou (PAP) smear done, which showed normal endocervical cells with no malignancy, and her copper IUCD was inserted in the same setting. The patient was planned to be followed up on in two months. However, she defaulted on her clinic appointment and was unable to follow up thereafter. Two years later, the patient was residing overseas and presented to the doctors there with a complaint of amenorrhea. During the consultations, she was informed of the migrated IUCD and underwent diagnostic laparoscopy. After the diagnostic laparoscopy, she was told by the surgeons that, due to the location of the IUCD, there was a high risk of bowel perforation if removal was attempted. As it was a small district hospital with no other specialty support, the decision was made to abandon the procedure and leave the IUCD in. She was advised to seek medical attention if she had any abdominal pain and remained well until her presentation to our institution.When she was referred to the gynaecologists, due to the involvement of the bowels, the management of the patient was done in collaboration with the colorectal surgeons. In view of the persistent abdominal pain and known findings of a migrated IUCD, the patient opted for surgical management. Preoperatively, she underwent a flexible sigmoidoscopy, which demonstrated an erosion of the distal tip of the IUCD into the rectosigmoid junction. The IUCD was intact with the wire present, approximately 18 cm from the anal verge on the patient’s right anterolateral region, as shown in Figure She was then prepared for surgery for the removal of the IUCD.Intraoperatively, her hysteroscopy noted a normal-sized uterus with an intact cavity with no IUCD seen inside. She underwent another flexible sigmoidoscopy, which demonstrated an erosion of the distal tip of the IUCD into the rectosigmoid junction. Gentle traction to attempt removal of the IUCD failed, and hence a diagnostic laparoscopy was performed to remove the impacted IUCD intra-abdominally with the repair of the defect in the rectum. Laparoscopically, the horizontal arms of the IUCD were noted to be embedded externally in the recto-sigmoid junction with surrounding chronic inflammation. The uterus was otherwise completely clear of the rectum, with no fistula noted. A partial rectotomy was done to remove the embedded IUCD, and the defect was closed in two layers with Vicryl 3-0 sutures. The migrated intrauterine device was eventually removed completely, as seen in Figure The patient recovered well postoperatively and was discharged two days later. On her first follow-up review in the outpatient clinic after discharge, the patient remained well with no abdominal pain. She continues to be followed up in both the colorectal and gynaecology clinics.The intrauterine contraceptive device (IUCD) is one of the most effective and reliable contraceptives used worldwide. The migration of IUCDs is rare. Most cases present with mild symptoms of either abnormal bleeding or mild lower abdominal pain, or both . Other cA review of the literature noted that the risk of uterine perforation is increased in a retroverted uterus if insertion is done during the early postpartum state or if the patient was breastfeeding at the time of insertion , 4, 6. AMigration or translocation of the IUCD into adjacent organs can have serious consequences. Translocation of the IUCD into the bladder, caecum, sigmoid, appendix, and small bowel have all been described in the literature , 12-16. In addition, the method of IUCD retrieval depends on the location of the migrated IUCD. There are reports of alternative retrieval methods for partially embedded IUCD in the sigmoid colon or rectum, which may provide a less invasive method if appropriate and thus avoid the need for exploratory laparoscopy or laparotomy. In a review by Assarian and Raja, they reported four cases in the literature whereby the migrated IUCD in the rectosigmoid region were removed by manual traction, five cases with the help of a proctoscope, three other cases with the help of rigid sigmoidoscopy, and one case where a colonoscope was used and the migrated device was removed by a snare . They suDue to the involvement of multiple organs, it is prudent to involve other specialists for a multidisciplinary approach in the care of such cases. Management should be based on a combination of radiological findings, endoscopic findings, and knowledge of the anatomy of the abdominal organs. In our case, the management was heavily reliant on the coordination between the colorectal surgeons and gynaecologists. We also employed a multifaceted approach, with the assistance of radiological imaging and endoscopic images preoperatively, for preoperative planning and counselling for this patient.This case presents many points for discussion regarding the management of a migrated IUCD. Many innovative ways were discussed regarding its assessment, which includes preoperative imaging or endoscopic evaluation. Novel methods of removal of migrated IUCD in the rectosigmoid colon, for example, with the use of a proctoscope or colonoscope, have been proposed as alternatives to the traditional diagnostic laparoscopy or laparotomy, reducing the need for general anaesthesia or operative intervention. Looking forward, long-term studies can be done to evaluate the need for intervention for asymptomatic patients where the risk of surgery may outweigh the benefits. Non-invasive surgical approaches could also be explored as alternatives to the management of a migrated IUCD. Albeit a rare complication from IUCD insertion, this case highlights the need for clinicians to be aware of potential complications arising from IUCD insertion and its subsequent management. It also emphasises the need for thorough counselling of patients regarding symptoms of abdominal pain and abnormal menses post-IUCD insertion and reiteration of compliance to follow-up after IUCD insertion.