To describe the use of 1% polidocanol as the sole treatment for a superficial orbital venous malformation in a horse.A 23‐year‐old Welsh Cobb cross gelding with a distensible swelling affecting the left lower eyelid, and secondary palpebral margin abnormalities and superficial keratitis.Color flow Doppler ultrasonography revealed non‐pulsatile blood flow within the tortuous vascular network most consistent with a superficial orbital venous malformation appearing to involve the lateral palpebral and transverse facial veins. An intravenous catheter was placed within the lateral aspect of the venous malformation, and agitated saline was slowly injected into the vessel while simultaneously ultrasound imaging the medial aspect in which the bubbles were observed coursing across, consistent with lateral to medial flow. Contrast venography confirmed a corkscrew vessel along the ventral aspect of the orbital rim. Under standing sedation, 1% polidocanol solution was administered slowly through the intravenous catheter while manual pressure was applied on the medial and lateral aspects of the venous malformation.Ultrasonography performed immediately after administration of polidocanol confirmed venous stasis, and formation of a thrombus. No adverse side effects were noted. The venous malformation and associated palpebral margin abnormalities and superficial keratitis resolved at the time of re‐examination at 4 months.Polidocanol as the sole treatment for a superficial orbital venous malformation in a horse was well tolerated and led to clinical resolution. Sclerosant monotherapy may be a safe treatment option for superficial orbital venous malformations. Mixed forms are present as well.Currently, there is no recommended first line of treatment for orbital venous malformations in veterinary patients. Previously published treatments include conservative management,Sclerotherapy is the administration of a sclerosant directly into a vessel leading to endothelial damage, inflammation, thrombus formation, and eventual regression of the vessel.22.1A 23‐year‐old Welsh Cob Cross gelding presented to the North Carolina State University Ophthalmology Service for evaluation of a mass affecting the left lower eyelid. This mass had been present since birth, with gradual enlargement over time and progressive distension when the head was lowered. By the time of presentation, the lesion had enlarged in size and was causing discomfort. The patient had been treated with 0.3% ofloxacin ophthalmic solution (Akorn Operating Company LLC) once daily for 1 week prior to presentation.Complete ophthalmic examination was performed by a board‐certified ophthalmologist, including slit‐lamp biomicroscopy, indirect fundoscopy, fluorescein staining, and rebound tonometry. A large, tortuous swelling affecting the left lower eyelid was identified Figure , in addi2.2Ultrasonography (B‐mode and Doppler) and contrast venography were performed to confirm diagnosis and characterize flow. The patient was sedated with 400 mg xylazine  intravenously (IV) and administered 500 mg flunixin meglumine  IV. An auriculopalpebral and frontal nerve block were performed with 1 ml 2% lidocaine each . The periocular area was clipped and aseptically prepared. B‐mode ultrasonography identified a large, tortuous, tubular structure superficially within the inferior palpebra measuring up to 0.45 cm in diameter and approximately 4.5 cm in length Figure . Color fA 22 gauge over‐the‐needle catheter was placed within the lateral aspect of the superficial orbital venous malformation using ultrasound guidance, attached to an extension set, and sutured in place using 2–0 nylon  administered via the catheter. Three orthogonal projections were obtained. Venography confirmed the presence of a corkscrew‐shaped vessel along the ventral aspect of the orbital rim, as well as an additional vessel extending ventrally from the region of the medial canthus Figure . Based oFollowing venography, 20 ml of 1% polidocanol solution  was slowly administered through the catheter. During the administration, a Jaeger eyelid plate and standard scalpel handle were used to apply manual pressure on the medial and lateral aspects of the superficial orbital venous malformation, respectively, to ensure the sclerosant remained within the venous malformation. Ultrasound of the left jugular vein was performed repeatedly to evaluate for visible thrombus formation. Immediately following administration, turbulence was noted within the vessel Figure . Twenty 2.3No change in the size of the superficial orbital venous malformation was seen the following morning, though it was firm on palpation consistent with thrombus formation. The patient was discharged with OptixCare ophthalmic lubricant  to be used three times daily for 1 week. One month following sclerotherapy, the venous malformation had reduced in size and the palpebral margin abnormalities and superficial keratitis had improved Figure . The ven3This is the first report describing the successful use of 1% polidocanol as monotherapy for a superficial orbital venous malformation in a horse. Based on the patient's history, the venous malformation was suspected to be of congenital origin. Diagnostic imaging was consistent with a venous malformation involving the lateral palpebral and transverse facial veins, and resolution occurred within 4 months following sclerotherapy.Diagnosis of orbital vascular malformations is dependent upon history, physical examination, and diagnostic imaging. Reported diagnostic imaging modalities include contrast radiography,A variety of sclerosants have been reported for treatment of periorbital venous malformations in humans, including ethanol,Ethanol is the most extensively studied and potent sclerosant. It acts by denaturing proteins, thereby damaging the vascular endothelium, leading to thrombus formation and eventual obliteration of the vascular lumen.Pingyangmycin is the sclerosant of choice in China, due to its high rate of efficacy (>95% response rate) and low risk of complications (average complication rate of 2%). Bleomycin similarly has a low risk of complications (6%), but a more variable efficacy rate (70%–100% response rate).Ethanolamine oleate, polidocanol, and STS are detergent‐type sclerosants that lyse endothelial cells and were developed to be safer alternatives to ethanol.Ethanolamine oleate, polidocanol, and STS are all commercially available in the United States. EAO  has been approved by the FDA for treatment of esophageal varices, whereas polidocanol  and STS  are FDA approved for the treatment of varicose veins of the lower extremity.Ethanolamine oleate, polidocanol, and STS can be administered either as a liquid or a foam. Foamed sclerosants are preferred over liquid sclerosants in certain cases as foamed sclerosants displace blood when administered, leading to increased contact time and use of a lower concentration sclerosant.Polidocanol was specifically selected in this case because of (1) availability, (2) FDA approval, and (3) reported success in the recent treatment of a nasolacrimal duct cystComplications during or following sclerotherapy were not observed in our study. In humans, there is a low complication rate following sclerotherapy as monotherapy of orbital and periocular venous malformations, with reported complications including swelling, discomfort, skin erythema, skin necrosis, scar formation, orbital compartment syndrome, vision loss, reduced infraorbital nerve sensation,In conclusion, sclerosant monotherapy of a superficial orbital venous malformation using 1% polidocanol in a sedated horse was well tolerated and led to clinical resolution. It is a safe treatment option for superficial orbital venous malformations and should be considered as a minimally invasive treatment option for future cases.None.


Lipoma is one of the benign soft-tissue tumors in the adipose tissue. Oral lipomas comprise 1%–5% of benign oral tumors. They are slow-growing, soft, asymptomatic, solitary tumors. In this case report, a 45-year-old female patient having swelling on the upper right arch for 2 months has been reported. Clinically, the right upper second premolar and first molar were grossly carious, with diffuse swelling on the adjacent vestibule. A provisional diagnosis of the periapical abscess was rendered. Radiological evaluation and routine blood tests were performed. After the tissue was obtained, following teeth extraction and socket curettage, it was sent for histopathological evaluation, and findings suggested intraoral intraosseous lipoma. Clinically, they are asymptomatic, and therefore, if it was not curetted and histopathologic evaluation not done, and only thought to be just a swelling or a periapical abscess, proper treatment could not have been established. This paper will surely bring out the importance of histopathology in routine dentistry and the role of histopathological evaluation of periapical soft tissues. Lipoma is one of the most common benign soft-tissue neoplasms encountered in the subcutaneous tissue. It is composed of matured adipocytes without any cellular atypia . HoweverLipoma of bone or intraosseous lipoma is a very rare intraosseous benign neoplasm, formed by adipocytes that can also originate on the surface of the bone –4. It caIn this case report, a very interesting case is shown which was thought to be a periapical lesion, but after extraction, a gelatinous lesion was attached to the root which was different from a granulation tissue, which urged us to go for histopathological investigation, which was diagnosed as intraosseous lipoma. Therefore, the purpose/aim is to show the role of histopathology and its importance.The nature of these lipomas is still debatable; the origin could be from medullary adipose tissue, trauma, or reactive changes , 10. TheThey are benign lesions, and therefore, their prognosis is very good . The recA female patient aged 45 walks into the clinic complaining of a slowly growing swelling on the upper right arch since 2 months. The pain was reported to be fluctuating, dull, and intermittent. There was a heaviness and discomfort over that area. On clinical examination, the right upper second premolar and first molar were found to be grossly carious with a diffuse swelling on the vestibule adjacent . The sweA routine blood investigation before any surgical procedure such as complete blood count, hemoglobin, blood sugar, bleeding time, and clotting time was done, and it was found to be within normal ranges.These tests were performed to see any abnormalities in these parameters, if any abnormalities were present then extraction or surgeries may have been delayed or any other options or medications may have been prescribed.The teeth were then extracted under local anesthesia and on socket curettage, a gelatinous soft mushy tissue was obtained, which was sent for histopathology. A provisional diagnosis of periapical granuloma was rendered.The histopathology revealed moderate to dense fibrocollagenous stroma with abundant dispersed chronic inflammation with a lot of dilated blood vessels engorged with RBCs. There is also evidence of abundant mature lobules of adipocytes separated by thin fibrous connective tissue septa. The fat cells did not show any atypia and mitotic figures. There was no evidence of a capsule. The inflammatory component was found to be minimal in these areas with few compressed blood vessels . LookingLipoma is a painless soft-tissue tumor of mesenchymal origin, which has slow growth and is usually well-circumscribed. Its origin is in the mature adipose cells . Its freIntraosseous lipoma is rare in occurrence and consists of 0.1% of all bone tumors. They have lots of degenerative changes and shows areas of fat necrosis, cystic changes, and areas of calcification .They are very rare in head and neck bones. They are divided into two subtypes according to the site of origin into intramedullary and intracortical types. Among them, few cases of intramedullary lipoma are reported in the oral region and they are symptomless and diagnosed accidentally on radiographs in patients having come for any other reasons .The cancellous and long tubular bones are the anatomical sites most commonly affected. In long bones, they are found in the metaphysis. Intraosseous lipoma may be traced anywhere in the skeleton. Pain is the main symptom in maximum cases and intraosseous lipomas are found accidentally in imaging studies that are done for other reasons .In some cases, when the tumor becomes large enough results in difficulty in speech and mastication , 9. Due They usually grow asymptomatic and slow, which is why patients do not seek treatment . These lThe gold standard for the proper diagnosis of Lipomas is always based on histopathological evaluation. It is also very necessary to omit malignant lipoma , 10, 11.Classification on the basis of histology is simple lipoma, fibrolipoma, spindle cell lipoma, intramuscular lipoma, chondrolipoma, pleomorphic lipoma, myxoid lipoma, angiolipoma, and sialolipoma .Histopathologically, in intraosseous lipoma, there is a three-stage classification as given by Milgram-stage I-a lesion having mature fat cells without calcification; stage II-a predominantly fat lesion with necrosis and focal calcification/ossifications, and stage III-a lesion having fat having multiple necroses, wide calcifications, cystic degenerations .In other intraoral lipomas, these lesions show thinly encapsulated lesions having mature adipocytes and inconspicuous vascularity . Just liThe malignant transformation of lipoma is extremely rare in occurrence. Surgical excision is the treatment of choice and shows an excellent prognosis , 18. DifIn the present case, it could very well be thought to be a dentoalveolar abscess, sinus inflammation, or any odontogenic lesions, but since it was firm and associated to grossly carious teeth, a provisional diagnosis of periapical abscess was rendered. The key intension to bring forward this case as sometimes the most obvious diagnosis turns out to be different. Lipomas are benign entity, never aggressive but can be a concern for the patient. So, the point which is loud and clear is periapical tissues if obtained attached to the tooth or during curettage must be treated with importance and sent for histopathological evaluation. Any chances of recurrence and the characteristic of the lesion should be well explained to the patient and documented in the case sheet for future usage. So histopathologic evaluation of every case even the smallest, doubtful case is must, and there is a very important role of oral pathologists in this area otherwise the treatment outcome will not be proper.Intraoral lipoma is a benign and rare mesenchymal neoplasm, and among them, intraosseous lipoma is considered very rare entity and forms 0.1%.The most common areas are the calcaneus and the lower long bones. Based on the location of the bone, intraosseous lipomas are of two types intramedullary and intracortical. Approximately, 15%–20% of lipomas are found in the head and neck parts. Among them, 50% occur in the buccal mucosa. The lesion may or may not be encapsulated. Intraosseous lipomas are not based on radiology alone and therefore differential diagnosis is very necessary and conducted for a long time.Even a simple periapical abscess or granuloma as assessed in the radiograph turned out to be intraosseous lipoma. Clinicians must understand the importance of diagnosis of the oral lesions and also differential diagnosis should be kept in mind for proper understanding and treatment protocols to be taken. Proper curettage, surgical excision must be done with follow-ups after histopathological diagnosis keeping in mind the health of the patient and giving the patient correct direction in their life.


Extraskeletal Ewing sarcoma (EES) is a rare tumor diagnosed in children or young adults and is even more unusual in individuals over 30 years of age. Due to its rare occurrence and low index of suspicion, this tumor can pose diagnostic and therapeutic challenges. We present a case of a 60-year-old male with EES of the sciatic nerve, an unexpected entity given the patient's age, tumor type, and tumor location. This can mimic a nerve sheath tumor on imaging. Ewing sarcoma family of tumors (EFT) is a spectrum of neoplastic disease that includes skeletal Ewing sarcoma, extraskeletal Ewing sarcoma (EES), primitive neuroectodermal tumor (PNET), Askin tumor (Ewing sarcoma of the thoracopulmonary region), and rarely visceral tumors ,2. EFT aWe present a case of a 60-year-old male with EES originating from the left sciatic nerve, the diagnostic workup, treatment plan, and a review of relevant literature.A 60-year-old male with no significant past medical history presented with a left posterior thigh palpable mass, swelling, and pain. He also reported paresthesias of his left lower extremity. He initially noticed the mass 6 months prior to presentation with interval growth and increasing pain. MRI demonstrated a large necrotic mass in the posterior compartment of the left proximal thigh which was continuous with the sciatic nerve -5. This Ultrasound-guided biopsy of the mass was performed. Histopathology showed proliferation of poorly differentiated malignant small round cells with increased mitotic figures and necrotic background A. Tumor Apixaban was started for anticoagulation. He received chemotherapy including doxorubicin, cyclophosphamide, vincristine and 6 cycles of ifosfamide and etoposide. Chemotherapy was complicated by syncopal episodes, neutropenic fever, and severe fatigue. The patient declined surgery since surgical resection would involve sacrifice of the sciatic nerve. He underwent radiation therapy of 55.8 Gy in 31 fractions.There was initially a decrease in size and enhancement of the thigh mass with chemotherapy and radiation. However, there was subsequent increase in size of the index lesion with development of a new lesion immediately next to it in the left thigh, new left inguinal and retroperitoneal lymphadenopathy and pulmonary nodules, consistent with disease progression and metastases. He also developed foot drop and diminished sensation to his left leg below the knee. The patient died approximately 1.5 years after the initial pathologic diagnosis, in large part due to respiratory distress and the extent of pulmonary disease. There were large malignant pleural effusions, with immunohistochemical stains on the pleural fluid showing positivity for CD99 and FLI1.EFT is a rare class of neoplastic diseases that most commonly affects the bone and soft tissues ,10. EFT Although most Ewing sarcomas arise from bone, up to 30% arise in soft tissue resulting in EES Imaging serves a critical role in the diagnosis, staging, treatment monitoring, and surveillance of EES. Imaging will often identify an aggressive mass suggestive of a sarcoma or nerve sheath tumor, although the exact diagnosis of EES is challenging since it demonstrates non-specific imaging characteristics. The initial diagnostic work-up of Ewing sarcoma often begins with a radiograph. While radiographs of Ewing sarcoma of the bone often demonstrate destructive lesions in long bones with an accompanying soft tissue mass, the extraosseous variant frequently manifests as a large soft tissue mass near bone without osseous involvement EWSR1-FLI1 gene [EWSR1-ERG gene [Definitive diagnosis of EES is often established by CT- or US-guided core needle biopsy and pathologic analysis. Grossly, EES is a soft, lobulated, gray/yellow/tan tumor with occasional cystic, hemorrhagic, and necrotic areas. Microscopic histological analysis confirms EES via monomorphic proliferation of small, round blue cells with large spherical nuclei with scant cytoplasm LI1 gene . About 1ERG gene . Both ofERG gene ,19,32.After establishing the diagnosis of EES, evaluation for metastases helps guide therapeutic approach. The primary prognostic factor of EES is the presence or absence of metastases ,21,33,34Therapeutic management of EES requires a multimodal approach. Although the mainstay of treatment for EES has been complete surgical excision of the tumor with negative histologic margins, the neurologic morbidity associated with resection of a peripheral nerve EES makes this undesirable. Moreover, if post-resection nerve grafting is performed, post-operative neuroma may hinder management and surveillance of tumor recurrence EES is challenging to diagnose due to its rarity and nonspecific symptomatology. Typically seen in children or young adults, EES would be very unlikely in a 60-year-old patient. Undifferentiated pleomorphic sarcoma, liposarcoma, and leiomyosarcoma are the variations more commonly found in the older adult population and thus the diagnosis of EES is unexpected in older patients. With ambiguous clinical and radiological findings, early histological diagnosis should be sought to avoid diagnostic delay and ensure appropriate treatment. To preserve nerve and limb function and since EES is typically radiosensitive and chemosensitive, radiotherapy and chemotherapy may be advised in addition to/rather than surgical resection.Written informed consent for the publication of this case report was obtained from the patient's next of kin.


Hepatocellular carcinoma (HCC) is a common form of cancer and the most common form of liver cancer. Multiple etiological factors leading to HCC include hepatitis B and C, diabetes, alcoholic fatty liver disease, and non-alcoholic fatty liver disease. Hepatocellular carcinoma in the late stages may present with tumor burden and thrombi that can extend into the right atrium (RA). This late-stage form of HCC has a poor prognosis. In this case, we present a 63-year-old male who presented to the hospital with acute encephalopathy with bilateral pulmonary emboli and a thrombus secondary to HCC extending into the RA. Clinical trials for non-surgical interventions are ongoing and are needed to treat patients with tumor burden who may be at bleeding risk from tumor resection. Hepatocellular carcinoma (HCC) is one of the most common forms of cancer globally, and it is the most common form of liver cancer . MultiplA 63-year-old male with a medical history of hypothyroidism, type 2 diabetes mellitus, and recent hemorrhagic stroke one month prior to admission presented to the emergency department with acute encephalopathy. Initial computerized tomography (CT) of the head was negative for hemorrhage but incidentally showed a bilateral pulmonary embolism (PE) Figure . A compuDue to the acute presentation of the encephalopathy, there was a concern for brain metastases from a previously unknown tumor. A magnetic resonance imaging (MRI) of the brain revealed diffuse embolic infarcts. His echocardiogram on a previous admission noted a patent foramen ovale. A transesophageal echocardiogram (TEE) during the admission was obtained and showed a large heterogeneous mobile structure in his IVC extending into his RA concerning for a thrombus versus a mass.Despite having a recent hemorrhage, the patient was trialed on anticoagulation to prevent a new stroke or a massive PE. Unfortunately, he did not tolerate this due to a new bleeding 2 × 3 cm right buccal mass not amenable to cauterization. This mass was biopsied and was consistent with HCC. His prognosis with metastatic HCC to the mouth, numerous cardioembolic cerebrovascular accidents, bilateral PE, cirrhosis with child-pugh class B, a large IVC, and an RA thrombus/mass with confusion and debility was estimated to be weeks to months without treatment. After many multidisciplinary meetings and discussions with the family, his care was transitioned to a comfort focus. He was discharged to hospice care and died within two weeks.Thrombi are infrequently found in a structurally normal heart; however, they may be seen in patients who have a hypercoagulable state, inflammatory state, or malignant tumors . In HCC,Rarely, patients with HCC may present with a thrombus extending from the IVC into the RA. This is due to invasion of the hepatic vein and IVC by the tumor forming a thrombus that traveled through the IVC up to the RA. This is a rare condition indicating a very poor prognosis. A consensus for the management of patients with advanced HCC with tumor thrombus has not been established. Treatment options include pharmacological (anticoagulation), surgical resection to reduce tumor burden, or palliative options including chemotherapy, radiation, or combination regimens ,3. In thManagement of advanced HCC is an ongoing field of research. Literature review shows that surgical resection of the thrombus with no further surgical resection of the liver confers an average survival time of six months . FurtherAdvanced HCC with the extension of a thrombus into the RA is a rare presentation. Multiple case reports have been published showing that advanced HCC with extension into the RA has a poor prognosis for patients even after surgical resection of the liver with a median survival time of 20 months. Despite this, clear guidelines for management are not readily available. It is important to note that HCC is a highly vascular tumor, especially when metastasized such that anticoagulation or thrombolytics are contraindicated. We believe it is of increasing importance to develop new therapies for less invasive tumor management modalities when patients are found not to be surgical candidates due to their bleeding risk. Some clinical trials are ongoing and may demonstrate further guidance.


Cardiac myxoma recurrence is uncommon following surgical resection. Recurrence is about 2-3% in familial cases; however, recurrence is uncommon in sporadic cases. Most of the recurrences will occur during the first three to four years. Ten percent of myxomas are of the inherited autosomal dominant disorder called Carney's complex, while the rest appear sporadic. We are reporting a nonfamilial case of atrial myxoma, recurring rapidly seven years after resection of the initial left atrial myxoma with a pathologically proven clear margin and no malignant transformation.Cardiac neoplasms are rare and occur less commonly than metastatic disease of the heart. Congestive heart failure symptoms and thromboembolism account for nearly half of the presenting signs and symptoms. The initial presentation of our case was an embolic phenomenon, presenting with a stroke. The patient subsequently underwent resection of the mass, with pathology confirming the complete excision of the myxoma with a clear margin and no evidence of malignant transformation. Our patient was closely followed up in the clinic on annual transthoracic echocardiography surveillance, with a recurrence noted on surveillance echocardiography in 2021  despite the patient being asymptomatic. This case illustrates transthoracic echocardiography as the mainstay of detection of recurrent left atrial myxoma; however, it also asks the question of how often patients need to be screened for recurrence of left atrial myxoma and for how long they need to have surveillance echocardiography. Clinical presentation and transesophageal echocardiographic views are extremely helpful in sharpening the accuracy of the diagnosis. Atrial myxoma is the most common primary cardiac neoplasm, with an estimated incidence of about 0.5-1.0 per million cases per year .A 60-year-old female patient with a prior history of CVA, diagnosed in 2014 and on further workup, was found to have a mass in the left atrium, which was subsequently diagnosed as a left atrial myxoma on histology following a resection . The patient at that time presented for regular follow-up with complaints of fatigue and exertional dyspnea. Transthoracic echocardiography during this time showed a mobile mass attached to the inter-atrial septum prolapsing into the LV through the mitral valve in diastole. The patient subsequently underwent resection of the mass, with pathology confirming the complete excision of the myxoma with a clear margin and no evidence of malignant transformation. The patient has been closely following up with the cardiology clinic with annual transthoracic echocardiography per the Dictionary of Occupational Titles requirement for a return to work for bus drivers. In July 2021, the patient, however, presented to the cardiology clinic for regular follow-up without any new symptoms. Transthoracic echocardiography was significant for the new finding of a 1.6 × 1.5 cm echogenic mobile mass attached to the proximal portion of the left side of the interatrial septum, consistent with a left atrial myxoma at the previous area of the stack , and metastatic recurrence" . In mostThe presence of concurrent lesions in the heart and clinical features such as hyperpigmentation, endocrine disease, or benign extracardiac connective tissue suggestive of syndromic association (Carney complex) should serve as a pointer to a familial transmission . FamiliaRecurrence of atrial myxoma after surgical resection is rare, usually less than 5% of cases. In the case of our patient, the first recurrence occurred seven years after the initial complete resection. This case illustrates a recurrence after surgical resection, which is extremely rare, with only 10 cases of multiple recurrences reported in the literature in the past 30 years . This caRecurrence of the most common cardiac, primary benign tumor-atrial myxoma, is rare, especially after multiple surgeries. Sporadic cases are less likely to be recurrent than familial cases. Our patient not only presented with a sporadic cause but also recurred seven years after resection with a pathologically proven clear margin and no malignant transformation. Our case also illustrates the risk of rapid progression despite previous negative screenings. The risk of recurrence, despite surgical resection, and the potential for worsening outcomes demonstrate the need for regular echocardiography surveillance post-resection. However, the question is: how often do we need patients to have surveillance echocardiography, and for how long?Further studies will help address these questions. It is important to detect recurrences early, especially in patients with a familial predisposition. However, additional studies are also needed to understand the reliable predictors of atrial myxoma recurrence better and more accurately.


Proximal epithelioid sarcomas are rare soft tissue sarcomas that have been documented in a diverse range of presentations. However, there have been few cases describing adrenal presentations. These neoplasms are thought to be driven by a loss of SWItch/sucrose non-fermentable (SWI/SNF)-related matrix-associated actin-dependent regulator of chromatin subfamily B member 1 (SMARCB1), also known as integrase interactor 1 (INI1). SMARCB1/INI1 is a tumor suppressor gene thought to play a role in multiple malignancies with varying degrees of gene expression. Complete loss of SMARCB1/INI1 has most commonly been described in the English scientific literature as malignant rhabdoid tumors of renal origin within pediatric populations and proximal epithelioid sarcomas in adult populations. We describe a case of a primary adrenal proximal epithelioid sarcoma demonstrating complete loss of SMARCB1/INI1 in a middle-aged adult female. SWItch/sucrose non-fermentable (SWI/SNF)-related matrix-associated actin-dependent regulator of chromatin subfamily B member 1 (SMARCB1), also known as integrase interactor 1 (INI1) is a tumor suppressor gene first discovered in yeast in the 1980s and thought to play a role in chromatin remodeling . It has A 44-year-old female patient with a past medical history significant for gastroesophageal reflux disease and hiatal hernia presented to the emergency department (ED) in May of 2021 with a complaint of left-sided abdominal pain with associated bloating for four months. Physical examination findings were remarkable for tenderness to palpation over the mid and left lateral abdomen with no peritoneal signs. Laboratory values were within normal limits. A non-contrast computed tomography (CT) scan of the abdomen and pelvis was performed as part of the workup, and the findings demonstrated a 4x2.4 cm left-sided adrenal mass  scan was recommended to assess for metastasis or recurrent disease. PET CT was chosen due to its high sensitivity (98.5%) and specificity (92%) for assessing malignant adrenal tumors . A PET sIt can be difficult to differentiate between proximal-type ES and MRT as previous literature has reported that both can demonstrate a complete loss of SMARCB1/INI1 expression. MRTs are typically described in pediatric populations, whereas ES are more common in adults . ProximaProximal ES typically have an aggressive course with poor five-year survival rates. In adult populations, they demonstrate a male predominance ,10. ProxProximal ES arising from the adrenal gland has been rarely reported. We believe that this is the fourth case described in the literature -6. CompaThis is most likely a primary tumor rather than metastatic disease. Initial imaging was only apparent for an adrenal mass, and follow-up PET CT postsurgical resection did not demonstrate any areas of increased metabolism. The tumor was positive for CDX-2 which can be a marker of colorectal metastasis ,12. HoweAlthough rare, the aggressive nature of these malignancies necessitates early removal. While rarely associated with adrenal masses, this case highlights the importance of removing non-functional adrenal masses that are larger than 4 cm. Because of the high rate of metastatic disease at presentation, follow-up after diagnosis and surgical removal should include a PET CT to assess tumor burden/metastasis. Follow-up should be consistent with national soft tissue sarcoma guidelines and based on initial tumor location.


Traumatic dislocation of the testes (TDT) is a rare sequela of blunt scrotal and perineal trauma. TDT can easily be overlooked during concomitant trauma due to other injuries, The damage to the testis appears to be not severe in dislocation and may be corrected by repositioning even if it is delayed. However, delayed intervention might be associated with pain and discomfort and may lead to abnormal sperm parameters and possible infertility. The urgency of surgical intervention increases whenever there is associated testicular torsion, rupture, or bilateral testicular TDT. We report two cases of unilateral traumatic testicular dislocation following motorcycle crashes with different presentations and approaches to treatment. We also engage in a review of the relevant literature. Traumatic dislocation of the testes (TDT) involves the displacement of one or both testes out of the scrotum . It is uCase 1A 25-year-old man with no children presented to the emergency department (ED) after a motorcycle crash injury to the perineum and scrotal area. He reported concerns about right scrotal pain. He had no previous history of similar pain or abnormal testicular positioning. On physical examination, we noted an empty right scrotum with ecchymosis and swelling associated with tenderness in the right inguinal area. The Doppler ultrasound (US) confirmed the diagnosis of TDT as the right testis was in the right inguinal canal with good vascularity without ultrasonic features of tunica albuginea rupture. The testis volume was approximately 18.1 mL. The patient declined to undergo immediate surgical treatment  OR (trauma[MeSH Terms])) AND (testis)) OR (testicular)) AND (dislocation) Non-English papers were excluded from the search. The search yielded 47 results, of which 31 papers were identified as reports on TDT in post-pubertal men . A totalBlunt scrotal trauma is not an uncommon injury, especially in young men. It can lead to injuries, including minor contusion, hematoma, ruptured tunica, and shattered testis. TDT is a rare entity, and the actual incidence is difficult to determine because it is underreported. TDT is usually a consequence of high-energy trauma like motorcycle crash-related injury, although it has been reported after trivial trauma like contact with the seat of a stationary exercise bike . The tesDiagnosis of TDT is not always straightforward and can be challenging, especially in the presence of concomitant severe injury that diverts the attention from the genital area, similar to what happened with case 2. Similarly, the presence of hematoma and inflammatory changes in the soft tissues of the scrotum can mask the diagnosis .High suspicion and thorough examination are important factors in TDT diagnosis, especially during the secondary survey. The classic finding is an empty, well-developed scrotum with a palpable tender mass outside the scrotum. Doppler US is the primary investigation that can assess the viability of the testis and rule out other injuries such as hematoma, rupture, torsion, or epididymal avulsion ,36. A CTAlthough manual reduction is possible, it has a low success rate 15%) compared to surgical reduction; moreover, it should not be attempted when there are coexisting injuries ,7. Surgi5% comparThe effect of TDT on the histological features of testis has been studied by Hayami et al.; an intraoperative testicular biopsy four months after an unrepaired dislocation revealed impaired spermatogenesis but no atrophy of seminiferous tubules. A follow-up biopsy after eight months of reduction showed a slight improvement in the spermatogenesis of the testis . RecoverWe presented two TDT cases in which one received delayed surgical intervention three months following the initial injury and the other received surgical intervention immediately, and both experienced similar surgical outcomes. The main factor for immediate surgical intervention was the associated testicular torsion that necessitated the urgent intervention.Our review and report showed that the damage to the testis does not appear to be severe in dislocation and may be corrected by repositioning even if it is delayed. However, delayed intervention might be associated with pain and discomfort and may result in abnormal sperm parameters and possible infertility. The urgency of surgical intervention increases whenever there is associated testicular torsion, rupture, or bilateral testicular TDT.TDT is a rare complication of blunt scrotal injury, and the diagnosis requires a high index of suspicion. Testicular Doppler US is the recommended imaging modality for diagnosing the condition and ruling out associated torsion or rupture. This report discussed two cases where one patient received immediate surgical intervention and the other one experienced delay in intervention for three months, yet both recovered with viable testes several months following surgical correction. Early surgical intervention is indicated, especially with associated testicular torsion or rupture of the testis, and delayed intervention is associated with pain and discomfort. Our review showed that the damage to the testis does not appear to be severe in dislocation and may be corrected by repositioning even if it is delayed.


Pleomorphic liposarcoma (PLPS) is the rarest liposarcoma subtype, with high‐local recurrence and metastasis rates. Fine‐needle aspiration cytology (FNAC) is successfully used in the diagnosis of primary or metastatic soft tissue tumors, but liver metastases of PLPS diagnosed by FNAC have never been reported. The cytological diagnosis depends on the identification of lipoblasts with sharply defined cytoplasmic vacuoles indenting and distorting the nucleus in the context of a pleomorphic tumor and in a proper clinical and imaging context. Despite its aggressive behavior, hematogenous liver metastases are rare, with just one case reported in literature. A case of PLPS liver metastasis and concomitant primary tumor diagnosed by FNAC and core needle biopsy is herein described. Serum and hematological parameters were normal; the patient did not suffer from any hepatopathy but he had undergone lung lobectomy  and six cycles of cisplatin and gemcitabine chemotherapy. Because of his past medical history, a metastasis from the primary lung carcinoma was suspected. The patient underwent abdominal CT and ultrasonography (US), which revealed a 52 × 48 mm, hypoechoic, well‐defined mass located in the right liver lobe Figure . A diagn3FNAC smears and CB histological sections were similar in both the liver and soft tissue lesions. Smears were hypercellular, showing tightly aggregated and loose groups of highly pleomorphic cells with epithelioid features Figures  and 2B, 4The liver is a rare site for PLPS metastases: to the best of our knowledge, only one such case has been described to date.The authors declare that they have no conflict of interest.Written informed consent was obtained from the patient for publication of this article. All potentially identifying information has been anonymized as much as possible. The authors have conducted their study in accordance with the World Medical Association Declaration of Helsinki.


We report unexpected death of a 72-year-old man due to a hemoperitoneum . Postmortem examination revealed that the cause of the hemorrhage was an arterial aneurysmal lesion in the greater omentum. The lesion measured 4 × 4 × 6 cm with a generally smooth wall, but with a focal area of rupture within a hemorrhagic region measuring 1 × 2 cm. There was a substantial feeding artery. Histological examination revealed features in keeping with a pseudoaneurysm, but also with some features of a true aneurysm. There was no history of trauma and the rupture of the aneurysmal lesion that had caused the hematoperitoneum was considered to be spontaneous. Prior to his death the deceased had attended hospital for epigastric pain, which was attributed to dyspepsia, but otherwise he had not had symptoms prior to his death. A 72-year-old man was found deceased on his bed at his home address. He had a past history of prostatic carcinoma with metastases to the pelvis, in addition to ischemic heart disease, hypertension, chronic kidney disease, and atrial fibrillation. Four months prior to his death he had attended hospital for epigastric pain and was thought to have dyspepsia not related to peptic ulcer disease.A postmortem CT scan was performed which revealed fluid, in keeping with blood, around the liver, with similar fluid in the region of the spleen and in the pelvis. A poorly defined mass could be identified in the anterior upper quadrant of the abdominal cavity Fig. . PostmorAt autopsy the deceased’s weight was 102 kg his height was 178 cm (BMI = 32). Opening the abdomen revealed 1.9 L of fluid and clotted blood predominantly in the right upper quadrant of the abdomen. In the greater omentum there was a fluctuant dark purple mass measuring 4 × 4 × 6 cm, with a generally smooth wall, which appeared to have ruptured on the right side within a hemorrhagic area measuring 1 × 2 cm. The mass was attached to the omentum, but had no other apparent connection to intra-abdominal structures. The contents of the abdomen and pelvis were otherwise normal with no alternative site of hemorrhage identified; the liver was not cirrhotic.Examination of the formalin-fixed specimen revealed a neck that comprised an artery measuring approximately 0.6 cm in diameter. This was in continuity with an approximately spherical, but partly collapsed, mass with an outer diameter of approximately 6 cm Fig. . An exitHistological examination of sections from the neck confirmed the presence of an arterial vessel with internal and external elastic laminae entering the mass. The artery showed variable loss of the internal elastic lamina with irregular areas of fibrosis and intimal thickening. The wall of the cystic mass was fibrotic with focal areas of lining resembling internal lamina; elsewhere there were mural arterial vessels Fig. . In areaDeath was attributed to intra-abdominal hemorrhage from a visceral aneurysm/pseudoaneurysm. There were no other organic diseases which to have contributed to death and there was no evidence of trauma.The initial finding in this case was the presence of blood in the abdomen, both on imaging and at autopsy. Due to a lack of history of trauma, the hemoperitoneum was attributed to rupture of a visceral aneurysm/pseudoaneurysm; however, there are a multitude of other possibilities to consider in the case of a hemoperitoneum.Previously referred to as ‘abdominal apoplexy,’ idiopathic spontaneous intraperitoneal hemorrhage  is a rarIn this case, the source of the fatal intra-abdominal hemorrhage was identified as a ruptured visceral aneurysmal lesion located in the greater omentum. The apparent origin from a large feeding vessel Fig.  suggesteThe deceased had no history of abdominal trauma, previous surgery or pathology (such as infective endocarditis or sepsis)  prior toVisceral artery aneurysmal lesions include vascular aneurysmal lesions (aneurysms and pseudoaneurysms) of the splenic, hepatic, superior mesenteric, celiac, posterior duodenal, gastroduodenal, gastric and renal arteries . RuptureVisceral artery aneurysmal lesions have been found over a wide age range (22–85 years) with a median age of 54 years and a male preponderance of around 3:2 . This caIt has been noted that incidental visceral artery aneurysmal lesions may be encountered during clinical angiographic investigations , 8. The Visceral artery aneurysmal lesions (aneurysms and pseudoaneurysms) are a rare cause of hematoperitoneumWe describe a fatal spontaneous hematoperitoneum due to rupture of a visceral artery aneurysmal lesion in the greater omentumHematoperitoneum from a visceral artery aneurysmal may be diagnosed by CT scan with contrast angiography


Spontaneous perforation of pyometra is a rare event associated with significant morbidity and mortality when diffuse peritonitis is present. While malignant lesions of the cervical tract are the most common cause of pyometra, several benign conditions can contribute to this diagnosis. Traditionally hysterectomy has been the surgical approach of choice for this clinical entity; however, in the setting of septic shock, temporizing techniques may offer the opportunity to stabilize patients and complete a thorough work up before committing to definitive resection. This report explores a case of septic shock secondary to spontaneous perforation of pyometra that was definitively managed with peritoneal lavage and wide drainage. Intraoperative hysteroscopy and uterine biopsy were performed, and no malignancy was identified on final pathology. Intraoperative hysteroscopy along with peritoneal lavage and wide drainage may reduce the morbidity and mortality associated with sepsis from spontaneous perforation of pyometra and potentially avoid unnecessary hysterectomy. Pyometra is defined as the accumulation of purulent material in the uterine cavity resulting from interference of its natural drainage , 2. It iEscherichia coli and blood cultures were negative.A 68-year-old postmenopausal woman presented to the general surgery service at a small rural hospital after being transferred from a peripheral facility. Her past medical history includes previous cerebrovascular accidents with permanent deficits, hypertension, type 2 diabetes mellitus and osteoarthritis. Her initial presentation was significant for abdominal pain of gradual onset, as well as signs of septic shock, including tachycardia, fever, hypotension and leukocytosis with a white blood cell count of 47.8. Generalized peritonitis was noted on examination. A chest X-ray performed prior to transfer revealed free air under the right haemidiaphragm. On arrival at the surgical facility, the patient was seen to have stabilized after the administration of crystalloids. Blood and urine cultures were sent, and broad-spectrum antibiotics were initiated. A urinalysis revealed elevated leukocytes but no other abnormalities. Urine cultures demonstrated colonization with A computed tomography scan revealed significant abdominal ascites and scattered locules of intraperitoneal free air suggestive of a perforated viscous, although no clear gastrointestinal (GI) source was identified  and 2. IGiven concerns regarding extensive inflammatory changes in the pelvis and the risk of morbidity associated with hysterectomy in the acute setting, the decision was made, to close the defect and widely drain the pelvis. A heavy absorbable suture was used for primary closure of the uterine defect and two drains were placed. Following closure of the abdomen, the patient was transferred to the intensive care unit and convalesced without complications, ultimately making a full recovery.Spontaneous perforation of the uterus in the setting of pyometra is often difficult to diagnose clinically, as the symptoms associated with this entity commonly mimic those of GI tract disease . In our Traditionally, total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO) has been considered the preferred surgical approach in the management of spontaneous perforation of pyometra . Howeveret al. [Matsumoto et al.  describeet al. , 11.It is worth highlighting the use of intraoperative hysteroscopy and uterine lavage that proved invaluable in this case. To the author’s knowledge, this technique has not been widely published in the literature with regard to management of spontaneous perforation of pyometra. Access to these tools undoubtedly aided in intraoperative decision making by allowing the uterine cavity to be directly visualized. In the absence of such resources, it is likely that more conservative approaches to management may be necessary, and hysterectomy may have a more well-defined role.Spontaneous perforation of pyometra is a rare event that is associated with significant morbidity and mortality. In the appropriate setting, repair of the uterine defect with peritoneal lavage and wide drainage may allow for avoidance of hysterectomy and mitigate the morbidity associated with this procedure. Intraoperative hysteroscopy and uterine lavage are indispensable tools in the management of this clinical entity.None declared.


A 43-year-old female underwent pelvic magnetic resonance imaging for uterine myoma that incidentally revealed a 4.6 × 2.8 cm soft tissue mass in the anorectal region. Rectal endoscopy showed a submucosal tumor just above the anal canal. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) revealed an anorectal tumor with very high FDG uptake. Aspiration cytology and needle biopsy were inconclusive, and the patient underwent trans-perineal tumor resection. The excised tumor was a 4.6 × 3.5 × 2.7 cm gray–white bifurcated nodular tumor. Light microscopy revealed fenestrated growth of poorly dysmorphic short spindle-shaped cells with eosinophilic sporophytes. Immunohistochemical staining was positive for αSMA and desmin, negative for CD117 (KIT) and S100, and the patient was diagnosed with benign leiomyoma. Tumor cells were also positive for glucose transporter-1 (GLUT1) immunohistochemically. It is important to keep in mind that FDG-PET/CT may show false-positive results even in benign anal leiomyoma for various reasons, including GLUT1 overexpression. Leiomyomas of the gastrointestinal tract occur most commonly in the esophagus and rectum. Rectal leiomyoma presents as small polypoid lesions arising from the muscularis mucosae . Althoug18F-FDG uptake  for uterine myoma that incidentally revealed a 4.6 × 2.8 cm soft tissue mass in the right perineal area . Rectal With the patient in the jackknife position, a 7-cm longitudinal incision was made on the right margin of the anus, the index finger was inserted into the rectum and the tumor was palpated to confirm. The tumor was covered with a thin capsule and sphincter fibers were stretched over the surface of the lesion. Complete extracapsular dissection was performed and the sphincter fibers were repaired with absorbable thread . The excLeiomyoma is a benign tumor that arises from smooth muscle cells. Gastrointestinal leiomyomas are most common in the esophagus and rectum. Anorectal leiomyomas are rare, occurring in one out of every 2000 or 3000 rectal tumors . There aIn recent years, FDG-PET/CT has been widely used for the differential diagnosis of benign and malignant neoplastic lesions. FDG-PET/CT is based on the principle that FDG, like glucose, is taken up into cells by the glucose transporter (GLUT) on the cell membrane and phosphorylated by hexokinase to FDG-6-phosphate . The GLURectal leiomyoma is a benign tumor with low mitotic activity and does not usually show increased accumulation on FDG-PET/CT. Meanwhile, leiomyosarcoma often shows mitotic activity and FDG accumulation has been reported in many cases , 11. We Anorectal leiomyoma is a rare benign lesion. We report a 42-year-old female with anorectal leiomyoma that was suspected to be malignant based on abnormal accumulation on FDG-PET/CT, which was associated with GLUT1 overexpression.


Amyloidosis is a mainly systemic rare disease and its localized presentation is even less frequent. Systemic forms are often associated with other conditions or entities (such as neoplasms), and a correct etiological study of patients with this disease is essential. A localized presentation has a better prognosis compared to systemic forms, which underlines the importance of a correct diagnosis. Primary localized amyloidosis in the head and neck region is a rare entity. Primary amyloidosis localized to the sinonasal tract is extremely rare. Although uncommon, case reports have been increasing in the face of new endoscopic and imaging techniques, and the report of these cases is crucial for a better characterization of this entity. Symptoms may include epistaxis, nasal obstruction, facial deformity, and vision changes.A 72-year-old female with a history of frequent nasal congestion with two years’ duration showed no improvement following symptom management. She was referred for nasal endoscopy and biopsy, thereby confirming the diagnosis of amyloidosis. Further diagnostic testing did not show evidence of systemic disease.This case report was previously presented as a poster presentation at the 19th European Congress of Internal Medicine in March 2021. Amyloidosis is a rare clinical entity characterized by the deposition of amyloid fibrils and insoluble protein polymers in organs or tissues, leading to cellular injury ,2. DiagnLocalized presentations are rare, representing about 10% of cases , and usuThis clinical case describes a nasopharyngeal presentation, which is extremely rare (3%) ,4,5, witThe patient was a 72-year-old female with a history of arterial hypertension and dyslipidemia receiving treatment with perindopril, indapamide, amlodipine, and atorvastatin. She had no history of hospital admissions or surgical interventions. Her family doctor referred her to an otorhinolaryngology consultation due to complaints of frequent nasal congestion and ear fullness with two years of evolution. For over one year she underwent symptom management with no improvement. Otoscopic examinations and tympanometry results were unremarkable. Due to the persistence of symptoms, a contrast-enhanced computed tomography (CT) scan of the head and neck was requested, revealing lymphoid tissue occupying the nasal cavity, without muscle tissue, bone, or skull base infiltration Figure . A nasalSubsequently, she was referred to internal medicine for a follow-up. An extensive clinical and laboratory work-up was carried out, including a biopsy of abdominal fat, bone marrow biopsy, serum immunofixation electrophoresis, urine protein electrophoresis, abdominal and renal ultrasound, chest radiograph, coagulation tests, complement factors, electrocardiogram and echocardiogram, liver function tests, renal function tests, serum alkaline phosphatase, and thyroid function tests. No evidence of systemic amyloidosis was found, and the patient was diagnosed as having localized nasopharyngeal amyloidosis.As previously mentioned, amyloidosis is a rare condition (incidence of 12 cases per million inhabitants per year ) whose dSystemic involvement has to be excluded given the marked differences in morbidity and mortality between these two forms . In its This localized presentation is usually a slowly progressive disease with a benign course . TherapyAlthough progression to systemic disease is rare, it can occur, which further highlights the importance of a complete diagnostic assessment given the worse prognosis of systemic forms (as was done in this case). Given the possible existence of small lesions not evident through imaging, it is also essential to keep these patients under careful monitoring. The patient presented maintains this follow-up in the Internal Medicine Consultation.


Colovesical fistula is an infrequent complication of diverticular disease that presents with pneumaturia, fecaluria, dysuria and, rarely, hematuria or hematochezia. Here we present a case of concurrent hematuria and rectal bleeding arising from a diverticular bleed traversing a previously undiagnosed colovesical fistula. Other causes of colovesical fistula include Crohn's disease, radiation, and malignancy, though it is most commonly caused by complicated diverticulitis as in this case. Computed tomography (CT) imaging, cystoscopy, and gastrograffin enema have been described as high-yield diagnostic tests. Interestingly, colonoscopy is only successful in diagnosing colovesical fistula in approximately 55% of cases. Management often requires surgical intervention, as in this case, given limited success with conservative management. Colovesical fistula should be considered in patients presenting with fecaluria, pneumaturia, and dysuria as well as in cases of hematuria. Colovesical fistula is an uncommon complication of complicated diverticular disease with an estimated prevalence between 2% and 23% . PatientA 66-year-old man presented to the emergency department with acute-onset gross hematuria and rectal bleeding. His medical history was notable for sigmoid and descending colon diverticulosis seen on colonoscopy in 2019 and benign prostatic hyperplasia (BPH), for which he underwent greenlight laser transurethral resection of the prostate 5 months prior. His postoperative course was notable for urinary tract infection, acute urinary retention, and persistent pneumaturia.Computed tomography (CT) of the abdomen and pelvis revealed sigmoid and bladder wall thickening, intravesicular gas, and a previously undiagnosed colovesical fistula shown in . The CT Escherichia coli, for which he was treated with cephalexin. After discharge, he underwent robotic sigmoid colectomy with colorectal anastomosis and colovesical fistula takedown.Colonoscopy showed old blood, sigmoid diverticulosis, and an area of indurated tissue 20 centimeters from the anal verge concerning for the fistula shown in . His preThis case highlights a unique presentation of complicated diverticular disease with concurrent hematuria and rectal bleeding caused by diverticular bleeding traversing a colovesical fistula. As in this case, management of diverticular disease complicated by fistulas relies on multidisciplinary discussion including colorectal surgery and urology given bladder involvement. While colovesical fistula rarely presents with hematuria, it should be considered, particularly in patients with known diverticulosis.In this patient, his colovesical fistula most likely stemmed from a prior episode of diverticulitis which is consistent with the sigmoid diverticula seen on his colonoscopy. While diverticular disease accounts for approximately two-thirds of cases of colovesical fistula, other etiologies include malignancy including bladder and colon cancer, radiation, and fistulizing Crohn's disease . These pComplicated diverticulitis refers to diverticular disease associated with obstruction, abscess, perforation, fistula, or stricture . These pDiverticulitis complicated by fistula remains a difficult entity to manage. Approximately 2/3 of diverticular fistulas are colovesical and these most commonly affect the sigmoid colon, as in the patient described above . The patDiagnosis of colovesical fistula in this case was made with CT imaging with contrast, though demonstrating the fistula radiographically can be challenging. The literature describes other diagnostic modalities that can be considered. In a study of 39 patients with a colovesical fistula, the diagnosis was made with CT imaging in 80% of cases. Other high-yield diagnostic modalities include cystograms, gastrograffin enema, and cystoscopy. Interestingly, the literature estimates the rate of successfully diagnosing a colovesical fistula via colonoscopy at 0% to 55%. Of note, oral charcoal administration and visualization of charcoal per urethra diagnosed colovesical fistula in all five cases when it was used . The litThis case highlights an unusual presentation of colovesical fistula in a patient with sigmoid diverticulosis. Colovesical fistula should be considered in patients presenting with pneumaturia, fecaluria, or recurrent urinary tract infection.


We report two cases of primary hepatic mesothelial cysts in neonates previously identified during perinatal imaging. Both neonatal cases were reimaged in the postnatal period, demonstrating the persistence of these cystic hepatic lesions. In both instances, the decision was made to treat with surgical resection and both patients tolerated the surgery well with no significant postoperative complications. Histopathological examination of these lesions discovered a cuboidal lining that was calretinin and WT1 positive and CD31 negative, indicating the diagnosis of a mesothelial cyst of hepatic origin. These cases bring attention to the broad differential diagnosis of congenital primary hepatic cystic lesions, as well as the diagnostic pathway to confirm a primary hepatic mesothelial cyst. Mesothelial cysts are congenital lesions that are rarely seen or reported in the literature. These lesions are remnants of previous coelomic structures that persist, sometimes into adulthood. They are characterized grossly by having a cystic appearance, often with thin septae (complete or incomplete). Histologically, the cystic space is lined with flat to round cells of mesothelial origin, which can be confirmed by positive immunohistochemical (IHC) staining for calretinin, WT1 and D2-40, and negativity for CD31 [Mesothelial cysts of hepatic origin or primary hepatic mesothelial cysts have been sporadically reported in the literature in both neonates and adult patients. During this review, 15 previously reported cases in the English and non-English literature were found, most of these were in adults, as this entity is rarely reported in the pediatric population. Mesothelial cysts have been observed in nearly every region of the liver, though there is a distinct bias for the round ligament observed in the reported cases. We present two cases of neonates with previously imaged hepatic cystic lesions that were surgically resected after delivery and were histologically characterized as mesothelial cysts via gross appearance and IHC staining.Case 1 The patient is a five-day-old male born at 36 weeks 5 days gestation to a 39-year-old G6P4 female with little prenatal care. Mother sought prenatal care at 34 weeks, at which time an ultrasound showed a large gestation fetus with a persistent right umbilical vein and an abdominal cystic mass measuring 4.0 x 3.0 x 2.9 cm. The patient was delivered at 36 weeks 5 days with Apgar scores of 7 and 8 at one and five minutes, respectively, but was placed on nasal continuous positive airway pressure and transferred to the neonatal intensive care unit due to respiratory distress. The patient was found to have a moderate-sized Secundum atrial septal defect and patent ductus arteriosus. Laboratory testing showed increased unconjugated bilirubin of 4.5 . Repeat ultrasound at one day old showed a well-circumscribed thin-walled anechoic structure without internal vascularity measuring 4.8 x 4.7 x 2.6 cm in the subhepatic region  2, and was discharged on POD 3. On POD 4, the patient developed serous drainage and mild erythema along the surgical incision concerning possible surgical site infection. Laboratory workup was notable for leukocytosis. No subcutaneous or intra-abdominal fluid collections were demonstrated on imaging. He was started empirically on antibiotics. The erythema and drainage resolved by POD 6.The antenatal and postnatal abdominal sonograms demonstrated a solitary cystic lesion with thin septae. During resection, it was found that the cystic lesion was in hepatic segments II-IV. After resection, the gross appearance showed a saccular cystic lesion with thin septae, a smooth lining and no cystic contents. Histological examination revealed flat to cuboidal cells lining the cystic space with mesothelial characteristics and no nuclear atypia Figures , 3B. IHCDuring the third trimester fetal sonogram, the attending physician’s differential diagnosis for the cystic mass observed was either a mesenteric cyst or a dilated loop of the bowel. After delivery, abdominal sonography was concerning for a 4.8 x 2.6 x 4.7 cm mesenteric cyst. The differential for congenital benign cystic lesions of the liver is quite large without considering potential malignant diagnoses. However, a brief list of potential diagnoses includes the following: 1) polycystic liver disease, 2) Caroli disease, 3) biliary hamartoma, 4) ciliated hepatic foregut cyst, 5) mesothelial cyst, 6) choledochal cyst, and 7) duplication cyst [A hepatic cyst excision was performed during an exploratory laparotomy five days post-delivery. The patient continued to do well post-operatively and was discharged on POD 3. On POD 4, the mother was concerned about the surgical site drainage that soaked a gauze bandage. After treatment with IV antibiotics, the patient was again discharged. Re-check examination on POD 8 showed the patient continues to do well during recovery.Case 2 The patient is a 17-day-old female with trisomy 16 mosaicism born at 37 weeks 2 days gestation to a 32-year-old G5P5 female. The patient was delivered with Apgar scores of 3 and 8 at one and five minutes, respectively, but was placed on nasal continuous positive airway pressure and transferred to the neonatal intensive care unit due to respiratory distress. The patient was found to have a complete atrioventricular septal defect with a common AV valve, a large inlet ventricular septal defect, a primum atrial septal defect, a large patent ductus arteriosus with a bidirectional shunt suggestive of increased pulmonary pressure and a small secundum atrial septal defect. Laboratory testing showed an increased AST of 73 U/dL (reference range 13-40). An abdominal MRI revealed a 3.5 x 2.1 x 3.7 cm T2 hyperintense structure  developmental, 2) inflammatory, 3) neoplastic, and 4) trauma-related .When determining a diagnosis for a congenital hepatic cyst, the first determining factor is the radiological appearance, either from intra-uterine imaging or ante-natal imaging. Ciliated hepatic foregut cysts are known to occur most often in segment IV and often in a subcapsular location. Simple cysts can appear as either solitary or multiple cysts with an imperceptible wall. Biliary hamartomas appear as multiple irregularly shaped lesions, that may show enhancement on imaging, but no communication with the intrahepatic biliary tree. Caroli disease also appears as multiple cystic lesions with an enhancing central-dot sign on imaging, and communication with the intrahepatic biliary tree, which does not occur with biliary hamartomas. Polycystic liver disease also appears as multiple lesions, though larger in size. Polycystic liver disease also often appears with polycystic kidney disease ,17. FinaWhen evaluating the histology, ciliated hepatic foregut duplication cysts will be lined with ciliated stratified pseudo-columnar epithelium, mimicking epithelium from the respiratory tract. If the duplication cyst is demonstrating malignant potential, there may be large septations present . Simple IHC differentiation becomes difficult, as simple hepatic cysts, biliary hamartomas, Caroli disease, and polycystic liver disease are all biliary duct origin. This means that all will be positive for CK7 and CK19, both characteristic of cells of biliary origin. Both ciliated hepatic foregut duplication cysts and biliary hamartomas are known to be negative for CD-X2, while biliary hamartomas will also be negative for CK20 ,18. CiliFinally, it is worth noting that in both cases these neonates presented with concomitant congenital cardiac defects. While no publication could be found to support a known connection between primary hepatic mesothelial cysts and congenital cardiac defects, we believe this connection may warrant further investigation in a future study.With the increasing use of intrauterine imaging, these entities are discovered in the antenatal and perinatal setting, rather than later in adulthood. When discovered on imaging, the differential is quite wide with both benign and malignant entities as possibilities. However, on histological and IHC evaluation, these entities can be clearly diagnosed due to their mesenchymal appearance and IHC characteristics, such as calretinin and D2-40 positivity with CD31 negativity of the cavity-lining cells.


We present a case of a newborn male with imperforate anus who was found to have colonic triplication with a high rectovesical fistula. The case is presented with a focus on surgical strategies for the management of this rare malformation. Alimentary tract duplications are rare congenital lesions that can occur anywhere from the mouth to the anus. Large bowel duplications account for only a small percentage ∼10%) of all alimentary tract duplications.0% of allA newborn male, born full-term, weighing 4kg, with no relevant prenatal history, was found to have an anorectal malformation (ARM) in the delivery room. He was taken to the operating room at birth to create a colostomy with mucus fistula. Upon division of the colon, he was noted to have three separate proximal colonic lumens and two distal colonic lumens. The ostomy and mucus fistulas were matured  and theUpon presentation to our center at 5 months of age, an exam under anesthesia, cystoscopy, and contrast studies of the colon were performed. There were three easily identifiable colonic lumens on the end colostomy. The mucus fistula was prolapsed and only two lumens were able to be identified There was no anus identified, but there was a good gluteal cleft. On cystoscopy, a colovesical fistula was seen just distal to the bladder neck, in close proximity to the left ureteral orifice. High-resolution and three-dimensional contrast imaging demonstrated two lumens of the distal colon with one ending as a fistula to the bladder and the other blind ending . ProximThe patient was taken to the operating room where an exploratory laparotomy was performed. The anal sphincters were marked at the start of the case using an electrical stimulator. An ileal duplication and fused appendiceal duplication were also identified intraoperatively . A stapTriplication of the colon is extremely rare, with only a few cases reported in the literature.At reconstruction, creating a single distal rectum with no communication with the urinary tract is vital to success. Any remnant of the original fistula that remains can lead to urinary tract infections, kidney damage, and even affect continence. It is also important to use a muscle stimulator to premark the anal sphincters prior to dissection to place the rectum within the center of the muscle complex.Another important consideration in the surgical approach to these patients should always include the possibility that they may need management of fecal or urinary incontinence in the future. Using the ARM continence indexColonic triplication with associated imperforate anus and rectovesical fistula is a rare congenital malformation that requires a complex surgical approach. In addition to correction of the imperforate anus and repair of any fistula, one must plan for the future possibility of bowel/bladder incontinence by keeping the appendix for future use and creating a single colonic lumen for mechanical antegrade flushes.


The treatment of gestational trophoblastic neoplasia (GTN) is one of the success stories in medical oncology. GTN in the cesarean scar is a rare entity, but most cases need to be treated with hysterectomy or localized uterine lesion resection because of chemoresistant lesions and/or massive bleeding. We present a patient with post-molar GTN in the cesarean scar who was non-invasively treated with ultrasound-guided high intensity focused ultrasound (HIFU) to preserve the uterus and fertility.A 32-year-old woman was diagnosed with low-risk GTN (FIGO Stage I: 2 prognostic score) after partial hydatidiform mole. The 5th cycle of chemotherapy was interrupted because of persistent hepatic toxicity and impaired ovarian reserve function. However, the uterine lesion persisted . Therefore, ultrasound-guided HIFU treatment was performed. A significant gray-scale change was observed during the HIFU treatment. Color Doppler ultrasonography and contrast-enhanced ultrasound (CEUS) was performed to evaluate the ablation effectiveness. Color Doppler ultrasonography showed disappearance of the signal of vascularity and CEUS showed no perfusion in the lesion located in the cesarean scar. The uterine lesion was obviously shrunken one month after HIFU treatment. Menstrual cycle resumed 48 days after HIFU. HIFU treatment decreased the number of chemotherapy cycles and there was complete disappearance of the GTN lesion at 4-month follow-up. The patient has shown no signs of recurrence as of 58-month follow-up.Ultrasound-guided HIFU may be a useful alternative to lesion resection for GTN in the cesarean scar in patients who show chemoresistance or are not suitable for chemotherapy. It has the potential to ablate the residual uterine lesion noninvasively to preserve the uterus and fertility, avoiding perioperative risks of lesion resection, especially acute bleeding. Gestational trophoblastic neoplasia (GTN) is a solid tumor that can be diagnosed without histologic evidence in patients with typical clinical, laboratory, and radiographic features . GTN in Due to the similar lesion location and bleeding risk, the successful treatment experiences of cesarean scar pregnancy (CSP) can help inform the treatment strategy for GTN in the cesarean scar. After the pretreatment with uterine artery embolization (UAE) or high intensity focused ultrasound (HIFU), hysteroscopic procedure is a safe and effective procedure for the management of CSP , 11; theHIFU is a non-invasive treatment in which the mechanism of therapeutic effect involves thermal and cavitation effects . Many stIn this case report, we present a patient with GTN in the cesarean scar who was successfully treated with HIFU with preservation of uterus and fertility. In addition, we review the pertinent literature and explore the value of HIFU as a viable fertility-sparing alternative to invasive lesion resection.A 32-year-old woman with one previous cesarean section developed post-molar GTN. She complained of cessation of menstruation for 68 days and irregular vaginal bleeding for 10 days. The uterine size was equivalent to 12 weeks gestation, and the beta human chorionic gonadotropin (β-hCG) level was 265,954 IU/L. The patient underwent initial uterine evacuation and the diagnosis of partial hydatidiform mole was confirmed by histopathological examination. Repeat uterine evacuation was performed 1 week later, and the third uterine evacuation was performed 3 weeks later because of the increase in β-hCG level. One month later, she was referred to our hospital as a case of post-molar GTN with β-hCG levels showing an increase of ≥ 10% on each of the 3 successive measurements made over a period of 2 weeks, from 13 to 2017 to 27 Feb 2017  every 3 weeks because the patient was allergic to methotrexate and dactinomycin was not available at our hospital. The hCG returned to normal level after three courses of chemotherapy. The 5th cycle of chemotherapy was interrupted because of persistent hepatic toxicity Table  and damaCorrect primary diagnosis is the cornerstone of treatment for GTN in the cesarean scar, and can prevent severe complications of massive bleeding and uterine perforation –9. AbnorIn the present study, the patient was asymptomatic. TVS showed a uterine mass with surrounding vascular flow. MRI indicated the size and the location of mass, along with the adjacent areas, especially the cesarean scar defect. MRI is our preferred imaging modality for diagnosis of GTN in the cesarean scar.Previous cesarean section was shown to be a strong risk factor for occurrence of post-molar GTN and invasive mole . In the Chemotherapy is the primary treatment for GTN in the cesarean scar. However, uterine lesion in the cesarean scar area is difficult to be absorbed because of the thin myometrium at this site. Moreover, chemotherapy resistance occurs easily, but the combination of chemotherapy with hysterectomy or localized uterine lesion resection can achieve a good prognosis. According to a study by Wang, complementary hysterectomy and localized uterine lesion resection were performed in 18 (58%) and 4 13%) patients, respectively, mainly because of chemoresistant lesions . One wom% patientAlthough there is no clear consensus on the effect of UAE on fertility, UAE may lead to impairment of ovarian reserve and severe intrauterine adhesions –22. UAE HIFU has been used as an adjuvant surgical procedure in GTN with chemoresistance or recurrence . A combiUltrasound-guided HIFU may be a viable alternative to lesion resection for GTN in the cesarean scar in patients who show chemoresistance or are not suitable for chemotherapy. It has the potential to ablate the residual uterine lesion noninvasively, preserve the uterus and fertility, and avoid perioperative risks of lesion resection, especially acute bleeding. HIFU helped reduce the courses of chemotherapy and no relapse was observed on long-term follow-up.


Cysts can be segregated according to their embryonic backgrounds. The cysts that were found in the mediastinum are usually divided into bronchogenic cysts, enteric cysts, esophageal cysts, and nonspecific cysts. We add to the relatively small body of literature that exists on this topic by reporting a case of a Müllerian cyst occurring in the posterior mediastinum of a 60-year-old female, showing diffuse nuclear positivity for estrogen receptor (ER) and PAX-8. We examined and summarized the findings of the unique reported cases in the literature. Lastly, an institutional retrospective review of all posterior mediastinal lesions in the last 38.5 years was performed. This revealed that out of 135 candidates within our own healthcare system, the only case consistent with the diagnosis of a mediastinal Müllerian cyst is the report included herein.  Mediastinal cysts are a relatively rare finding and can have a varied and diverse presentation, representing 12%-30% of all mediastinal masses . MeanwhiWith so few reported instances in the literature, Müllerian cysts of the mediastinum are quite rare. However, they can be responsible for common symptoms ranging from discomfort to frank chest pain and shortness of breath with many found incidentally on imaging . MediastA 60-year-old woman presented with nonspecific complaints of back pain. On CT, a right posterior mediastinal mass was identified. An MRI confirmed an unenhancing right-sided mass, 2.6 cm x 2.2 cm x 3.1 cm, adjacent to the T4 vertebral body  via a respiratory therapist, at which point the arterial line and the chest tube were removed. On post-op day 1, the patient stated her neck was sore by where the central line is, otherwise her pain is well controlled, no shortness of breath or other complaints. Chest X-ray was done on the second day and it was stable with no traumatic pneumothoraces and no air leak was seen. The patient was allowed to be discharged and given a follow-up appointment. Three weeks later, the patient was seen. She was stable, her incisions were well healed, and had no complaints.Pathologic findings A gross pathologic examination of the specimen revealed a tan-gray disrupted saccular fragment of fibromembranous tissue, measuring 2.0 cm x 1.0 cm x 0.2 cm. Histologic sections with hematoxylin and eosin staining demonstrated a cyst wall lined with pseudostratified columnar epithelial cells resting on thin fibromuscular tissue with some of the lining cells appearing ciliated  and PAX-8 Figure . These fRetrospective reviewMaterials and Methods After institutional review board (IRB) approval, the Geisinger Medical Center pathology database was queried for posterior mediastinal lesions for dates ranging between January 1, 1980 and June 11, 2018 (38.5-year period). H&E and immunohistochemical stains, per institution protocols, were performed as needed at the time of initial pathologic examination. All of the queried posterior mediastinal lesion reports were reviewed and select slides were reviewed for diagnostic confirmation. Immunohistochemical stains ER, progesterone receptor (PR), D2-40, WT-1, CD31, CDX-2, and TTF-1, and PAX-8 were performed and ordered to determine whether or not these cases expressed receptors consistent with Müllerian differentiation.Results Some 135 posterior mediastinal lesions were identified within the database. Hematologic malignancies and metastatic carcinomas were excluded. Seventeen posterior mediastinal lesions were schwannoma/neurilemmomas. Seven cases, including the current case, were cystic posterior mediastinal lesions, including bronchogenic cyst, enteric cyst, lymphangioma, and non-specific benign cyst. All seven cases were re-reviewed to confirm the prior diagnoses. The demographic and diagnostic information is provided in Table Of the seven cases, the only one that demonstrated findings consistent with Müllerian differentiation as described within the literature was the current case. No previously diagnosed case within the last 38.5-year period that was notable for cystic components within the posterior mediastinum was found to have Müllerian differentiation. DiscussionIn 2005, Hattori was the first to describe posterior mediastinal cysts with Müllerian differentiation . A revieA differential diagnosis of mediastinal cystic lesions can be generated based on a three-compartment mediastinal anatomic model . The difSeveral theories have been proposed for the development of mediastinal Müllerian cysts. Ludwig’s theory proposes that the “thickening of the coelomic epithelium develops on the cranial end of the plica mesonephridica at the level of the third to fifth thoracic vertebral blastemal and forms the anlage of the funnel area of the fallopian tube” . This woWe have reported a case of posterior mediastinal Müllerian cyst with a review of the literature and summary of the reported cases in addition to an institutional retrospective review. Any type of paravertebral findings in females, symptomatic or otherwise, should include Müllerian cysts within the differential. Furthermore, any ciliated cyst found within this region should be considered a Müllerian cyst until shown to be otherwise. This was the first case of posterior mediastinal Müllerian cyst within our health system. Unfortunately, due to the limited number of cases within the literature as well as lack of documented follow-up, there exists limited information to determine long-term clinical outcome and how these cysts might differ from bronchial or esophageal cysts. Nonetheless, it is important to consider Müllerian cysts when encountering cystic findings in the posterior mediastinum in order for patients to be counseled, managed and followed appropriately.


The third most lethal cancer in the world is gastric adenocarcinoma, which is uncommon in children. Patients with gastric adenocarcinoma typically experience vomiting, abdominal pain, anemia, and weight loss. We present a case of a 14.5-year-old male with gastric adenocarcinoma that manifested as left hip pain, epigastric pain, dysphagia, weight loss, and melena. Physical exam revealed cachexia, jaundice, a palpable epigastric mass, palpable liver edge, and left hip tenderness.Laboratory tests showed microcytic anemia, increase in carcinoembryonic antigen (CEA), and abnormal liver function test. Endoscopy revealed a cardial mass extending to the esophagus involving the gastroesophageal junction (GEJ). The gastric mass biopsy was consistent with invasive, moderately-differentiated gastric adenocarcinoma, which confirmed the diagnosis of gastric adenocarcinoma. Furthermore, a bone isotope scan revealed mildly hypervascular active bone pathology within the left proximal femur implying possible metastasis. Computed tomography scans and barium swallow were also helpful in supporting the diagnosis. Our case report emphasizes that gastric adenocarcinoma should be encompassed in the differential diagnosis of pediatric patients with hip pain. Gastric adenocarcinoma is a rare diagnosis in children but it is the third deadliest cancer worldwide . It consA 14.5-year-old male patient presented to the outpatient clinic with left hip pain for three months. The pain was dull, achy, with sudden onset, and non-radiating. Moreover, his pain was not relieved by non-steroidal anti-inflammatory drugs (NSAIDs) and was associated with fatigue and dizziness. He also reported mild, intermittent epigastric pain of gradual onset, associated with dark, tarry stools and significant weight loss (60 kg to 40 kg) over the last two months. These symptoms prompted the patient's family to seek medical attention, and blood units were given accordingly. However, the patient was discharged against medical advice before any further investigations. Starting a month ago, the patient also developed dysphagia and loss of appetite. All of which justified admitting the patient for further investigations. It’s worth mentioning that there was no family history of gastric cancer or any other type of cancer, and his parents were not consanguineous. No other significant history or medications were noted, and the review of systems was otherwise unremarkable.On physical examination, the patient looked cachectic and in pain. Temporal wasting and jaundice over the sclera were also evident. Upon palpation, left hip tenderness, a palpable epigastric mass, and a palpable liver edge were confirmed. Furthermore, the left supraclavicular lymph node was not enlarged (Virchow's node). Cell blood count (CBC) and red blood cell (RBC) indices were consistent with microcytic anemia Table . Labs alHelicobacter pylori. Additionally, the patient underwent chest, abdomen, and pelvis CT with IV contrast, Tc 99m-methylene diphosphonate (MDP) bone isotope scan (3 phase + whole body (WB)), and barium swallow.Endoscopy was performed that showed a circumferential, fragile, ulcerating cardial mass extending to the esophagus involving the gastroesophageal junction (GEJ) and gastric polyps, from which biopsies were taken for histopathology examination. The gastric mass biopsy was consistent with invasive, moderately differentiated gastric adenocarcinoma and the biopsy taken from the gastric mucosa was positive for To check for the extent of tumor spread and metastasis, a chest, abdomen, and pelvis CT was performed that revealed a suspicious thickening of the GEJ and the lesser curvature of the stomach Figure  along wiTo further assess the lesion involving the left femoral neck, a bone isotope scan was performed. It showed a mildly hypervascular active bone pathology within the left proximal femur Figure  with no Dysphagia and the extent of obstruction resulting from the mass were evaluated by a barium meal. Significant hold-up of contrast at the distal end of the esophagus and impaired swallowing mechanism with aspiration of contrast were noted Figure .ManagementSince oral feeding was insufficient, we tried a nasogastric tube at first, but failed. So, jejunostomy was done, with the placement of a feeding tube. Pain was mainly managed with morphine and followed by the palliative team. The patient was eventually scheduled for chemotherapy; however, he passed away of cardiovascular collapse before receiving any of it, 16 days after admission.Gastric cancer is a challenging diagnosis in children and is considered rare in children with very limited information on the clinical presentation and outcome . PediatrIn a study conducted using the United States National Cancer Database, 0.1% of gastric adenocarcinoma cases were pediatric cancer and pediatric cases were more advanced and poorly differentiated than those of adults. It was also stated that young adults were appreciably more likely to present with bone metastases compared to older patients .It’s also worth mentioning, that gastric adenocarcinoma at the cardia, as in our case, tends to have a poorer prognosis when compared to other sites . To elabH. Pylori and gastric adenocarcinoma at the cardia, the patient in our case was positive for H. Pylori [The chance of long-term survival in patients with gastric adenocarcinoma is only possible with total surgical resection of the tumor, but patients are not always candidates for surgery because of their widespread metastases during diagnosis . Young p. Pylori .A genetic test was not performed for our patient. However, there are genetic associations that have been reported for pediatric gastric adenocarcinoma. In one study, gastric adenocarcinoma was present in an atypical case of Li Fraumeni syndrome . In anotEndoscopy of our patient has shown gastric polys, to which there might be a link to gastric adenocarcinoma, as supported by the literature . There iThere was a marked elevation of CEA in the course of the disease of the patient in our case. On the other hand, other tumor markers could be elevated. A study by Emir and colleagues reported a mild elevation of alpha-feto protein levels in a 12-year-old boy with gastric adenocarcinoma of hepatoid origin [Our case presented with non-specific symptoms such as hip pain, with multiple metastases at the time of diagnosis. Interestingly, there is a case reported with a similar presentation . There hGastric adenocarcinoma is not common in the pediatric age group. Children with this diagnosis often present with vomiting, abdominal pain, anemia, and weight loss. This is a rare case of a child with pediatric gastric adenocarcinoma, presenting with a chief complaint of hip pain, along with other symptoms. Our case adds another presentation with a unique finding to the literature, supporting the growing differential diagnosis of gastric adenocarcinoma for children presenting with hip pain, especially in developing countries with low awareness.