The present study is a case report of vulvar lipoma. The vulva is a rare site for the development of lipomas, and the aim of the study is to determine if the current imaging modalities can diagnose lipomas correctly. A 43-year-old patient presented with a painless, slowly progressive, oval, mobile and non-tender right vulvar mass compressing the vagina and totally covering the introitus. Both the ultrasonography and magnetic resonance imaging (MRI) exams suggested the diagnosis of lipoma. Surgical excision was performed, and the histopathological examination of the mass confirmed a lipoma. Lipoma is a common benign tumor of soft tissue, and its diagnosis is confirmed by the histopathological description of a well-circumscribed collection of mature adipose tissue.Typically found in subcutaneous fat, lipoma is frequently observed in the upper back, the neck, and the proximal upper and lower extremities.A 43–year-old woman presented to our clinic complaining of a vulvar mass that lately had been causing her discomfort during walking and sitting. The mass was painless, with an insidious onset and slowly progressive course over 4 years. The woman is a house wife, p5, with no past history of clinical importance. There was no past personal or family history of a similar condition.Upon examination, there was a single oval mass involving the whole right labia majora and covering the introitus . The masAn ultrasonographic examination showed a homogenous echo texture with no cystic changes or vascularity surrounded by an echogenic capsule with minimal vascularity. A magnetic resonance imaging (MRI) scan revealed an oval soft tissue mass with a well-defined capsule showing a homogenous high signal with suppression of a signal similar to subcutaneous fat, and showing no diffusion restriction or postcontrast enhancement .The patient underwent surgical excision; an elliptical incision on the skin was performed to aid dissection and to remove redundant tissue for better cosmetic closure. The mass was easily separated from the surrounding tissue, and was removed completely from its capsule . The hisMesenchymal tissue, also referred to as soft tissue or connective tissue, is a derivative of the mesoderm. It comprises a variety of cell types, including fibroblasts and adipocytes. The most frequent benign mesenchymal tumor is lipoma, which is typically observed in subcutaneous fat, but may develop in almost all body organs, including the vulva, which is a rare site for lipoma development.The etiology and pathogenesis of lipomas remain undetermined. Trauma, obesity and gene rearrangement are risk factors for the development of lipomas.Lipoma commonly develops between the fourth and sixth decades of life, but it can be found in all age groups. Like other lipomas, vulvar lipoma has a similar pattern, being reported in all age groups,The diagnosis of lipoma is usually made through a clinical examination. It may present as a painless mass that has a slowly progressive course and is soft, mobile and not adherent to the overlying skin. In the current case, the clinical examination was suggestive of lipoma, but due to the rarity of the condition, we preferred not to rely on clinical findings alone, and decided to subject the patient to further imaging investigations.The ultrasound examination of a case report of vulvar lipoma showed that the appearance of an encapsulated homogenous echogenic mass is a diagnostic criterion for lipoma.Lipomas can be managed conservatively, especially if they are small in size and asymptomatic, for, if they grow large, they may cause discomfort and disfigurement, and may result in psychological and social problems. Surgical excision, liposuction, laser, ultrasound and injection of pharmaceutical agents are management options for the treatment of lipomas.The vulva is a rare site for the development of lipomas. Ultrasonography and MRI are the preferred diagnostic modalities for lipoma. In symptomatic cases, surgical excision is the treatment of choice.


Leiomyoma is a rare tumor that arises from mesenchymal cells, with few reported cases of treatment using holmium laser enucleation of the prostate. A 74-year-old man with dysuria had a mass near the bladder neck in magnetic resonance imaging; this entity was suspected to be a leiomyoma. The patient underwent holmium laser enucleation of the prostate and one lobe was removed. However, the mass was firm and morcellation was difficult to break into small pieces. Therefore, it was fragmented via trans-urethral resection and removed with a curette. The postoperative course was favorable, with a positive clinical outcome. This case highlights the efficacy of holmium laser enucleation of the prostate in the management of prostatic leiomyoma and emphasizes its importance as a viable treatment option. Leiomyoma is a rare benign prostatic tumor that originates from smooth muscle cells within the prostate gland. Typically, its management includes endoscopic, surgical, and transarterial embolization therapies . In a prA 74-year-old man presented to our hospital complaining of prolonged dysuria. He had pre-existing hypertension, sleep apnea syndrome, and insomnia. The PSA level was 1.92 ng/dL, the international prostate symptom score (IPSS) was 16, and his quality of life (QOL) score was 3. The patient had a maximum urine flow rate of 6.2 mL/s, an average flow rate of 4.4 mL/s, a residual urine volume of 20 mL, and a prostate volume of 53 mL.MRI revealed a 3 cm mass in the bladder neck protruding toward the bladder, with a clear border and low signal in T2-weighted images Figure .A leiomyoma of prostatic origin was suspected.The patient subsequently underwent HoLEP and one lobe was removed during the procedure. However, the mass was very firm, which presented challenges during the morcellation process. Therefore, it was fragmented by transurethral resection and collected with a curette.The operating time was 46 min, the bleeding was minimal, and the weight removed was 7 g. The Foley catheter was removed on the second postoperative day, and the patient was discharged on the third postoperative day.Pathologically, the enucleated prostate mass consisted of proliferated spindle cells with no epithelial involvement; the cytoplasm was eosinophilic, and there was no characteristic arrangement. There was no necrosis and the mitotic pattern was unremarkable (0/10 high power fields) Figure .Immunostaining indicated that the tissue was Desmin+, αSMA+, CD34-, STAT6-, CD117-, S100-, and PSA-. These findings were suggestive of a leiomyoma.Three months postoperatively, the patient’s maximum urine flow rate had increased to 16.1 mL/s and the volume of residual urine had decreased to 4 mL. The IPSS improved markedly to 4, while the QOL score improved to 1. There were no significant postoperative complications. After one year following the surgery, there has been no sign of recurrence.Leiomyomas originating in the prostate are rare, and very few cases have been treated endoscopically, especially via HoLEP . We expeHistologically, leiomyomas have well-organized fascicles, which are rarely observed in stromal nodules. Furthermore, they have minimal to no nuclear atypia, virtually no mitotic activity, and occasionally have scattered degenerative nuclei within a normocellular background . ImmunohAdvances in preoperative imaging studies have made it possible to diagnose leiomyoma with greater precision . MRI shoThe use of HoLEP in the treatment of prostatic leiomyoma offers several advantages over traditional surgical methods. It allows enhanced visualization and accessibility, enabling the precise removal of the tumor, while minimizing complications such as bleeding and damage to surrounding structures that causes urinary incontinence. Moreover, HoLEP offers a shorter hospital stay and faster recovery time compared to open surgery, making it an appealing choice for patients, and can be used to treat leiomyomas in close proximity to the urethra.In our case, the leiomyoma was well-circumscribed and could be completely removed by enucleation. However, because the tissue was very hard, morcellation using the VersaCut™ Tissue Morcellator System was difficult, and endoscopic resection was necessary to cut it into smaller pieces. To deal with this issue, an oscillation-type morcellator, which is better for extraction than a reciprocating system, may be the best choice.  This shoIn conclusion, prostatic leiomyoma associated with dysuria can be managed effectively with the use of HoLEP. Accurate preoperative diagnosis by imaging is possible and helps determine the surgical approach. However, the histological hardness of leiomyoma must be taken into consideration, and appropriate morcellation machines must be utilized. Consequently, HoLEP is a valuable therapeutic modality for prostatic leiomyoma due to its demonstrated efficacy, safety, and positive patient outcomes.


Neuroendocrine tumors (NETs) constitute ~0.5% of all diagnosed malignancies. In our case, a 72-year-old male, who was asymptomatic aside from mild left lower abdominal pain, was scheduled for elective ventral hernia repair, evident on computed tomography. The laparoscopic ventral hernia repair necessitated the conversion to laparotomy due to extensive adhesions and the incorporation of surgical mesh into the small bowel wall. The patient suffered from delayed small bowel injury resulting in the second emergent laparotomy when numerous calcified lesions were incidentally noted in the small bowel wall. Pathology confirmed Grade 1 well-differentiated NETs of the jejunum. This case highlights the importance of considering NETs as part of a differential diagnosis in patients with nonspecific symptoms and negative imaging studies. This case also emphasizes the importance of early detection of this rare pathology to improve prognosis and outcome. Neuroendocrine tumors (NETs) are an umbrella term for various malignancies with histologic similarities, often identified with “dense core granules.” NETs are relatively rare, constituting ~0.5% of all diagnosed malignancies . AccordiA 72-year-old male was referred for surgical consultation of a ventral hernia. The patient had a past medical history of colon cancer status post colon resection 11 years ago with subsequent hernia repair 10 years ago. The patient noted a ventral hernia 6 months ago associated with left lower quadrant pain. He denied any nausea, vomiting, or changes in bowel movement. Significant family history includes colon cancer  and lung cancer (sister).On examination, his vital signs were stable. A gastrointestinal exam was notable for the palpable weakness of the anterior abdominal wall with a definite diastasis component and a possible fascial defect.At the time of the initial surgical consultation, the patient had already undergone a computed tomography (CT) scan of the abdomen and pelvis, demonstrating diastasis recti and slight herniation of mesenteric fat superior to the umbilicus. Six months later, he underwent elective diagnostic laparoscopic incisional hernia repair. Conversion to laparotomy was subsequently performed due to extensive adhesions with incorporated mesh to the small bowel wall. During postoperative day 1, leakage of clear to slimy green drainage was found to saturate his abdominal binder, likely due to delayed small bowel injury, which necessitated an emergency exploratory laparotomy. During this operation, an enterectomy was performed due to the incorporated mesh to the small bowel. During this exploration, numerous calcified lesions within the small bowel were noted to be scattered throughout the second half of the small bowel. The pathology report revealed numerous Grade 1 metastatic well-differentiated NET involving mucosa, submucosa, and muscularis propria . The tumHis postoperative recovery was uneventful. After 4 weeks post laparotomy, he followed up with his oncologist. The positron emission tomography (PET) scan showed a general physiologic activity distribution in the thorax, abdomen, and pelvis. There is a small, modestly fluorodeoxyglucose (FDG) avid node in the left iliac chain with a standardized uptake value (SUV) max of 2.85 of undetermined origin. At this time, his oncologist recommended surveillance with CT imaging annually for 10 years.Due to the heterogeneity of the term NETs, we will limit the terms of this discussion to those in the small bowel, as is this case. Diagnosing NETs is challenging. These tumors are often incidentally found when patients undergo evaluation for other disease processes, as they are usually asymptomatic. Even when patients are symptomatic, the clinical presentation is often nonspecific. Although some hereditary conditions, including multiple endocrine neoplasias, predispose individuals to develop this disease, most NETs occur sporadically.Our patient was classified as having numerous well-differentiated Grade 1 tumors as per WHO classification for Neuroendocrine Neoplasms with 1 mitosis per 2 MM2. Grade 1 neoplasms have <2 mitotic counts. His staging was III. Treatment guidelines vary depending on the primary tumor’s location, grade, and stage. In general, if able, low-grade tumors are surgically resected, while unresectable tumors are treated with somatostatin analogs. High-grade tumors or patients presenting with metastatic disease are treated with platinum-based chemotherapy [Overall, our patient received treatment similar to current guidelines. Current ENETS guidelines recommend imaging every 6–12 months with more frequent imaging for Grade 3 tumors .NETs can present as carcinoid syndrome when functioning tumors secrete endogenous substances like serotonin. These patients will present with additional symptoms such as diarrhea, wheezing, and signs of heart disease. This presentation often occurs in patients already with metastatic disease. Although most jejunal and ileal tumors are nonfunctioning, up to 20% can present with carcinoid tumors. Common clinical manifestations will include abdominal pain, diarrhea, and obstructive symptoms. This location has a more unfavorable prognosis due to lower detection rates and advanced spread by the time of diagnosis [None declared.None declared.The data underlying this article are available in the article and in its online supplementary material.Patient consent for study inclusion obtained.G.R. is the guarantor of this article.


A 9-month-old, female Pomeranian dog presented with vomiting and lethargy. Ultrasonography revealed multilobulated anechoic round shape structures at the ovarian and uterine locations. Through computed tomography scan, an extensive non-contrast multilobulated fluid-filled mass suspected of originating from the walls of the ovary, uterus, urinary bladder and rectum was observed. Ovariohysterectomy and urinary bladder biopsy were performed. Histopathological examination revealed numerous cystic lesions lined by plump cuboidal cells believed to be of epithelial origin. Immunohistochemical staining showed that the cyst-like lesions lining cells were strongly positive for lymphatic vessel endothelial hyaluronan receptor 1. Based on these results, lesions were identified as generalized lymphatic anomaly (GLA), in which lymphangiomas develop in multiple organs. After 6 months follow-up, the size of the cysts remaining in the region of the bladder did not undergo much change. GLA should be included in the differential diagnosis when multiple cystic lesions are interspersed in multiple organs. Lymphatic anomaly , a rare congenital disorder of the lymphatic system, is considered to arise from a failure of primitive lymphatic systems to adequately separate from or communicate with the venous system . These mCanine lymphatic anomalies have most commonly been reported in the skin, soft tissue, and retroperitoneum –7. It isIn human, according to the International Society for the Study of Vascular Anomalies (ISSVA), Lymphatic anomlies can be divided into cystic lymphatic anomaly and complex lymphatic anomaly, depending on whether they occur in solitary lesions or multiple organs. Cystic lymphatic anomaly mainly occurs in the head, neck and extermities, and is divided into macro and micro depending on the size. Complex anomalies have been reported in <1% of humans and have not yet been reported in animals. It occurs in various organs such as various bones, liver, and spleen. There are three types of complex anomaly, GLA, Gorham-Stout disease (GSD), and Channel type lymphatic anomaly (CCLA), and there is a subtype of GLA, Kaposiform lymphangiomatosis (KLA). KLA is characterized by being surrounded by Kaposi-form cells, and mainly causes diseases in the chest. GSD is a disease that causes bone destruction and CCLA is a disease known as lymphangiectasia, which occurs when lymphatic vessels are damaged by obstruction of lymphatic vessels. GLA can also occur in bone, but it does not cause destruction , 11.The clinical symptoms and prognosis of lymphatic anomaly varies depending on the locations of the affected organ and sizes of cystic lesions. Leakage of lymph or chyle may be intraperitoneal or intrathoracic, and hypoalbuminemia, hypoproteinemia, and lymphocytopenia may occur due to lymphangiectasia .Lymphatic malformation is characterized by cystic lesions on Ultrasonography (US), Computed tomography (CT), and Magnetic resonance imaging (MRI). The existence and location of the cystic structures can be determined using US, and information about the range of lesions and adhesion of the surrounding tissues can be obtained through CT. In human, when GLA is suspected, MRI is used to identify abdominal and thoracic lesions and to identify mesenteric and retroperitoneal cyst-like lesions. MRI can evaluate soft tissues with good resolution and without radiation exposure. Also, MRI is known to be good for detecting minimal lymphatic lesions, and it is known to show hyper signal intensity in fat-saturated T2-weighted MRI and intense enhancement in gadolinium contrast agent –14.However, immunostaining such as lymphatic vessel endothelial hyaluronan receptor 1 (LYVE-1), podoplanin, and Vascular endothelial growth factor receptor 3 (VEGFR-3) specific to lymphatic vessels is required for diagnosis. In humans, studies on genes related to lymphatic anomaly have been conducted, but no studies have been conducted in dogs yet , 16.This is the first case of a dog with lymphatic anomaly in several parenchymal organs including ovary, uterus, intestine and bladder. Imaging diagnosis and immunohistochemistry was performed, and follow-up was performed 6 months later.A 9-month-old Pomeranian dog presenting with vomiting and lethargy, was admitted to a local animal hospital. No abnormal findings were observed in body temperature, blood pressure, respiration rate, or pulse. Also, No remarkable abnormal findings were observed in the serum biochemistry panel and complete blood count.Abdominal radiography  was performed. In the lateral view, a tubular structure of soft tissue opacity with a size of 11.17 × 5.92 mm was observed in the ventral aspect of the descending colon in the caudoventral aspects of abdominal cavity at L1 to pelvis level. Therefore, the small intestine was cranially displaced . In the Abdominal US  using 3.6–12.9 MHz linear transducers identified multiloculated anechoic structures with acoustic enhancement at the ovarian and uterine locations , which wCT was performed using a multislice CT scanner . The imaging parameters were as follows: 120 kVp, 200 mAs; matrix size, 512 × 512; rotation time, 0.75 s; and, slice thickness, 1 mm. For CT scans, the dog was induced with propofol , and anesthesia was maintained by isoflurane. After obtaining the pre-contrast images, iohexol (750 mg iodine/kg) was manually injected into the cephalic vein. Postcontrast images were obtained after 120 s. Multilobulated structures were observed, starting from the vagina and extending to the uterine cervix and horns. The septa of the cystic structures were connected to the uterine wall, and the margin of the uterus was spiculated , E. TherOvariohysterectomy and biopsy of the UB were performed to remove and diagnose the lesions. The dog was induced with propofol , and anesthesia was maintained using isoflurane. Multiple cystic lesions originating from the walls of the uterine, ovary, urinary bladder, and intestine were widely observed, and cyst-like lesions and adjacent organs adhered to each other. Therefore, it was difficult to clearly demarcate and remove the lesions. After ventral median celiotomy, the ovarian pedicles and uterine body were clamped and ligated with polydioxanone. As complete resection of the cysts was impossible; debulking was performed. Tissues of the ovaries, uterine horns, and UB were fixed in 10% neutral-buffered formalin and sent for histological evaluation in a laboratory .Grossly, multiple pale yellow, clear-to-serous cystic structures were observed in the ovary and uterus . HistoloDNA was extracted from the formalin-fixed and paraffin-embedded (FFPE) samples through the MagMAX™ FFPE DNA/RNA Ultra Kit  and QIAamp DNA FFPE Tissue Kit  for Neuroblastoma RAS viral oncogene homolog (NRAS) gene sequencing. The NRAS coding region was amplified twice using forward (TACAAACTG GTGGTGGTTGG) and reverse (TCCAACAGACAGGTTTCACC) primers by HotStarTaq master mix kit .As a result, the peak size of the our patient was observed to be 44 base pairs both the times, instead of 150 base pairs with NRAS gene in a normal dog.At the 6-months follow-up, the vomiting had disappeared and no significant change in the size of the cystic lesions remaining in the region of the bladder was seen .In human medicine, lymphangiomatosis refers to lymphatic anomaly occuring in multiple organs and is known as CLA. GLA, one of the CLAs, is distinguished from other types like GSD, CCLA in that there are no bone destruction and no leakage of lymph , 11. OurLymphatic anomalies in humans, most commonly occurs in the neck (75%) and axillary sites 20%) and have rarely been reported in the mediastinum, omentum, mesentery, retroperitoneum, colon, pelvis, and bone. Less than 1% of cases are reported in internal organs, and involvement of three or more intra-abdominal organs is extremely rare in humans . Canine 0% and haCystic structures are observed in various orgnas on US and CT in our case. In Considering the patient's age, the possibility of neoplastic cyst was considered low. Since the lumen was intact on CT, the possibility of intraluminal lesions was considered low. Considering that the wall of the uterus is irregularly observed in connection with the septa of the cystic lesions, it was considered that the cyst originated from the wall of the organ rather than from the mesentery or peritoneal lesion. Therefore, GLA, adenomyosis and paramesonephric cyst were considered as differential diagnoses, which can't be ditinguished by imaging alone, and immunostaining tests are required. Becase GLA has been reported not only in young human patients, but also in older human patients, care should be taken not to misdiagnose GLA as metastatic cancer when cystic lesions occur in multiple organs , 21.In human, the presence of chylous fluid in cysts with high triglycerides is pathognomonic for lymphangioma, and according to what has been reported so far, it has a common feature that small lymphocytes are mainly seen , 23. TheLymphangiography can reveal leakage or obstruction of the lymphatic pathway. If a patient presents with pleural effusion or ascites, lymphangiography may be helpful to identify the lymphatic pathway for diagnosis and treatment planning . HoweverHistopathology and immunostaining of LYVE-1, a marker associated with lymphatic vessels, must be performed to distinguish whether it is derived from lymphatic vessels vs. vascular endothelium . CautionIn humans, the PIK3CA gene and NRAS gene are known to be associated with generalized lymphatic anomaly, but there is no study on the related genes in animals , 16. TheIn humans, five out of six patients with lymphatic anomaly of the UB showed clinical signs of hematuria . To reduThe best treatment for lymphatic anomalies is surgical removal. However, since lymphangioma often includes deep tissue, complete resection may not be possible, and if only the superficial part is removed, the recurrence rate is approximately 20% in humans . If compOur study has several limitations. First, biopsy of the rectum was not performed. However, the US and CT showed the same pattern as the cysts in other organs, and since the same immunostaining results were obtained in all other five sites, the cyst observed in the rectum was also considered to be caused by GLA. Second, complete resection was not achieved in our case. Only debulking was performed because the cysts were so extensive that complete resection was impossible. In addition, sclerotherapy was not performed, because the cyst was multilobulated. Radiation therapy can be applied, but radiation hazards can occur in the heart and lungs, and since there is a case that showed a good prognosis without treatment other than debulking in humans, only debulking was performed in our case , 32. At To the best of our knowledge, in veterinary medicine, this is the first case of lymphatic anomaly of the ovary, uterus, bladder, and rectum, and the first case of GLA involving more than two parenchymal organs. In the case of multiple cysts in multiple organs of the abdominal cavity in young dogs, GLA should be included in the differential diagnosis.Ethical approval was not required for the study because the case report is a description of a clinical case. Written informed consent was obtained from the owners for the participation of their animals in this study.S-HP and J-HL drafted the manuscript. S-HP, J-HL, and HY contributed to case management. HY confirmed the cases and revised the final submission. ES performed the pathological studies. MK and J-iH performed the gene analysis. All authors contributed to the article and approved the submitted version.


Cystic medial necrosis is a disorder of large arteries, particularly the thoracic aorta, characterized by an accumulation of a basophilic ground substance in the media with cyst-like lesions. A male in his late 20s was brought to our trauma bay after he met with a road traffic accident with a complaint of abdominal pain. Clinical examination revealed tenderness in the left lumbar region. The contrast-enhanced computerized tomography revealed an aneurysm of size 11×9.6×9.2 cm in the left lateral aspect of the abdominal aorta at the origin of the left renal artery. Intraoperatively, an aneurysm of size 10×10 cm from the juxta renal abdominal aorta was identified, and aortic rent was repaired with a polyester graft. The tissue was sent for histopathology, which showed complicated atherosclerosis with cystic medial degeneration and aneurysmal rupture of the abdominal aorta containing thrombus. The patient had an uneventful postoperative course and is doing well without any complaints at a two-year follow-up. The prevalence of abdominal aortic aneurysm (AAA) in the United States is estimated at around two to eight percent, increasing with age with a male predisposition . The ane2. Abdominal ultrasonography revealed a saccular outpouching from the left lateral aspect of the abdominal aorta inferior to the superior mesenteric artery at the level of the left renal artery with a partial thrombus. The contrast-enhanced computerized tomography revealed an aneurysm of size 11×9.6×9.2 cm in the left lateral aspect of the abdominal aorta at the origin of the left renal artery  stain Figure . DisruptBabes and Mironescu described the CMN in aortic dissection in 1910 . In 1928CMN is not the cause but a common pathological finding secondary to primary disorder, like fibrillin deficiency or advanced apoptosis. CMN is a common finding in elastic arterial specimens, and the difference between normal and abnormal is the amount of ground substance in the media . In patiCMN as a cause of AAA is exceedingly rare in young patients. The literature regarding the characteristics of this entity is lacking. Hence, we must call on vascular surgeons worldwide to report more such cases to comment on the epidemiology and clinical presentation. However, moving toward the endovascular treatment for aortic aneurysms might be a roadblock to learn about the pathological causes of the aneurysms.


Primary hyperparathyroidism (PHPT) can be associated with osteoporosis (OP) and fractures. We present a case of a 49-year-old male referred to our osteoporosis outpatient clinic due to a right femur osteoporotic fracture. At the age of 38, a right plantar nodular lesion was excised, and its histology was compatible with a deep dermis nodule formed by mononuclear and giant osteoclast-like cells. He has reported osteoporotic fractures since age 39 and renal colic episodes since age 45. His father had lipomas and renal colic episodes, and his paternal grandmother had lipomas. The laboratory evaluation was compatible with PHPT. A cervical ultrasound showed a 10mm single solid nodule in the left thyroid lobe, strongly hypoechogenic, with microcalcifications. Its cytology showed parathyroid tissue without atypia. Parathyroid scintigraphy had no uptake. A dual-energy X-ray absorptiometry scan showed a femoral neck Z-score of -4.3. He started alendronate/cholecalciferol (70mg/5600IU) weekly. He was submitted to a left hemithyroidectomy. Its histology showed an intrathyroidal parathyroid adenoma. Ectopic parathyroid adenomas are rare, of which 0.7%-6% are intrathyroidal. The excised foot lesion could be a brown tumour. Furthermore, calcium metabolism evaluation at that time might have allowed a PHPT diagnosis and its morbidity prevention. Osteoporotic fractures in young men must alert to secondary OP. Secondary osteoporosis (OP) is defined as bone loss with microarchitectural alterations leading to fragility fractures caused by medication or underlying diseases. Medical disorders responsible for secondary OP include endocrine diseases, gastrointestinal/biliary tract disorders, renal diseases, cancer and prolonged immobilisation . EndocriIn assessing a man with suspected OP, it is recommended to consider secondary causes because 50%-70% of male OP cases have a secondary aetiology . ConcernPrimary hyperparathyroidism (PHPT) is diagnosed, in most cases, as an incidental finding on routine laboratory tests , and theHyperparathyroidism leads to bone loss and increased fracture risk, particularly in the cortical bone. Studies describe a prevalence of OP due to PHPT ranging from 39% to 62.9%, with the peripheral skeleton preferentially affected . OsteopoA 49-year-old man was referred to our osteoporosis outpatient clinic after a right femoral neck fragility fracture . At the age of 38, this patient had an excision of a nodule in his right plantar foot that was incomplete in length and depth performed at the dermatology clinic. Its histological report showed ‘a nodule constituted by mononucleated cells without atypia and giant cells like osteoclast in the deep dermis, compatible with tenosynovial giant cells tumour’. After that procedure, he quit the medical follow-up.He also reported progressive complaints of several renal colic episodes associated with generalised muscle weakness, fatigue, diffuse bone pain and multiple non-associated trauma fractures of the right shoulder and fingers of both hands since the age of 39. He denied other diseases and chronic medication. His father had some renal colic episodes and several chest lipomas, and his paternal grandmother also had a few chest lipomas. Due to the painful complaints, he reported a marked limitation of his daily activities and quality of life. His physical examination was unremarkable, except for several scattered lipomas Figure .Initial blood tests were compatible with PHPT. The pituitary function and neuroendocrine hormones were normal Table .The cervical ultrasonography documented a unique 10mm solid and markedly hypoechogenic nodule with microcalcifications in the left thyroid lobe. Its fine-needle aspiration cytology (FNAC) showed parathyroid tissue without atypia. Its immunochemistry was positive for parathyroid hormone (PTH), GATA3 and AE1/AE3 and negative for TTF1 and thyroglobulin. The PTH measurement in the FNAC washout was >5,000 pg/mL. The sestamibi parathyroid scintigraphy was negative Figure .A dual-energy X-ray absorptiometry scan revealed a mean Z-score of -4.3 in the femoral neck and the total hip and a mean Z-score of -3.1 in the lumbar spine (L1-L4). There were no vertebral fractures on his dorsal-lumbar X-ray. Bone scintigraphy demonstrated microfractures in several costal arches. The abdominal computerised tomography scan showed left kidney obstructive uropathy and lithiasis. A genetic analysis including next-generation sequencing (NGS) 17 genes panel identified no pathologic form of genetic PHPT. He started alendronate/cholecalciferol  weekly and was submitted to a left hemithyroidectomy. Histology demonstrated an intrathyroidal parathyroid adenoma without other alterations in the remaining parenchyma.This case illustrates a probable long progressive history of PHPT ending with a femoral neck fracture. Despite PHPT is diagnosed by an abnormal result in biochemical screening or by non-specific symptoms in most cases, there are rare cases of advanced PHPT that are presented with bone disease, such as osteitis fibrosa cystica, osteomalacia and, rarely, brown tumours .In this report, we described a case of a young man with a long history of fragility fractures. We consider that this progressive history in a young man must signal secondary OP . The cruAs found in the patient’s foot, osteoclast-like giant cell lesions can be presented in different types of bone or soft tissue tumours, like brown tumours, mesenchymal phosphaturic or tenosynovial tumours. Despite being similar in histology, its clinicopathological characteristics, prevalence and behaviour differ according to the tumour type . Due to In a patient with OP due to PHPT, the management of the OP includes not only its medical treatment but also a parathyroidectomy. This surgery can usually reverse the bone loss after one to two years . In thisThe family’s history of recurrent renal colic and the patient’s younger age may point out a genetic cause of PHPT. Lipomas, a possible cutaneous manifestation of multiple endocrine neoplasia type 1 (MEN1) syndrome , made usIn conclusion, this case contrasts with the most common presentation of PHPT nowadays as, over the recent decades, its clinical presentation shifted from overt disease to mild biochemical presentation without symptoms. We reported a PHPT presentation causing severe bone disease and OP fractures in a young man. This must alert to secondary OP. It was identified as an ectopic parathyroid adenoma with a rare intrathyroidal location. The biochemical evaluation, at the foot excision time, might have diagnosed PHPT and prevented 10 years of disease morbidity.


This case report presents a rare instance of a 73-year-old male diagnosed with a yolk sac tumor (YST) coexisting with adenocarcinoma components in the stomach. YSTs are primarily gonadal and seldom occur in extragonadal sites such as the gastrointestinal tract. The patient underwent curative resection followed by chemotherapy, resulting in long-term survival without recurrence. This case contributes to the limited existing literature on gastric YSTs, emphasizing the importance of early diagnosis and effective treatment for this aggressive malignancy. It serves as a valuable addition to our understanding of the pathophysiology, diagnosis, and management of this rare condition. Yolk sac tumors (YSTs) are primarily known to originate in the gonads, either as standalone tumors or as components of mixed germ-cell tumors. While they are predominantly gonadal, approximately 5% of YSTs manifest in extragonadal sites, including midline structures such as the brain, lungs, upper aerodigestive tract, anterior mediastinum, retroperitoneum, and sacrococcygeal region . Their oThe objective of this report is to enrich the sparse literature on gastric YSTs with adenocarcinoma components. We present a unique case successfully managed with curative resection and chemotherapy, achieving long-term survival without recurrence. This case underscores the importance of early diagnosis and effective treatment for this rare, aggressive malignancy, serving as a valuable addition to existing research.A 73-year-old male presented to the hospital complaining of epigastric pain, anorexia, and melena. The patient had a known history of gastritis and had been taking non-steroidal anti-inflammatory drugs (NSAIDs) for knee joint pain. Upon admission, a comprehensive physical examination was conducted, revealing signs indicative of anemia. Laboratory investigations, including a complete blood count, showed a hemoglobin level of 9.1 g/dL. The constellation of history and clinical findings raised suspicions of gastric carcinoma.To further evaluate the suspected diagnosis, a gastric endoscopy was performed, revealing an ulcerated and hemorrhagic mass in the antrum of the stomach. A biopsy of the lesion confirmed the histological features of adenocarcinoma. Subsequent imaging studies, including a computed tomography (CT) scan of the chest, abdomen, and pelvis, demonstrated stomach wall thickening and regional lymph node involvement, although no distant metastasis was observed.Following diagnosis, the patient underwent a total gastrectomy with D2-lymphadenectomy and a subsequent Roux-en-Y gastrojejunostomy. The excised specimen was sent for histopathological analysis, revealing a 50 x 40 mm lesion. The tumor was located 25 mm, 72 mm, 37 mm, and 90 mm away from the proximal, distal, lesser omental, and greater omental margins, respectively. Histopathology confirmed poorly differentiated adenocarcinoma with YST differentiation, extending into the subserosal fat but not invading the visceral peritoneum or nearby structures. Of 16 lymph nodes examined, 13 were involved, and lymphovascular invasion was present. The pathological stage was classified as T3N3aM0 stage III gastric adenocarcinoma with YST differentiation, per the American Joint Committee on Cancer (eighth edition).Microscopically, the adenocarcinoma component consisted of poorly differentiated tubular structures. The YST component exhibited a reticular pattern lined by a variable combination of flattened malignant cells, papillary structures, and cuboidal cells. Immunohistochemical staining revealed that the YST component was SALL4-positive and contained glycogen and hyaline globules. Schiller-Duval bodies were sporadically present. Additionally, the YST component tested positive for p53, carcinoembryonic antigen, and alpha-fetoprotein (AFP), while the adenocarcinoma component was only p53-positive. Features obtained on biopsy are elaborated in Figure 2, both administered bi-weekly (q2 weekly). The patient demonstrated a favorable response to the treatment, showing no signs of disease recurrence on regular CT scan follow-ups for 18 months post-chemotherapy initiation. Given the absence of any features of recurrence on the follow-up CT scans, the same chemotherapeutic regimen was continued, with a strong emphasis on regular monitoring and follow-up.Following surgical intervention, the patient was referred to the oncology department for further management. After a thorough review of the patient’s history, investigations, and surgical findings, adjuvant chemotherapy was initiated. The regimen consisted of four cycles of carboplatin at a dosage of AUC 3 and paclitaxel at 100 mg/mChoriocarcinoma and YST-like differentiation in gastric cancers are exceedingly rare. While there have been reports of gastric adenocarcinomas concurrently possessing choriocarcinoma and YST components, our case specifically discusses the coexistence of adenocarcinoma and YST differentiation in the stomach, adding to the limited literature on this topic . The patMen, with a mean age of 65.2 years, are more susceptible to gastric YSTs than women. The clinical symptoms often include epigastric discomfort, hematemesis, anorexia, abdominal fullness, and weight loss, but these are generally non-specific . EarlierElevated serum AFP levels, commonly seen in YSTs, usually decline post-resection but remained stable in our case, suggesting their potential as a predictive marker for recurrence and survival . The genThe optimal treatment strategy beyond early diagnosis and curative resection remains undetermined. More research and clinical data are needed to establish the most effective treatment for gastric YSTs. To date, only 20 cases have been reported . To our One of the limitations of this case report is the absence of endoscopic images of the stomach. While we were unable to procure the endoscopy images, we have included detailed histopathological biopsy pictures, which provide valuable insights into the tumor’s characteristics. These images, combined with the comprehensive clinical, surgical, and histological data presented, offer a thorough understanding of this rare case.Adjuvant chemotherapy agents such as cisplatin, vinblastine, bleomycin, and etoposide have not proven effective in enhancing long-term survival for gastric YSTs, which are typically chemotherapy-resistant . CurrentThe confluence of adenocarcinoma and YST differentiation in gastric cancers is exceptionally rare, leaving its exact pathogenesis largely uncharted. Generally linked to poor outcomes, early diagnosis via routine screenings could improve prognosis. The ideal treatment approach, combining medical and surgical interventions, remains undetermined.This case report holds multifaceted value for medical literature. It augments sparse biostatistical data, aiding future research. It also sheds light on the pathophysiology of a complex, poorly understood malignancy and serves as a clinical guide for similar cases. Thus, this report is a pivotal addition to existing studies, aiming to catalyze further research and enhance patient care.


Membranous fat necrosis is a rare histological finding. Despite its low incidence and lack of clinical significance, it can involve various organs. Majority of membranous fat necrosis cases are diagnosed in breast lumps and skin in comparison to intra-abdominal lesions. There has been only one reported case of membranous fat necrosis of gall bladder in literature.A 56-year-old female patient with previous history of diabetes mellitus and hypertension was administered due to abdominal pain and fever. Based on her physical exam, lab data, and ultrasonography, she was diagnosed by cholangitis. After primary care, she went under cholecystectomy. The histological finding of gall bladder revealed crenulated fatty membranes phagocytized by macrophages in Hematoxylin and Eosin (H&E) staining. Moreover, necrosis and giant cells were seen on Sudan black staining. Hence, the diagnosis of membranous fat necrosis in gall bladder was made.Membranous fat necrosis occurs when peripheral blood circulation is compromised. Ischemia of fat tissue cause fatty membranous material accumulation acting as foreign bodies. Hence, it can attract inflammatory response. Regarding pathology, phagocyted membranous by macrophages and giant cells is diagnostic. Sudan black, Luxol fast blue (LFB), long Ziehl-Neelsen, and D-PAS are positive in membranous fat necrosis.Membranous fat necrosis of gall bladder is a rare entity. This is the second reported case of such diagnosis. Nonetheless, further pathological investigations are necessary. •Membranous fat necrosis, gall bladder, acute cholangitis However, it is a rare entity in other organs . In 1973In the following study, we represent the second and most recent case of membranous fat necrosis of gall bladder as well as literature review.2An obese 56-year-old woman was admitted in the emergency department due to acute abdominal pain. Constant pain was located mostly in the RUQ radiating to all abdominal quadrant. Although she had had previous history of similar pain from 6 months age, this episode of intolerable pain started 3 h before patient's admission after having a large meal. Also, she complained of fever, nausea, and vomiting. Regarding her history, she suffered from insulin dependent diabetes mellitus and hypertension. In her physical exam, she was agitated, dehydrated, feverish, icteric, and tachycardic. She had generalized abdominal tenderness. Lab data showed high total bilirubin and leukocytosis. Ultrasonography showed pericholecystic fluid, wall thickening and edema of 51 mm, and positive Murphy sign. Based on the diagnosis of acute cholangitis, primary pain management, fluid resuscitation, GI rest, and antibiotic therapy were done. After stabilizing the patient and resolving abdominal pain for 3 days, she went under laparoscopic cholecystectomy. She experienced full post-op recovery and she was discharged with no complications. Her follow-up was uneventful. Written informed consent was obtained from the patient's parents for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Regarding pathology, eosinophilic, crenulated fat membranes in macrophages and giant cells could be seen in H&E staining , Fig. 2 The article has been reported in line with the SCARE criteria ,9.33.1Fatty cells, also known as adipocytes, are distributed in human organs. Fat necrosis, like every necrosis, is directly related to vascular circulation. Hypoxia leading to ischemia is a trigger for fat necrosis. After ischemia occurs, adipose cells are fragmented which creates intracellular vacuoles. The necrotic lipid in such vacuoles attracts accumulation of fibroblasts, multinucleated giant cells, and lipid-laden or foamy histiocytes (“fat-filled macrophages” or “foam cells”). Although phagocyted membranous is a characteristic feature of MFN, it was not reported in some cases. Moreover, the lipase released by enucleated adipocytes causes triglyceride breakdown and the presence of fatty acid in the interstitium. As a result, membranous fat necrosis happens when liquefactive necrosis causes cavity formation. The fibrinogen from damaged vessels is turned to active fibrin by thrombin leading to fibrosis. Furthermore, combination of negatively charged fatty acid and positively charged calcium ions develops calcification in necrotic fat tissue. However, the greater the ischemia, the greater the damage and necrosis will be. Hence, fibrosis and calcification are reported in cases of breast membranous fat necrosis .3.2Despite MFN rarity in intra-abdominal lesions, it is commonly reported in pancreatitis patients. Enzymic fat necrosis, also known as intra-abdominal fat necrosis, is the characteristic diagnosis of pancreatic disorders . FurtherFollowing the same etiology, circulatory disturbances and ischemia in cholecystitis is the most considered underlying cause in MFN presentation. The degraded fatty liquid is detected as foreign body. It is supported by the presence of macrophage and phagocytized products in necrotic fat tissue. Our patient suffered from diabetes mellitus and hypertension which could be the risk factors for MFN. Accumulation of inflammatory cells can shape MFN. Subsequently, such inflammatory response ends in fibrosis and hemorrhage in the affected organ, naming gall bladder . Neverth3.3Z-N are diagnostic for membranous fat necrosis [Membranous fat necrosis is a pathological term. In fact, diagnosis of MFN relies on histology. Membranocystose-like feature of MFN was first introduced in the osseous cystic lesions of a Japanese man in 1961. Macroscopically, hemorrhage, bright yellow liquified fat, necrotic area, calcification, and fibrosis can be seen ,7. Micronecrosis ,11,13,144Membranous fat necrosis is a pathological finding of fatty tissue, mostly in skin disorders and breast lesions. Till now, the real underlying cause of MFN is unknown. Thus far, this is the second case of membranous fat necrosis of gall bladder. Further studies are essential to investigate the pathophysiology of MFN in gall bladder.Not applicable.This study received no funding.Authors' contributions: Dr. Mahsa Salehi and Sheidaei provided the main idea behind this research. Dr. Mahsa Salehi, Jafari, Rehman, Nourbakhsh, and Mehrnaz Salehi gathered data. Dr. Mahsa Salehi and Jafari wrote the manuscript and did the final revision and editions. Dr. Sheidaei submitted the manuscript.Dr. Mahsa Salehi.N/AWritten informed consent was obtained from the patient's guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.Not applicable.It is provided.There is no conflict of interest.


Necrotising fasciitis caused by a perforated colon cancer is a very rare occurrence and can be very life threatening needing urgent intervention involving tissue salvage and oncological treatment. There is not enough evidence in the literature regarding management of the same. This case report highlights one such case along with management principles.We present a 66 year old male with 3 weeks of a progressive right lower quadrant lump and constitutional symptoms. He had a computed tomography scan demonstrating a complex collection in the right anterior abdominal wall, containing multiple locules of gas and air fluid levels near an abnormally thickened hepatic flexure. He was taken for an urgent debridement followed by laparotomy which demonstrated extensive abdominal wall necrotising fasciitis secondary to a perforated hepatic flexure tumour invading into the duodenum. He was given a diverting ileostomy. He had a relook laparotomy the next day for a right hemicolectomy and part of the duodenum resected with a refashioned end ileostomy. He was subsequently managed on the ward for two weeks and then discharged home. He remains well and has been referred to medical oncology for adjuvant chemotherapy.A two step surgical approach was key in this case, first step for source control and the second step focused on an oncological resection.This case explains the importance of excluding malignant causes of necrotising fasciitis. Perforated cancers can manifest as necrotising fasciitis and management should include timely debridement as well as oncological principles. •Necrotising fasciitis can be life threatening due to progressive necrosis.•Perforated cancers are a rare but important cause of necrotising fasciitis.•Timely debridement is vital as well as finding out the cause for the same.•Oncological resection is the next vital step after debridement in case of a perforated cancer. It can Management also includes consideration of rare causes such as perforated cancers to be the potential cause. According to Kumar et al., the incidence of necrotising fasciitis secondary to perforated gastrointestinal cancer is only 16% . This caThis case report has been produced in keeping with the SCARE criteria .2A 66 year old male presented with abdominal pain and a 3 week history of a right lower quadrant (RLQ) lump that had progressively developed since he attempted to move a large bottle of oil (approximately 15 L). This was associated with 2 weeks of anorexia and a 5 kg weight loss in 2 weeks. He was not clinically obstructed, he had opened his bowels the morning of presentation and was passing flatus. He had no symptoms of nausea or vomiting. He has got no significant medical or surgical history. He was not a diagnosed diabetic and his random blood sugar level was 5 on presentation. He denied any previous medical history including any kidney or liver related conditions. He has never had a colonoscopy in the past and denied any history of bowel cancer or inflammatory bowel disease in the family.His vital signs on arrival to the emergency department included the following: Temperature of 37 degree Celsius, Heart rate 75 beats per minute, Blood pressure 123/75 mmHg, Respiratory rate 15, Oxygen saturation 98 % on room air. His abdomen was very distended on examination, with overlying erythema over the right side . His RLQHe underwent a CT Abdomen which demonstrated a complex collection in the right anterior abdominal wall, containing multiple locules of gas and air fluid levels  A and B. A bolus of IV Hartmanns was prescribed followed by IV Hartmanns at a maintenance rate of 125 mL/h. Triple antibiotics  were charted as per the therapeutic guidelines [He underwent an emergency operation during late hours that night, wherein the anterior abdominal wall over the right lower quadrant demonstrated necrotising fasciitis, containing extensive purulent fluid needing drainage, and dead tissue including fascia needing debridement. A transverse incision was made over the right lower quadrant overlying the abscess. Extensive debridement was performed of all necrotic tissue including fascia.This was then followed by a laparotomy to determine the cause of the necrotising fasciitis. Laparotomy was performed through the initial incision, cut was extended to facilitate adhesiolysis – careful adhesiolysis was done to separate small bowel from the anterior abdominal wall and then further adhesiolysis to separate omentum and hepatic flexure from the anterior abdominal wall. A mass was found at the hepatic flexure which was presumed to be the source of the necrotising fasciitis due to perforation. However, given the mass was quite adherent to the duodenum and due to lack of safety deemed with regards to separating the mass in order to perform a right hemicolectomy, the decision was made to perform a diverting ileostomy and for a relook the next day during day hours.Ileostomies are normally made on the right side of the abdomen given the location of the terminal ileum, however it was challenging in this case as the anterior abdominal wall was debrided in the right lower quadrant. Hence, an end ileostomy was brought out at a trephine in the left abdomen that was marked preoperatively.He was sent intubated to Intensive care post operatively, with a view to bring him back to the operating theatre the next day for an oncological resection. He was requiring minimal vasopressor support in Intensive care whilst awaiting the second operation – about 7 mL of Noradrenaline.During the relook the next day, the mass appeared to be perforating into the duodenum thereby needing a right hemicolectomy with resection of part of duodenum. The 3rd part of the duodenum was involved. Therefore, it was difficult to mobilise the hepatic flexure away from the duodenum as part of the right hemicolectomy. Transverse colon was then resected using a EndoGIA 80 mm stapler. Mesentery was then controlled with a ligasure impact (energy device) followed by stitch ties. Ileocolic pedicle was then taken down. An EndoGIA 60 mm stapler was then used to resect duodenum off hepatic flexure by stapling across the duodenum. A patent lumen was noted post stapling. Transverse colon stump was then brought out via stoma opening – for mucus fistula and end ileostomy was refashioned. His management was then continued with vac dressings and a slow diet upgrade. 2 weeks later, his abdominal wound was eventually closed in the operating theatre. He also had a barium meal which revealed a patent duodenal anastomosis A and B.FThe initial tissue culture showed a heavy growth of mixed coliforms, the histopathology of the abdominal wall was consistent with an abscess – dense neutrophilic abscess in the subcutaneous tissue with necrotic debris. No fungal organisms were seen. There was no evidence of invasive malignancy.His hepatic flexure histopathology came back positive for high grade adenocarcinoma with mucinous differentiation, loss of MSH-6 → pT4b with tumour perforating into the duodenum. There were 16 lymph nodes in the final specimen but none of them were positive for metastases.There was positive staining with CK20 and CDX2 and negative staining with CK7. He was then referred to medical oncology for adjuvant chemotherapy who have organised follow up for the patient in the community. He was then discharged home. His chemotherapy was initiated about 4 weeks after the surgery. There were no post operative complications that delayed his treatment.3Perforated cancers that manifest as necrotising fasciitis are fairly rare and do not seem to be very well known in the literature, with only a few reported cases . The incNecrotising fasciitis is more predisposed in patients with diabetes, malignancy, chronic liver and kidney disease as well as a history of alcohol abuse . Signs aSuspicion for necrotising fasciitis warrants an urgent computed tomography (CT) which usually shows a subcutaneous gas and fluid collection . In certIn this case, our patient was very stable and his presentation was not very typical for necrotising fasciitis. He did not have any risk factors like diabetes, immunosuppression or smoking. He presented with a 3 week history of a progressively worsening lump post heavy lifting which was initially suspicious for an incarcerated hernia more than necrotising fasciitis. Therefore, a CT was warranted to further investigate this lump. It is however agreed that if there is a high clinical suspicion for necrotising fasciitis, surgery should not be delayed for imaging .LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score is a diagnostic scoring tool which helps differentiate necrotising fasciitis from other soft tissue infections . It usesThe management of necrotising fasciitis includes Intravenous fluid resuscitation, broad spectrum antibiotics and emergency surgical intervention. Urgent surgical intervention ie debridement down to healthy tissue is still considered gold standard when it comes to management as it aims to stop progression of infection and reduce systemic toxicity . Delay iIn our case given suspicion of malignancy, principals of oncological resection were key. Therefore, a two step approach was useful – the first step helped achieve initial source control and the second step helped focus on the oncological resection, thereby optimising post operative recovery and enabling consideration of adjuvant chemotherapy .Vac dressings have been shown to be very important in the closure of wounds associated with necrotising fasciitis . Vac dre– The rationale behind choosing an ileostomy and mucus fistula over an ileocolic anastomosis is the fact that there was contamination in the abdomen from a perforated colonic tumour. Given the high risk of anastomotic breakdown in the context of recent contamination and sepsis from the necrotising fasciitis, the decision was made not to perform an anastomosis. Calderillo-Ruiz et al [There is a controversy about making stomas in such situations iz et al  further iz et al . HoweverIn conclusion, this case demonstrates an atypical presentation of necrotising fasciitis secondary to a perforated colonic cancer and highlights the importance of considering important rare causes such as perforated cancers to be the potential cause of necrotising fasciitis. This thereby enables us to provide timely management including appropriate surgical intervention. Certain features of patient's history such as development of right lower quadrant lump post heavy lifting and progressive worsening of lump with pain are more suggestive of a hernia over a presentation of necrotising fasciitis. Moreover, the chronicity of his symptoms (ie 3 weeks) makes it less favourable for a necrotising fasciitis. These features thus justify the use of a CT to aid in the diagnosis which was supported by the patient's stable haemodynamic status. This case thus teaches us that sometimes imaging can be useful to diagnose necrotising fasciitis as this changes management – if no imaging was performed and patient was managed as a clinical incarcerated hernia, the operation principles would have been different.There were no sponsors for this case report.This study has been exempted from ethical approval by our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.This case report is not a “First in Man” and therefore does not require any registration.There are no conflicts of interest in the creation of this case report as declared by the authors.


Ruptures of the intra-abdominal vein causing a spontaneous hemoperitoneum in cirrhotic patients is a rare condition. However, diagnosis must be considered early in cirrhotic patients with hematic ascites as a delayed diagnosis with hemodynamic instability is associated with a poor prognosis.We present the case of a 54-year-old cirrhotic patient who presented a spontaneous hemoperitoneum due to the rupture of the intra-abdominal vein that was diagnosed during exploratory laparoscopy.Early diagnosis and management of spontaneous hemoperitoneum due to the rupture of intra-abdominal vein helps improve its prognosis. Spontaneous hemoperitoneum is a rare but catastrophic condition caused by the rupture of the liver, spleen or abdominal vessels. In patients with cirrhosis, diagnosis of spotaneous hemoperitoneum is difficult. This is a case report of a 54-year-old cirrhotic man with a spontaneous hemoperitoneum due to the rupture of a vein within the abdomen. The diagnosis was suspected as the patient had signs of blood in the abdomen. To confirm spontaneous hemoperitoneum, the doctors performed a procedure called exploratory laparoscopy, which involves inserting a small camera into the abdomen. The laparoscopy confirmed the presence of blood and thus the diagnosis of spontaneous hemoperitoneum. Portal hypertension, seen in patients with cirrhosis, often leads to collateralization of blood flow via variceal vessels that shunt blood from the portal to the systemic circulation, which can be the cause of paraumbilical vein permeabilization or intra-abdominal varices . The rupWe present the case of cirrhotic patient who presented with a spontaneous hemoperitoneum due to the rupture of the intra-abdominal vein. This was diagnosed during exploratory laparoscopy.A 54-year-old man with a history of hypertension treated with calcium channel blockers and steatohepatitis (NASH) cirrhosis was admitted to the gastroenterology department for oedemato-ascitic syndrome.3 and the prothrombin time was 53%. Liver tests revealed elevated transaminase levels with ALAT at 86 UI/l and ASAT at 98 UI/l. Total bilirubin blood level was 36 μmol/l and albuminemia 27 g/dl.On examination, the patient had no fever or jaundice. Blood pressure was measured at 140/90 mmHg and heart rate at 68 bpm. He presented peripheral edema. Abdominal examination revealed collateral venous circulation with a grade three ascites. The biological findings showed anemia with hemoglobin at 10.2 g/dl. The platelet count was 112,000/mmThe ascites was hematic. It was a transudate with protein level at 10 g/l and cytological examination showed the presence of numerous red blood cells >10,000 elements.As part of the etiological assessment of this spontaneous hemoperitoneum, an abdominal CT-scan was performed and showed the absence of active bleeding and absence of hepato-cellular carcinoma (HCC). However, a significant portal hypertension and collateral venous circulation was observed .A diagnostic laparoscopy was performed which showed an important intra-abdominal and parietal venous circulation, more developed in the left abdominal wall but without active bleeding. This parietal circulation may be the cause of the hemoperitoneum as the bleeding could be intermittent.Seven days after surgery, the patient presented with abdominal pain secondary to a fluid ascites infection. Antibiotic therapy with tazocillin and albumin perfusion was prescribed. Nevertheless, the patient presented with septic shock and multi-visceral failure. Unfortunately, the patient continued to present with septic shock and mutli-visceral failure and passed away 3 weeks later.Spontaneous hemoperitoneum is defined as blood within the peritoneal cavity in the absence of a traumatic cause . It is aWhen spontaneous hemoperitoneum occurs in patients with cirrhosis, we should firstly consider the diagnosis of hepatocellular carcinoma and intra-abdominal varices rupture .The rupture of an intra-abdominal vein is rare. In fact, few case reports and series have been reported in the literature . There aReviewing the cases that are previously reported in the literature, this condition seems to be associated with a significant mortality of 75%. This is due on one hand to a delayed diagnosis and on the other hand to the own comorbidities of cirrhotic patients ,7.The clinical presentation is nonspecific. The diagnosis is usually made in a cirrhotic patient with hemodynamic instability without external bleeding, a recent in-vascular gesture (puncture) or a significant abdominal traumatism ,8. In ouet al. reported that attenuation values of active hemorrhage and clotted blood ranged from 85 to 370 HU (mean 132 HU) and 40 to 70 HU (mean 51 HU), respectively [Diagnosis of this condition remains difficult. The role of the abdominopelvic scan in this case remains very limited. It can show the presence of an intra-peritoneal effusion and the absence of other causes of bleeding (splenic rupture or hemorrhage from hepatocellular carcinoma). Shanmuganathan U mean 13 HU and 4ectively . Interprectively . In our Data concerning the management of spontaneous hemoperitoneum due to the rupture of intra-abdominal vein are rare. There are no randomized trials due to the rareness of this situation. However, this condition seems to be underestimated, probably because most of the patients present tense ascites and terminal stage hepatic disease leading rapidly to death .Reported treatment approaches include local umbilical vein ligation, embolization of paraumbilical veins, transjugular intrahepatic portosystemic shunt (TIPS), and laparoscopic clipping of the intra-abdominal vein .The role of arteriography is controversial. Some authors suggest that arteriography and embolization has proved to be an inefficient investigation for diagnosis and treatment of retroperitoneal bleeding varices, it postpones the surgical treatment ,8. OtherThe main treatment of hemoperitoneum due to intra-abdominal variceal bleeding is surgery especially in patients with hemorrhagic shock. Nevertheless, the surgical portosystemic shunt or the TIPS can be considered for selected patients ,13. ThesSpontaneous hemoperitoneum due to rupture of an intra-abdominal varicose vein in cirrhotic patients is a rare condition associated with a significant mortality. An early diagnosis can improve prognosis as it depends on early surgical management.Spontaneous hemoperitoneum due to rupture of an intra-abdominal varicose vein is a rare condition in cirrhotic patients with a poor prognosis.Diagnosis of spontenous hemoperitoneum must be considered in a cirrhotic patient with hematic ascites or in the case of hemodynamic instability without external bleeding.Early diagnosis and management significantly improves the prognosis.


Chylolymphatic cysts are an extremely rare variant of mesenteric cysts and account for 7.3% of all abdominal cysts. They can develop anywhere along the mesentery of the gastrointestinal tract and present in a wide range of symptoms. A 46-year-old male presented with mild abdominal pain and intermittent claudication in his right leg for the last 2 months and a history of a retroperitoneal resection of a simple abdominal cyst 5 years ago. Abdominal ultrasound and computerized tomography showed a fluid-filled cystic lesion measuring 17 × 11 × 10 cm in the right retroperitoneum. The cyst was surgically excised, and the histopathological examination was consistent with the chylolymphatic cyst. On a 1-year follow-up, the patient is recovered with no recurrence observed. Our report presents a case of a giant retroperitoneal chylolymphatic cyst with uncommon presenting symptoms and a rare etiology. Mesenteric cysts are rare intra-abdominal lesions with an incidence rate of 1:100 000 in adults and 1:20 000 in pediatric admissions [A 46-year-old male presented with mild abdominal pain for the last 2 months. The pain was generalized, recurrent and did not relieve on medication. The patient showed intermittent claudication in his right leg. He presented with a similar complaint five years ago; abdominal pain and urinary urgency and hesitancy, which led to a diagnosis of a simple abdominal cyst. Past medical history was insignificant. Surgical history included retroperitoneal cystectomy, herniorrhaphy and a cleft palate repair. Patient had no other complaints and was not on any medications. He was a smoker with a 22 pack-year smoking history. His temperature was normal, and there was no history of weight loss or loss of appetite or change in bowel movement. On physical examination, the abdomen was soft and non-tender without distention. There was a palpable mass in his right flank. Vital signs and blood tests were within normal limits. Abdominal ultrasound (US) showed a large fluid-filled cystic lesion . SubsequChylolymphatic cysts are an extremely rare variant of mesenteric cysts, and account for 7.3% of all abdominal cysts. They might develop anywhere within the mesentery of the gastrointestinal tract. Chylolymphatic cysts have variable clinical manifestations, ranging from common to rare presentations, depending on the cyst’s size, location and age at presentation. They commonly present with abdominal pain or abdominal distention, to more severe cases presenting with an acute abdomen secondary to intestinal obstruction, hemorrhage or rupture , whereasOur case highlights uncommon symptoms. The presentation of intermittent claudication in a 46-year-old male was indicative of an abdominal mass causing compressive effects, which was confirmed by an abdominal US and a CT scan.Mesenteric cysts are most commonly found in the mesentery of the small intestine 60%), followed by the large intestine (24%) and the retroperitoneum (14.5%) [0%, folloRecurrence of mesenteric cysts is uncommon; however, it was significantly correlated with the location of the cyst, and is more likely to occur in retroperitoneal cysts due to the proximity of major vessels and visceral organs, which prevents complete excision, subsequently increasing recurrence rate .Chylolymphatic cysts of size >15 cm are considered giant, and due to the location of the cyst in the retroperitoneum, our patient developed compressive symptoms that lead to its early detection despite having initially presented with mild abdominal pain, which was not characteristic for any specific disease.Chylolymphatic cysts were studied in adult and pediatric populations separately, which resulted in different characteristics accordingly. In children, the mean age of presentation is 4.9 years with a slight male predominance , 8, wherChylolymphatic cysts were classified based on underlying etiologic factors into four groups: congenital and developmental cysts, traumatic or acquired cysts, neoplastic cysts and infective and degenerative cysts . ChylolyAccordingly, the findings of this case suggest a chylolymphatic cyst of traumatic origin, considering the histopathologic features of the cyst wall consisting of fibrous connective tissue and infiltrated by lymphocytes and congestive blood vessels, and a history of a surgical intervention on the same location resulting in trauma to the lymphatic channels.Another possible etiology is the recurrence of the previous retroperitoneal cyst.Complete excision of these cysts is the treatment of choice, however, due to the huge size and location of the cyst in the retroperitoneum, partial excision through an open laparotomy was the proper choice of management. The early diagnosis and management despite subtle presenting symptoms yielded into complete recovery with an uneventful 1-year follow-up.In conclusion, notwithstanding its rarity, diagnosis of chylolymphatic cysts should be considered whenever an abdominal mass is recognized regardless of the patient’s age or gender. Regular follow-up imaging is recommended considering the risk of recurrence. We accentuate the importance of reporting new emerging cases in unravelling clinical obscurities related to chylolymphatic cysts.


Anal canal duplication (ACD) is a congenital malformation that typically presents and is diagnosed early in life. It can be associated with other syndromes or congenital malformations. ACD is one of the rarest duplications of the gastrointestinal tract, with no more than 90 to 100 cases reported in the literature. It can be confused with more frequent pathologies such as perianal fistula, especially when it occurs in adulthood. We present the case of a 25-year-old female patient who presents with a second orifice above the native anal orifice. An arthroscopic examination was performed, an incidental diagnosis of ACD was made, and a complete excision of the duplicated anal canal was performed. The aim of the study is to expand the information on this rare pathology in order to take it into account as a differential diagnosis in patients with abscesses, recurrent fistulous tracts, or any other anorectal pathology. Anal canal duplication (ACD) is a congenital malformation located in the midline above the native anal orifice ,2. It waA 25-year-old female patient had spontaneous daily intermittent purulent fluid discharge through the perianal region for one month with no relieving or aggravating factors. Due to the persistent symptomatology, she presented as an outpatient for medical evaluation. Physical examination revealed a punctate lesion of 0.5 x 0.5 cm at approximately 3 cm in the 6 o'clock radius of the native anal orifice in the lithotomy position Figure , with feWith intermittent pain and purulent fluid discharge clinically mimicking a fistulous tract, the patient was scheduled for an anal exploration under general anesthesia. During the surgery, an anoscopy was performed and the anal canal was found to be intact, without lesions and without a fistulous tract between the orifice located at 6 o'clock in the lithotomy position and the native anal orifice. The secondary orifice was explored, finding smooth muscle fibers that contract with the application of energy Video , suggestACD is a congenital malformation that typically manifests early in life ,5, but iACD occurs more commonly in females, with a predilection of nine females for every male ,4,6. CliACD tends to be asymptomatic in the first two years of life, and thereafter, the incidence of clinical manifestations increases . ClinicaThe most useful diagnostic studies are fistulography, magnetic resonance imaging, and anoscopy ,7; howevACD has benign behavior, and only one case of malignant transformation has been reported in history . HoweverDuplication of the anal canal is a rare malformation with few cases described in the literature, mostly in pediatric patients. It is the physician's task to keep in mind this diagnostic possibility in patients with recurrent abscesses or fistulous tracts, especially in adulthood and in pediatric patients with a secondary orifice close to the native anal orifice. The therapeutic option should be surgery, which should be performed as soon as possible, even if the patients are asymptomatic, in order to avoid complications such as malignant transformation. Finally, it is necessary to intentionally look for and be alert to probable associated malformations.


In this study, a 50-year-old male patient had a painless swelling on his right forearm. The lump on the forearm started one year ago and increased in size in the last two months. The mass was 3x6 cm and had a malignant appearance on radiological imaging. The case was reported as pilomatrixoma in the histopathological examination after marginal excision. In this case report, we emphasized that pilomatrixoma is one of the diagnoses we considered in mass formations that can be seen in the upper extremity, although rare. The large mass displaying a malignant character in radiological imaging can be pilomatrixoma, and the Tru-cut biopsy before the final surgery may help diagnosis by preventing the surgeons from aggressive surgical treatment. The marginal excision shall be enough in the definitive treatment. With this study, we aimed to discuss the place of pilomatrixoma in the orthopedic literature, which is published chiefly by otolaryngology, pathology, and dermatology clinics and lacks in the orthopedic literature because it rarely involves the extremities. Pilomatrixoma is a rare skin tumor observed from pluripotent precursor matrix cells of the hair follicle. It is also known as the calcified epithelioma of Malherbe. In 2018, in a literature review, the cases were common in the first and second decades . In thisA 50-year-old male visited our clinic with a painless swelling on the right forearm. He was an active cigarette smoker and had no known comorbidity. The mass started one year ago and increased in size in the last two months. In the physical examination, an atypical malignant nodular 3 x 6 cm lesion was in the lateral 1/3 of the right forearm, with a slightly hyperemic appearance  with heterogeneous contrast enhancement, with a size of 44 x 28.5 mm in the subcutaneous fatty tissue of the forearm mid-section anterolaterally, after intravenous contrast material injection. There was no invasion of the bone tissue. F18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) examination revealed a soft tissue density mass, hypermetabolic soft tissue tumor , located in the lateral of the right forearm middle part, located in the subcutaneous tissue, with intense FDG uptake  whose widest axial diameter measuring 3.0x5.8 cm. Ultrasonography-guided Tru-cut biopsy was applied to the patient by interventional radiology. The epithelial tumor with pilomatrical differentiation was pilomatrixoma. The patient underwent surgical marginal resection. After surgical marginal resection, the wound layers were sutured in accordance with their anatomy. The histopathological diagnosis of the excised material was pilomatrixoma , and there was no recurrence.Pilomatrixoma is usually seen below 20 years of age. It is more common in females than males F: M, 3/2) . There a/2 . TherIn this case report, we emphasized that pilomatrixoma is one of the diagnoses to consider in mass formations in the upper extremity despite being rare. Its treatment is surgical marginal excision of the mass and then close follow-up of the patient for recurrence. Although radiological and nuclear medicine imaging methods showed that the lesion had a malignant appearance in a patient who presented with a large mass with a malignant appearance on the forearm, the final pathology result may be pilomatrixoma. The preoperative Tru-cut biopsy shall guide the diagnosis, and marginal resection rather than aggressive surgery may also be sufficient as the definite treatment.