The diagnosis should be suspected in young girls with chronic abdominal pain and palpable swelling of the lower abdomen. Conservative surgery is the first therapeutic procedure that consists of a total resection of the mass with preservation of the reproductive function. Circulating tumor markers have the potential in diagnosis, prognostic stratification and for follow-up.mixed ovarian germ cell tumors are uncommen in children. Their management must be multidisciplinary and conservative surgery by laparotomy represent the standard of care. •Mixed ovarian germ cell tumors are rarely seen in the paediatric population.•They must be suspected in young girls with chronic abdominal pain and palpable mass of the lower abdomen.•Total excision with preservation of ovarian reproductive function followed by chemotherapy is the gold standard of treatment. Their estimated annual incidence does not exceed 2.2 cases per 100,000 girls and only about one-fourth of all ovarian tumors in females younger than 16 years are described to be malignant (27%) . Accordi2A 13-year-old girl with no significant pathological history was referred by family physician to our department of Paediatric Surgery for swelling associated with a right abdominal flank pain. The patient had no family, drug history or any past surgery nor a particular genetic predisposition to any diseases. Clinical examination found an apyretic child and in a good general condition. On abdominal examination, a right flank tenderness with a solid mass measuring 12 cm was characterized. Additionally, an abdominal ultrasound was performed and showed a poorly limited right para-uterine mass with 100*52 mm in size. Magnetic resonance imaging (MRI) revealed a right ovarian tumoral mass measuring 97*47 mm with irregular seams, on iso-signal T1, peripheral hypersignal and central hyposignal T2 in relation with a central necrosis . Moreove3In children and adolescents, GCTs represent the most common histological type of ovarian tumors and are benign in the majority of cases ,7. AccorThe clinical presentation of patients with ovarian GCTs can be similar in both benign and malignant forms; the most common signs are the presence of a mass of the lower abdomen and abdominal pain which is usually chronic . This neDysgerminomas appear usually as a mass containing multiple lobules that are divided by fibrovascular intensively enhanced septa on MRI and computed tomography (CT) imaging . These sRadiologically, a yolk sac tumor has the property to appear as a voluminous mass with heterogeneous composition: cystic and solid components with areas of necrosis and hemorrhage . The MRI1.Intact ovarian removal without rupture of the tumor capsule. A salpingectomy must be performed if the fallopian tube is adherent.2.Examination of the contralateral ovary with biopsy if a suspicious aspect is seen.3.Inspection of the peritoneum, the liver and the omentum and resection of any abnormal tissue.4.Inspection of aorto-caval and iliac lymph nodes and biopsy of suspicious ones.5.Sampling of ascitic fluid for cytological examination. If ascites is absent, a washing is required ,19.The initial surgical procedure is crucial as it is the first therapeutic option consisting mainly of ovariectomy or ovarosalpingectomy which allow the diagnosis of the disease as well as its extension. Depending on the malignant behavior of the neoplasm and the tumor size, surgery can be performed by a transverse infraumbilical or a Pfannenstiel incision or through a midline approach. During the operation, the following staging priciples should be considered according to the Children's Oncology Group for pediatric ovarian germ cell neoplasms:Biopsy by laparoscopic approach is the best option in case of involvement of neighboring structures or if there is an evidence of a bilateral form. When the initial surgical approach consists of a biopsy or an excision with micro/macroscopic residues or in patients with metastatic disease, a neoadjuvant chemotherapy is recommanded. A post-chemotherapy evaluation show generally a surgically resecable tumor. If the tumor is bilateral, the majority of authors recommend ovarian preservation on the least involved side. Mutilating excisions and bilateral ovariectomies are accepted only when chemotherapy is not effective . Despite4Ovarian tumors and especially mixed ovarian germ cell tumors are uncommen in children. Their management must be multidisciplinary between pediatricians, pediatric surgeons and pathologists. Surgery is the standard of care, which should be conservative to preserve reproductive function. A laparotomy approach still the decision of choice if malignancy is suspected, surgical staging is required, and in case of large tumors.During her last visit and follow-up, our patient achieved a complete remission and her family was satisfied with our management strategy.Not commissioned, externally peer-reviewed.None.Not required.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.Larbi Benradi collected patient's data. Larbi Benradi and Kamal El Haissoufi conducted the literature review, and wrote the manuscript. Abdelouhab Ammor, Youssef Benmoussa, Imane Kamaoui, Anas Haloui, Amal Bennani and Houssain Benhaddou reviewed and supervised the case report writing. All authors approved the final version of this paper.Not applicable.Houssain Houssain and Larbi Benradi.The authors have no conflict of interest to declare.


Spleen hemangiomatosis is the most common type of benign vascular tumor, and it is usually associated with other visceral localizations such as the liver, lymph nodes, skin, and bone marrow. The diffuse form of this condition is defined by the number of locations in one organ. We report the case of a 48-year-old female who sought consultation for left hypochondrium chronic pain. Physical examination subsequently revealed splenomegaly. Imaging showed a diffuse capillary spleen hemangiomatosis, hepatic dysmorphia, and several signs of portal hypertension. While hemangiomas are the most frequently occurring benign vascular tumor of the spleen, hemangiomatosis is a very rare condition  and is cA 48-year-old female with no medical history presented with the complaint of left hypochondrium chronic pain. Physical examination revealed moderate splenomegaly without hepatomegaly. Abdominal ultrasound was performed, which showed heterogeneous splenomegaly measuring 170 mm in the craniocaudal diameter with multiple nodular hyperechoic lesions. The portal vein was dilated, measuring 22 mm, and the liver was dysmorphic with a regular surface. Blood tests including albumin, liver enzymes, bilirubin, and viral hepatitis serology were normal. We completed the exploration with a CT scan. Before contrast iodine injection, we noticed an enlarged spleen, measuring 173 mm in the craniocaudal diameter as well as irregularly lobulated hepatic contour. In the arterial phase, we noticed an enhancement of multiple rounded and nodular lesions of up to 3 cm in size. The splenic artery measured 14 mm in diameter in contrast with the small hepatic, coeliac, and left gastric arteries. These lesions tend to get homogenous in the parenchymal and tardive phases. The portal vein was also enlarged, with portosystemic collateral mapping. No hemangiomatosis was found on the liver or any other visceral area. The patient is currently under medical surveillance. The CT scan follow-up control over the past three consecutive years has revealed the same observations.Isolated spleen hemangiomatosis is a very rare condition secondary to a congenital malformation. Its incidence varies between 0.03-14% based on autopsy findings . In our Spleen hemangiomatosis is a congenital malformation affecting capillary vessels. It is usually asymptomatic and most commonly presents as chronic left hypochondrium pain in late adulthood. In this report, we described a very uncommon situation where spleen hemangiomatosis was associated with portal hypertension and splenomegaly.


Urethral caruncle is a rare condition primarily affecting elderly. Sometimes, it resembles urethral prolapse or malignancies. It can even cause outflow obstruction or urinary retention. A case of 83-years-old woman with urinary retention since a week prior was presented. Physical examination revealed a bulging mass originating from posterior lip of external urethral meatus. Due to the size, it caused outflow obstruction. The whole mass was excised. Histology examination reported the mass as urethral caruncle. Urethral caruncle is a common problem in elderly which rarely cause outflow obstruction. A thorough examination is required to distinguish it from malignancies and other disorders. Urethral caruncle is a benign lesion, usually originating from the posterior part of urethra. It is one of the most common benign tumor of female urethra, especially in elderly. Due to its low incidence and benign feature, there is no wide scale research regarding its etiology. However, it is thought to be related to low estrogen level in postmenopausal women.This study aims to present a case of giant urethral caruncle resembling urethral prolapse, which caused outflow obstruction.An 83-year-old P6A0 postmenopausal woman came to our urogynecology center with chief complaint of urinary retention which exacerbated since a week ago. She said that her urine was only dripping even after straining herself. This symptom had occurred since a year ago. However, she thought that it was one of the symptoms of aging, thus she never went for medical examination. She also complained of a bulging sensation felt at her vagina.There was no complaint of defecating problem nor abnormal vaginal discharge prior to the visit. Her last menstruation was more than 30 years ago. However, she had seen some blood stains on her underwear over the past week. She was a widow and her last sexual activity was more than 20 years ago.She had 6 child, all of which was born vaginally. She had never known the birth weight of her babies. Previously, she had never used any kind of contraceptive. There are no complaints of fatigue nor rapid loss of weight. Her prior medical condition was also unremarkable.Patients vital sign was stable at the time of arrival. Physical examination revealed bulging pedunculated red mass originating from posterior lip of the external urethral meatus. Its dimension was 25 mm × 25 mm, was soft and fixated on palpation. At a glance, it was thought to be urethral prolapse. However, additional examination showed that the prolapse only occurred on the posterior lip of the urethra. It was then thought to be a urethral caruncle. .Fig. 1UrPhysical examination revealed no other pathology on bladder and kidney. Complete blood count, urine examination, and uroflowmetry were done following the meeting. Her blood and urine result was within normal limit while her uroflowmetry result revealed intermittent flow due to abdominal straining with reduced average flow rate without any residual urine.Due to the disturbing symptoms, the patient was scheduled to have total surgical excision of the urethral caruncle on the same day. Following preparation and acquisition of informed consent, total excision under general anesthesia was performed. Following the urethral dilatation, urethrocystoscopy was also performed with normal result.The whole mass was totally resected, while the urethral meatus was then sutured with 3–0 absorbable sutures and 18 French (F) Foley silicon urinary catheter was placed in order to prevent stenosis and help urine drainage. The patient was then discharged while the mass was sent for histology examination.On the seventh day following the surgery, there were no complications found and the catheter was removed accordingly. The histopathologic result reported the mass as hyperplastic urothelium overlying inflamed stroma. The result was consistent with a urethral caruncle. Follow up uroflowmetry on the 14th day showed normal result. There was no sign of residual symptoms or recurrence after 6 months of follow up.Elderly women are prone to having gynecological problem due to various anatomical and hormonal changes, such as sexual dysfunction, pelvic floor disorders, and malignancies.There are some confusions regarding the difference between urethral caruncle and urethral prolapse. Urethral caruncle is a benign mass of the urethral meatus, arising from epithelial hyperplasia, subepithelial inflammation, and fibrosis, sometimes mimicking a neoplasm.Although it is commonly asymptomatic, urethral caruncle can present as a gigantic mass, causing either outflow obstruction or even urinary retention.,Initial treatment for urethral caruncle consists of topical estrogen and oral anti-inflammatory treatment.Although previous study has stated that urethral caruncle does not have any association with increased risk of malignancy, thorough examination is required in order to distinguish urethral caruncle from other disorders.Urethral caruncle is a common gynecological problem especially in elderly. Giant urethral caruncle can cause urinary outflow obstruction and even urinary retention. Thorough examination is required to identify and treat it accordingly.The protocol for this research project has been approved by a suitably constituted Ethics Committee of the institution and it conforms to the provisions of the Declaration of Helsinki. Committee of Research Ethics Committee of Faculty of Medicine, University of Indonesia, approval No. KET-285/UN2.F1/ETIK/PPM.00.02/2019. All informed consent was obtained from the subject(s) and/or guardian(s).Written informed consent was obtained from the patient for anonymized patient information to be published in this article.Authors declare that the study has never been presented on scientific presentation before.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Not applicable.Alfa Putri Meutia: Conceptualization, Formal analysis, Investigation, Resources, Writing – original draft, Supervision, Funding acquisition. Kevin Yonathan: Methodology, Software, Writing – original draft, Validation, Project administration. Fina Widia: Validation, Investigation, Supervision.Authors declare that there is no conflict of interest in this study.


Duodenal lipoma is a rare location of visceral lipomas, most are found incidentally via endoscopy or surgery and usually are asymptomatic. We report the case of a 58-year-old patient with an active bleeding duodenal lipoma. Although endoscopic treatment was scheduled initially, surgical intervention ultimately was indicated due to large size of tumor. Lipomas of the duodenum are nonepithelial benign tumors of relatively uncommon findings; 64% of gastrointestinal lipomas are diagnosed in the colon, but only 4% seen in the duodenum . It is aMr MC, 58 years old, without any particular pathological history. For the past 3 months, he had intermittent episodes of melena and symptomatic anemia. A physical examination of his abdomen was normal. Laboratory test results revealed normocytic anemia (hemoglobin 7.8 g/dL). Esophagogastroduodenoscopy showed a smooth, soft, sessile polypoid lesion measuring around 10 cm in the bulb of the duodenum. At the most distal end of the mass, there was a Forrest type 2B ulcer that was oozing blood and remnant bloody material in the stomach were noted. Multiple biopsies taken from the ulcerated lesion and underlying polypoid lesion. No significant submucosal tissue or malignancy was present in histological analysis. Endoscopic ultrasonography showed a homogeneous and hyperechoic tumor in the submucosal layer of the duodenal wall, which was suggestive of a duodenal lipomatous mass. Given the size of the lesion and the bleeding character on contact, endoscopic polypectomy was practically impossible.The surgical indication was established. He underwent a surgical excision of the polyp by laparotomic approch. After 5 cm longitudinal incision of D2, a 10-cm polyp with ulceration of the tip was found protruding from the bulb of the duodenum . The polLipomatous tomors of the gastrointestinal tract are rare and those of the duodenum are extremely unusual; 64% of gastrointestinal lipomas have been described in all parts of the colon, but only 4% occur in the duodenum. They are usually located in D2 where they arise from the submucosal adipose tissue in 95 % of cases ,2. The mCurrent imaging means, such as computed tomography (CT) scan, magnetic resonance imaging (MRI) and endoscopic ultrasonography can give a correct diagnosis. Duodenal lipomas appear on CT as a well-circumscribed hypodense lesion with a fat density. In MRI, lipomas have high-intensity on T1 and usually present intermediate intensity on T2. Endoscopic ultrasonography is useful to dispense information about the original layer, echogenicity, the depth and invasion . SymptomThe surgical extirpation is indicated in sessile and large lesions because of the high risk of duodenal perforation. Operative management is mainly divided into: excision of the lipoma via a duodenotomy, segment bowel resection, pancreas-sparing duodenectomy or bypass. The type of procedure adopted to perform depends on the patient´s condition, the size and specially the localization of the lesion which is the key step. Most of the cases are managed by opening the duodenum and resected the mass as for our patient .Duodenal lipoma is a rare cause of gastrointestinal bleeding. The successful diagnostic means is esophagogastroduodenoscopy with biopsies. The endoscopic resection is the main treatment but many of these lesions need surgery as a result of their size and position.


Despite being an infrequent crime, parental homicide has been associated with schizophrenia spectrum disorders in adult perpetrators and a history of child abuse and family violence in adolescent perpetrators. Among severe psychiatric disorders there is initial evidence that delusional misidentification might also play a role in parricide. Parricides are often committed with undue violence and may result in overkill. The authors present the case of an adult male affected by schizoaffective disorder and Capgras syndrome who committed patricide. Forensic pathologists classify such cases as overkill by multiple fatal means comprising stabbing, blunt trauma and choking. Accurate crime scene investigations coupled with psychiatric examinations of perpetrator allow reconstruction of the murder stages. This overkill case is discussed in the context of a broad review of the literature. In Roman times this kind of homicide was punished more severely than any other kind of homicide, with the so-called to water . Nowadayto water , 3. Depeto water , 4.Parental homicide is an infrequent event accounting for only 2–5% of all homicides, depending on the country examined . Given tForensic experts and mental health professionals have recognized that the perpetrators usually fall into three categories: abused or mistreated children, mentally ill offspring, and children with antisocial traits , 13, 16.We report here a case of overkill patricide perpetrated by an adult male affected by a schizoaffective disorder and Capgras delusion, who killed his father using multiple fatal means; we also analyze the case in the light of the existing literature on parricide and overkill. Capgras syndrome is a type of delusional misidentification syndrome in which the subject holds that a well-known person has been replaced by an identical or very similar impostor . SchizopAn 83-year-old man, killed by his son, was found dead in the dining room of his apartment, with plenty of blood staining the surrounding floor and the walls. Following the murder, the offender phoned his sister and brother-in-law to reassure them that “everything had been fixed”. He then rang the neighbor’s doorbell, but they did not open the door, so he remained in a state of perplexity on their stairs with a tattered towel in his hands.The victim was lying supine on the floor with his head adjacent to a broken marble baseboard. He was wearing a white t-shirt that had been raised above the chest, a pair of male underpants, and a pair of shorts that had been lowered to the ankles. He was holding a bread knife loosely in his right hand Fig. ; the blaThe external examination of the body revealed fingerlike imprints of dried blood on the left side of the victim’s face Fig.  and on t1 → superficial subcutaneous tissue;2–3 → subcutaneous adipose tissue → muscles of the abdominal wall → anterior gastric wall → posterior gastric wall;4 → subcutaneous adipose tissue;5 → subcutaneous adipose tissue → muscles of the abdominal wall → greater omentum → mesenteric root;6–7 → subcutaneous adipose tissue → muscles of the abdominal wall → greater omentum → mesenteric root → aorta Fig. .At autopsy, a hemorrhagic infiltrate of the scalp and temporalis muscles was found, in the absence of skull fractures; a slight subarachnoid hemorrhage in the right temporal lobe was also observed. Hemorrhagic infiltration of the masseter and pterygoid muscles was described bilaterally. The tongue presented superficial blood infiltrates which were also detectable in the palatine region, along with a small laceration of the mucosa, and in the hypopharynx. Blood was seen in the trachea and the bronchial tree. The seven stab wounds showed trajectories which can be summarized as follows:Hemorrhage infiltrates were revealed on the greater omentum and the mesentery. The volume of the hemoperitoneum was nearly 1.5 l and we observed a retroperitoneal hematoma that involved an area comprised of the left kidney fibrous and adipose tissues, the psoas muscles, and the surrounding bladder space. No skeletal fractures were observed. Toxicological analyses were negative.The perpetrator was the decedent’s 45-year-old unmarried son, who lived with his father. He was the third and youngest son, and no family history of psychiatric disorders was found. A regular psychosocial development was reported, and his personality was described as lively. He had graduated from high school despite failing 2 years. Thereafter, he had had occasional jobs before finding a permanent job in a shoe factory.The man had been unemployed for 19 years before the crime, when he underwent his first psychiatric admission due to acute delusions; he was then diagnosed with a bipolar disorder. An initial unspecified psychopharmacological therapy was introduced, and the case notes analysis revealed good treatment adherence and a diagnostic change to a delusional disorder. Following a readmission 12 years prior to the crime, he was diagnosed with “depression and personality disorder”. At the time of the crime he was supposed to be taking prescribed quetiapine and lithium carbonate.No significant changes were reported in the medical records until the day before the murder, when a request for a medical examination was made by the offender’s father, apparently due to treatment non-adherence. After the homicide, the forensic psychiatric expert examination yielded a diagnosis of a schizoaffective disorder with acute paranoid delusion. The expert concluded that the offender should be held criminally irresponsible due to acute delusion that motivated an uncontrollable homicidal behavior. The offender affirmed that he killed his father because he had been replaced by an impostor that threatened both his father’s and his own life. He also reported that at times he perceived the impostor as an inanimate object, such as a “sack of potatoes”.A history of psychosis is frequent in parricide offenders, who often perceive their father as threatening due to delusions involving the parental figure , 24. TheIt has been observed that three circumstances are mainly associated with murder, namely a history of child abuse, serious mental illness, and financial issues , 16. ThuChild abuse is one of the main factors associated with juvenile-perpetrated patricides , 5, 12. Among clinical factors, an antisocial personality is one of the main risk factors for parricides among juveniles and it is often related with familicides involving parents and other kin , 27. It Psychosis has also been associated with juvenile parricide in a minority of cases, whereas it is the most common psychiatric diagnosis in adult perpetrators , 6, 10. Despite showing a high prevalence of psychiatric disorders in parricide offenders, including psychotic disorders, major depression, bipolar disorder, and antisocial personality disorder, the few retrospective cohort studies on parricides were carried out on samples drawn from coroners’ files and forensic medical institutions , 13, andSuch differences also emerge from the comparison of a double case report on double parricide , which oOverall, there is a strong consensus that considers psychosis with delusions or hallucinations as the main motivating factor for parricides.Data regarding the association between alcohol or substance abuse and parricide are inconsistent, as some studies reported a significant association , 10, 33,One more aspect which has been investigated in parricides is the weapon choice made by the offender. Globally, the choice of the weapon used to carry out a homicide depends on many variables, such as the context in which the murder takes place and the social availability of the instrument used , 36. ThuGiven both the particular nexus of biopsychosocial factors connecting children with their parents, and the psychiatric disorder frequently identified in the perpetrators, parricides are often committed with undue violence and result in overkill , 16, 23.In the present case, the criminological analysis recalls several of the characteristics of adult parricide offenders discussed in the literature. The offender was a middle-aged, unmarried, unemployed man, living with his father. He also presented a long history of psychiatric disorders, having been diagnosed firstly with a bipolar disorder and personality disorder about 20 years before the murder. Despite his treatment adherence being reported as good for several years, there is evidence that the day before the murder he had refused treatment, and his father had requested an appointment for his son at the outpatient service of the Public Department of Mental Health. The crime took place before the psychiatrist had the possibility to reevaluate him. The analysis of the murderer’s personal case file at the Department of Mental Health, however, disclosed that in the last 3 years his psychiatric outpatient follow-up had been characterized by a decreased adherence.This report adds to the few existing data highlighting a possible association between delusional misidentification syndromes and homicidal behavior , 22. DelAs regards the manner of killing, this murder featured overkill by multiple fatal means. The murder stages were reconstructed by the forensic pathologist through the autopsy, whose results are interpreted in the light of the crime scene findings. The victim was found supine on the kitchen floor, with his t-shirt raised up above his chest and showing no tearing on its anterior portion, and he was loosely holding a kitchen knife in his right hand; the blade was consistent with the seven wounds, detected in the epigastric region. The wounds were close to one another and of different depths, with a single lethal injury of the abdominal aorta. These elements led the pathologists to hypothesize that the stab wounds were inflicted one after another in a short time period, when the man was already lying on the floor. The presence of the contusive head trauma with multiple ecchymoses on the scalp and the presence of a wide lacerated wound on the right frontoparietal region, which was adjacent to a broken marble baseboard, suggested that the perpetrator gripped his father’s head and smashed it against the baseboard. This trauma produced a slight subarachnoid hemorrhage in the right temporal lobe, detected at autopsy.The fingerlike imprints of blood on the man’s face caused the pathologists to suppose that, at least partly, the blunt head trauma occurred after the stabbing, whereas the bruises on the back of the torso and on the upper limbs could be caused by the perpetrator shoving the victim, who fell down. The most interesting finding was the presence of a set of five keys with a whistle-like keychain in the victim’s throat, detected at inspection of the victim’s oral cavity, associated with superficial blood infiltrates of the tongue, of the palatine region, which also presented a small laceration of the mucosa, and of the hypopharynx. According to these findings, along with the presence of a bilateral hemorrhagic infiltration of the masseter and pterygoid muscles, the pathologists hypothesized that the perpetrator forced the set of keys down his father’s throat when the victim was still alive and gasping. From the murderer’s confession, this behavior can be assumed to be the result of a bizarre attempt to silence his victim. According to autopsy findings, the cause of death was ruled to be hemorrhagic shock due to stab wounds with omentum, mesentery, and aortic injuries coupled with severe cranioencephalic blunt force injury and asphyxia.In reconstructing the dynamic of the homicide, we hypothesized that the aggression started with an altercation and subsequently led to physical assault, causing the victim to fall on the floor. Then the murderer repeatedly stabbed his father with the bread knife, causing the abdominal lesions . Thereafter he violently banged his father’s head against the baseboard causing the blunt head trauma. In the last stage of the murder, the perpetrator pushed the set of keys down inside the victim’s throat in order to silence him. We also assumed that the knife was placed by the assailant in the victim’s hand at the end of the murder, as the handle was abnormal and inappropriate for threatening or hitting.As commonly described in the scientific literature, also in our case the injury location differed according to the weapon type , 44, theExisting data on homicides suggest that bodies found at the same scene where they are slain, facing up and uncovered, with multiple wounds to one body area, are usually victims of a homicidal impulsive behavior with no great degree of planning by the perpetrator . NonetheParricide is a complex, behaviorally and criminologically heterogeneous crime, as it results from a multiplicity of personal, environmental and clinical factors. The case reported here highlights the association between a major psychiatric disorder (schizoaffective disorder), in a phase of acute decompensation with delusional misidentification syndrome, resulting in overkill which includes a rare form of asphyxiation. The evocative relationship between severe mental disorders, delusional misidentification syndrome and overkill deserves further attention.Parricide is a term used to identify offspring-perpetrated homicides. It is an infrequent event accounting for only 2–5% of all homicides.Psychosis with delusion or hallucinations is regarded as the main motivating factor for adult-perpetrated parricides.Delusional misidentification syndromes, including Capgras syndrome, are rare psychiatric conditions which can be associated with homicidal behavior.Parricide is often committed with undue violence and may result in overkill. It is sometimes carried out using multiple fatal means.Homicidal asphyxia by choking is a very rare occurrence and it seldom involves adult victims.


Glomus tumors are rare, painful, and usually benign neoplasms that typically occur at the subungual aspect of digits. Rarely, glomus tumors may arise in other areas of the body. We present a case of an extradigital glomus tumor on a forearm with prior trauma that presented with symptoms of an isolated peripheral neuropathy. Our review of literature reveals how upper or lower extremity glomus tumors can mimic neuropathies secondary to intrinsic nerve tumors , radiculopathies, or manifestations of a complex regional pain syndrome (CRPS). We emphasize the need to consider a broad differential diagnosis that includes glomus tumor when evaluating patients with painful dermal masses producing peripheral neuropathy or radiculopathy signs owing to the infiltrative growth pattern into or mass effect exerted on nearby nerves. Glomus tumors are very painful neoplasms arising from glomus cells of glomus bodies, which are specialized arteriovenous structures within the subcutaneous connective tissue of skin involved in body temperature regulation by regulating blood flow ,2. TheseA 48-year-old Caucasian man with past medical history of asthma, diverticulitis, benign prostatic hyperplasia, presbyopia, and obesity presented with a tender palpable left forearm mass. The pain started five years after the patient sustained a deep knife wound in this area that required stitches. Initially, without significant discomfort, the mass progressively grew for years. The pain worsened significantly in the last eight months prior to presentation as he began experiencing dysesthesias that radiated distally to his thumb, index, and middle fingers when the mass was lightly touched. The pain had become so bothersome to the patient that even the wind blowing across his forearm caused extreme discomfort. It affected his livelihood as a truck driver and was deterring him from playing golf. Plain radiograph revealed a 1.6 cm ovoid density within the lateral soft tissues of the left forearm Figure . The masOn physical examination, light touch of the mass elicited significant discomfort and dysesthesias in the distribution of superficial branch of radial nerve, but sensation to both light touch and pinprick was intact as well as the motor function of the entire hand. No atrophy of the hand muscles was observed. Considering the patient’s prior trauma to the forearm at the same location as the tumor and the imaging features, the presumptive diagnosis became neuroma, a reactive neoplasm that can arise from an injured nerve . The patient was taken to the operating room where general anesthesia was administered. The left forearm was prepped and draped in standard fashion. A 5 cm curvilinear incision was made over the palpable mass in the left forearm. The mass was seen just below the subcutaneous fatty tissue superficial to the fascia. A small nerve fiber was seen in the vicinity of the mass, appearing to be contiguous with the mass. Vessel loops were used to isolate the nerve fiber, and the nerve was directly stimulated. There was no movement in the hand with direct intraoperative stimulation. The mass was slowly dissected in a proximal to distal fashion off the nerve. The mass appeared to have a robust blood supply that was controlled with bipolar coagulation. The mass was grossly resected, and hemostasis was achieved. At the two-week follow-up, the patient reported significant improvement in his pain, mentioned mild tingling around the site of incision, and resolution of his pre-operative pain symptoms. Histologic examination demonstrated a well-circumscribed, encapsulated soft tissue nodule consisting of sheets, nests, and trabeculae of glomus cells interspersed with small hyalinized vessels Figure . ImmunohGlomus tumors account for one to six percent of all diagnosed soft tissue tumors, and there is significant heterogeneity in the clinical presentation of these tumors ,4. In a Trauma in association with the formation of a glomus tumor has been mentioned in the literature, but the possible underlying pathogenesis has not been elucidated. Of patients studied by Schiefer et al., 20% reported trauma to the site of the extradigital glomus tumor before the onset of symptoms . Lunn etOwing to the benign nature of most glomus tumors, they grow slowly, and the symptom onset is typically insidious like in this case. This slow growth potentially translates to the mass effect that a glomus tumor can have to present like a progressive peripheral neuropathy. In our case, the patient experienced pain that progressively worsened in the forearm, which likely indicated a mass effect of the glomus tumor on the lateral antebrachial cutaneous nerve in addition to the superficial branch of the radial nerve. Similarly, Smith reported an unusual case of a patient demanding an arm amputation after his extradigital glomus tumor at the metacarpal base of his small finger was misdiagnosed as CRPS secondary to ulnar neuropathy for over nine years . SchiefeOnly histopathological analysis often aided by immunohistochemistry is used to make a definite diagnosis of glomus tumor although a high clinical suspicion is necessary for it to be considered in the differential diagnosis ,9. It isThe reported reoccurrence rates of benign glomus tumors are in the range of 12-33% and are often due to incomplete resection, so careful and complete excision of the glomus tumor is essential . MalignaExtradigital glomus tumors are typically benign, soft tissue tumors that presents as a dermal nodule with one or more symptoms from the classic triad of pain, focal tenderness, and cold insensitivity. The nodule may be palpable and the typical MRI findings of low signal intensity on T1-weighted imaging, higher intensity signals with contrast, and T2-weighted imaging should raise the suspicion of a glomus tumor. Color Doppler USG can be used to differentiate glomus tumor variants with prominent vasculature from other soft tissue tumors. Ultimately, to confirm the diagnosis, surgical resection with subsequent histopathologic analysis is required.A history of prior trauma may be the cause for extradigital glomus tumors to arise. The pathophysiology of glomus tumors secondary to trauma requires further investigation. Since the presenting signs and symptoms of an extradigital glomus tumor mimic those of peripheral neuropathy, providers need to consider a broad differential diagnosis when evaluating patients in the setting of an unrevealing spine survey. Patients with painful, superficial dermal masses or non-palpable masses seen only on imaging adjacent to peripheral nerves may harbor a glomus tumor instead of an intrinsic nerve tumor.


Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, celiac axis syndrome, and Dunbar Syndrome, is a rare disorder that results from compression of the celiac artery by the median arcuate ligament. The following is a case that depicts an interesting presentation of a patient diagnosed with this rare condition. A 44-year-old male with a history of mutism was brought in by his family for weight loss of 100 lbs with intermittent abdominal pain, weakness and lethargy over a period of five years. His family reported that he had poor nutritional intake, and could only eat a small amount before he seemed to be in pain, and eventually refused to eat. He had no other prior medical history except for mutism, no family history of malignancy, no history of trauma, surgeries, smoking or substance use, and did not take any medications. Physical exam was largely unremarkable. Mesenteric vascular duplex demonstrated severe grade stenosis of the celiac trunk with post-stenotic velocity of 520 cm/sec. Contrast enhanced computed tomography angiography revealed acute angle J-configuration of the takeoff of the celiac axis, with stenosis at its origin and focal post-stenotic dilatation, confirming the diagnosis of CACS.CACS is an elusive diagnosis that should be considered in patients where other causes of abdominal pain and weight loss have been ruled out. The disease can present with the classic triad of post-prandial abdominal pain, weight loss, and an abdominal bruit. Imaging modalities including mesenteric vascular duplex, computed tomography abdominal angiography, magnetic resonance angiography and celiac artery angiography can help make the diagnosis. Treatment involves surgical decompression via division of the median arcuate ligament, with most patients experiencing significant and long-lasting relief from their symptoms. Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, celiac axis syndrome, and Dunbar Syndrome, is a rare disorder that results from compression of the celiac artery by the median arcuate ligament . The disA 44-year-old male with past history of mutism was brought in by his family for significant weight loss with associated intermittent abdominal pain, weakness and lethargy over a period of years. Per the family, he used to be overweight four years ago. The patient has been living in Haiti his entire life and recently migrated to the United States one month ago. Per the patient’s family, he has had chronic abdominal pain for five years associated with weight loss of nearly 100 lbs. His family also reported that he had poor nutritional intake; he could only eat a small amount before he seemed to be in pain, and eventually refused to eat. He also exhibited constipation, passing small hard stools once every few days. He had no other prior medical history, no family history of malignancy, no history of trauma or surgeries, no history of smoking or substance use, and did not take any medications. The gastroenterology team was consulted to investigate the etiology of abdominal pain and chronic weight loss. The patient was non-verbal but did follow some commands. When asked to point to the area of pain, he pointed to his epigastrium. He was unable to assist much further in answering questions.2. Physical exam revealed a thin cachectic male with a scaphoid abdomen and mild tenderness in the epigastrium. His abdomen was otherwise soft and non-distended with normal bowel sounds, no guarding or rebound tenderness, and Murphy’s sign could not be elicited. No abdominal bruit could be heard on auscultation. His skin was dry with tenting and his mucous membranes were dry. There was no scleral icterus. Cardiopulmonary exam was normal. He was nonverbal, but cooperative and calm, with spontaneous movement observed in all extremities without evidence of focal weakness. There were no signs of skin rash or bruising.His vital signs were normal. His height was 5’ 8”, weight was 90 lbs, and body mass index (BMI) was 13.7 kg/mLabs were significant for mild normocytic anemia with hemoglobin 13.1 g/dL. Chemistry panel was normal. Hepatic function panel showed a mildly elevated aspartate aminotransferase and alanine aminotransferase at 60 U/L and 74 U/L, respectively, mildly reduced albumin at 3.4 g/dL and elevated alkaline phosphatase at 199 U/L. Lactic acid, amylase, lipase, erythrocyte sedimentation rate and c-reactive protein were normal. Stool samples were negative for bacteria, viruses, ova and parasites. Abdominal X-ray revealed a normal bowel gas pattern without signs of obstruction. Abdominal duplex and computed tomography abdominal angiography were performed Figures -3. The mesenteric vascular duplex revealed patency of the abdominal aorta with a peak velocity of 152 cm/second Figure . Thus, tCeliac artery compression syndrome , is a rare disorder that results from compression of the celiac artery by the median arcuate ligament, a fibrous arch that forms at the base of the diaphragm where the right and left diaphragmatic crura join medially to form the anterior portion of the aortic hiatus .This disorder can occur in the setting of anatomic anomalies such as an abnormally cephalad origin of the celiac trunk, or abnormally caudad insertion of the diaphragm ,3. PhysiCACS is a rare disorder, diagnosed in only 2 out of 100,000 cases in patients with abdominal pain where other causes have been ruled out. The disorder has a predilection for females with a ratio of females to males of greater than 3:1 and tends to present in younger patient populations ,6. This Although most patients with CACS are asymptomatic, they may clinically present with the classic triad of post-prandial abdominal pain, weight loss over time, and an abdominal bruit on physical examination ,4. SymptThe diagnosis is challenging to make and is one of exclusion, as a majority of patients are asymptomatic, and because patients’ symptoms are nonspecific and mimic other more common causes of abdominal pain, such as gastritis, peptic ulcer disease, cholecystitis, pancreatitis, and appendicitis. Patients often undergo significant workup for other causes of abdominal pain, and in some cases may undergo unnecessary procedures and surgeries prior to the diagnosis being made . After oTreatment is achieved primarily through surgical decompression of the celiac trunk via open, laparoscopic or robot-assisted division of the median arcuate ligament, with select patients requiring intravascular procedures to relieve stenosis of the celiac artery ,3,8. PatCACS is a rare disorder that results from compression of the celiac artery by the median arcuate ligament. The diagnosis is one of exclusion, as a majority of patients are asymptomatic, and symptoms can mimic those of other more common causes of abdominal pain. CACS should be considered as a differential diagnosis in patients with ambiguous abdominal pain, where other etiologies have been ruled out. Several imaging modalities including mesenteric vascular duplex, computed tomography abdominal angiography, magnetic resonance angiography and celiac artery angiography can help make the diagnosis. Treatment involves surgical decompression via division of the median arcuate ligament, with select patients requiring intravascular procedures to relieve stenosis of the celiac artery. Patients who undergo surgical decompression often have significant and long-lasting relief from their symptoms.


Gouty tophi indicate a symptom of chronic gout as a result of an accumulation of monosodium urate crystals in tissues and joints, which is the most predominantly seen form of inflammatory arthritis in the middle-aged and elderly. The rarity with which it is encountered in young adults makes this a formidable diagnostic challenge.In this report, we describe the clinical and cytopathological features of a rare aggressive case of polyarticular tophaceous gout in a young 25-year-old man with atypical involvement of hands, elbow, ankle, and feet to emphasize the importance of considering this disease entity in the differential diagnosis of multiple soft tissue masses in this age bracket as well. Gout is a disorder of uric acid metabolism prevalent in the middle-aged and elderly population, characterized by recurring episodes of inflammatory arthritis along with the formation of gouty tophi . It compChronic tophaceous gout commonly occurs 10 years or more after the first acute episode . We repoA 25-year-old male patient was referred to the cytopathology outpatient department for FNAC from swelling on the left elbow. He gave a history of trauma three years back and as a result, a clinical diagnosis of hematoma was made. Multiple swellings on the left big toe, right ankle, and third fingers of both hands were shortly noticed after the initial complaint of swelling on the left elbow. The swellings did not respond to immobilization, physical therapy, or prolonged rest nor did they subside with medications and gradually increased in size. He also complained of occasional episodes of dull aching pain which was aggravated on movement. There was no family history of joint disease and systemic illnesses. He reported occasional alcohol use and had no history of renal disease. On clinical examination, there was an approximately 5×4cm swelling over the dorsal aspect of the left elbow Figure , which wPlain radiographs Figure  revealedFine-needle aspiration from the swellings yielded thick chalky white aspirate. Cytopathology smears prepared from the aspirate examined showed abundant small needle-shaped crystals in a blood-mixed amorphous background Figure .On examination of Leishman-stained cyto-smears with a polarizing microscope, the needle-shape crystals were negatively birefringent consistent with monosodium urate crystals Figure .On the basis of these findings, a diagnosis of polyarticular tophaceous gout was rendered. The patient was undergoing treatment with Department of Rheumatology on the conservative line but was lost to follow-up after few visits in the outpatient department.The underlying pathology of gout was proposed by Garrod in the 18th century to be a causative relationship between elevated uric acid levels and urate crystal formation . Acute eThe differential diagnosis for gouty tophi includes chondrocalcinosis (pseudogout syndrome), a condition in which the symptoms result from diffuse deposition of calcium pyrophosphate dihydrate crystals, septic arthritis, tumoral calcinosis, synovial cysts, nodal osteoarthritis, rheumatoid arthritis, sarcoidosis, lymphoma, or neoplasms like chondrosarcoma ,6.Synovial fluid or tophus aspiration provides the most accurate diagnosis through visualization of needle-shaped negatively birefringent MSU crystals to differentiate from rhomboid weak positively birefringent crystals of calcium pyrophosphate dihydrate (CPPD) using polarizing microscopy and continues to be the gold standard for diagnosis of gout ,4,7.Management includes non-steroidal anti-inflammatory drugs (NSAIDs), allopurinol, corticosteroids, dietary and lifestyle modifications ,4,7. AcuIn summary, our patient presented with polyarticular tophi as an initial presentation of gout; although very rare, such cases have been reported previously in the literature ,7. In adAwareness of the variable age spectrum and presentation of this metabolic disorder along with its inclusion in the differential diagnosis of soft tissue masses can aid in providing a timely diagnosis to minimize surgical intervention, joint deformities, and complications. This report highlights untreated young-onset gout complicating into multiple large tophi.


Bleeding complications due to IHs are generally limited. Secondary abscess formation after hemorrhage has not been reported. Rapid expansion of an IH should raise concern for hemorrhage in IHs that have been an involutionary phase. The vast majority of these tumors spontaneously involute over time. Herein, we report a patient with a pathologically proven intramuscular IH who experienced hemorrhage at age 14 months, complicated by secondary abscess formation that necessitated surgical management.Infantile hemangiomas (IH) are the most common tumors in infancy, occurring in approximately 5% of infants.We report an unusual case of an intramuscular hemangioma complicated by late‐onset acute hemorrhage and suppurative infection that required surgical management. The diagnosis was ultimately confirmed pathologically.2Our patient initially presented to our otolaryngology clinic at 4 months of age with swelling in the right posterior neck that had undergone outside computed tomography (CT) imaging with intravenous contrast. Imaging was consistent with an intramuscular hemangioma involving the deep aspect of the right sternocleidomastoid muscle. He had already been diagnosed with a small, 1 mm IH of his right leg that was not undergoing treatment. After a normal electrocardiogram was obtained, propranolol therapy was initiated at 2 mg/kg/day. He followed a typical treatment course until 11 months of age when he returned to our clinic with concerns for recent growth after a period of involution. A neck ultrasound demonstrated slight increase in size of the lesion compared with prior CT. An injection of triamcinolone was performed in the clinic, and a 4‐month follow‐up visit was planned. One month later, a propranolol taper was initiated as he had reached 12 months of age.Although improvement occurred, 3 months after the injection he presented to the emergency department (ED) with new expansion of his neck lesion. There was no history of preceding neck trauma. He was subsequently returned to a normal weight‐based dose of propranolol and discharged home. Outpatient magnetic resonance imaging (MRI) showed enlargement of the IH with central cavitation compared with imaging studies 1 year prior Figures . The cenComputed tomography (CT) of the neck showed a larger fluid collection in the right posterior neck. Concern for abscess formation was also noted due to the presence of air within the collection. The patient was started on Clindamycin with planned excision the following day.Streptococci. The patient had no difficulties with oral intake postoperatively and was discharged on the second postoperative day after removal of the drain. The mass was confirmed by pathology to be an infantile hemangioma via GLUT‐1 immunohistochemistry, with an associated abscess cavity.In the operating room, purulence was quickly encountered upon dissection of the abscess capsule. The associated mass was dissected off of the posterior border of the sternocleidomastoid and internal jugular vein and removed with the abscess capsule en bloc. Cranial nerve XI was identified and preserved during dissection. The wound was closed primarily with a suction drain. Cultures ultimately grew Group A 3This case presents a deep IH with an unusual clinical course and complication. IHs can be classified as focal or segmental. Focal IH can be further subclassified as superficial, deep, or compound.Deep IHs usually present at 2‐3 months of age, which notable as it is 1‐2 months later than superficial lesions.The subsequent presumptive diagnoses of infantile hemangioma hemorrhage and secondary infection, upon representation, were both made via sequential imaging studies. Unfortunately, the diagnosis was delayed several days by the need for patient travel to our tertiary care children's hospital and the family's reluctance to schedule an MRI following the initial ED visit. Hemorrhage in the present case also raises the possibility that the IH was in a prolonged growth phase. While deep IHs are known to have more prolonged growth phases than their superficial counterparts, at age 14 months even an intramuscular IH would be expected to be undergoing involution, which caused our team to question the presumptive diagnosis until confirmed by microbiology and pathology after surgical intervention.This case demonstrates an extremely rare occurrence of a supposedly involuting IH experiencing a hemorrhagic event. Fortunately, the hemorrhage was contained, and not hemodynamically significant. The resulting secondary infection makes this case even more rare. Most of the reported bleeding complications of IHs correspond with ulceration and minimal blood loss.4Bleeding complications due to IHs are generally limited. There are few reported cases of large volume hemorrhages related to ulceration of IHs.The authors report no personal or financial conflicts of interest.JRG: contributed to design, data acquisition, and drafting and revision of manuscript. CF: contributed to conception, design, and drafting and revision of the manuscript. ABJ: contributed to the conception, design, and drafting and revision of the manuscript.Approval was obtained from the Institutional Review Board (IRB# 202187).


A 10-year-old intact female Rottweiler dog weighing 29 kg presented with 2 days history of vomiting, anorexia, and lethargy to KonKuk University Teaching Hospital, Seoul, South Korea. Ultrasonography and computed tomography (CT) scannings revealed a well-demarcated, large mass (29 × 19 × 11 cm) with numerous fluid-filled cavities. Metastases to adjacent lymph nodes were also identified on CT. This large mass and the affected intestinal segments were excised for palliative purposes. Postoperatively, the dog recovered uneventfully without any complications. The cut surface of the mass showed an exophytic growth pattern of multiloculated cystic lesions filled with serosanguineous fluid, large cavities filled with necrotic exudate, and fistulous connections between the intestinal lumen and the necrotic cavity in the mass. On histopathology, the mass was a spindle cell neoplasm expanding from the jejunal muscular layer and with pseudocystic changes. Additional immunohistochemical analysis using antibodies against smooth muscle actin, desmin, and CD-117 demonstrated that the mass was consistent with a leiomyosarcoma. Six months post-operatively, plain radiography revealed an abdominal mass, suspected to be recurrence from jejunal leiomyosarcoma. The owner decided to euthanize the dog due to financial constraints. This case report describes the atypical morphology and clinical progression of a large canine jejunal leiomyosarcoma, which had similar clinical features as those of human leiomyoma and leiomyosarcoma. Leiomyosarcomas (LMS) are malignant mesenchymal neoplasms that originate from smooth muscle tissue and, therefore, can arise from any organ containing smooth muscle, such as the gastrointestinal tract, respiratory, urinary tract, genital tract, skin, liver, spleen, and other abdominal organs , 2.Intestinal LMS account for around 30% of canine nonangiogenic, nonlymphogenic intestinal mesenchymal tumors –6. CompaThis case report describes an atypical morphology and clinical progression of jejunal canine LMS, which was characterized by being large, multiloculated, pseudocystic and fistulated. To the author's knowledge, this is the first case showing an atypical morphology of LMS and its clinical significance.A 10-year-old, 29 kg sexually intact female Rottweiler dog was referred for evaluation of persistent vomiting, anorexia, and lethargy. The referring veterinarian suspected an ovarian tumor based on abdominal ultrasound, which showed a large, cystic, pedunculated intra-abdominal mass. On presentation, the dog was depressed, and had a body condition score of 3/9. Complete blood count and serum biochemistry tests revealed thrombocytopenia  and elevated C-reactive protein levels . Plain abdominal radiography  showed aFor the surgical removal, the patient was premedicated with cefazoline , famotidine , butorphanol , and midazolam , followed by anesthesia induction with propofol . The patient was intubated, and anesthesia was maintained with isoflurane in oxygen. A ventral midline celiotomy incision was made. During the exploration of the abdominal cavity, a large mass attached to jejunal segments was exteriorized from the abdominal cavity . The masOn gross examination, the giant mass was 29 × 19 × 11 cm in size, weighed 2.4 kg, and represented a multiloculated cystic appearance covered with thin fibrous tissue. The mesenteric part of the jejunal segment that enclosed the mass had spread to most of the associated mesentery . The cutThe excised mass and affected jejunal segments were examined histologically. An encapsulated, expansile neoplasm was composed of spindle to stellate cells that were haphazardly arranged in short bundles and streams with multiple variably sized fluid-filled pseudocystic structures. The neoplastic cells expanded into the mesentery but did not infiltrate the submucosa and the mucosa . The resAt 6 months post-operatively, the owner reported a recurrence of anorexia in the patient. Abdominal radiology was performed at a veterinary referral hospital, revealing an abdominal mass suspected of being a recurrence of the previous leiomyosarcoma. The owner declined further treatments and opted to euthanize the patient due to financial constraints and concerns for the patient's quality of the life.The jejunal LMS mass in this dog showed a relatively large size (29 × 19 × 11 cm) compared to the canine intestinal LMS of its type that has been reported thus far. According to previous reports, canine gastrointestinal LMS and leiomyoma (LM) have been reported to be generally larger than 5 cm . To our Common morphological characteristics of canine intestinal LMS and LM are that they are typically solid masses and polypoid tissue that often contain hypo/anechoic cavities . The forThe most distinctive feature in the present case is that the multiloculated pseudocystic mass had expanded around the central cavities, unlike the common morphology of canine intestinal LMS. The multiloculated LMS of this dog is the first case reported in small animals that we are aware of, despite being commonly reported in LMS and LM of the uteri of human beings , 26. A fThe prognostic factors of canine gastrointestinal LMS have not been characterized because the presence of metastases and histologic features have not clearly impacted prognosis , 8, 14. The canine jejunal LMS in the present report had atypical macroscopic and morphological features, including the giant size, multiloculated and pseudocystic and exhibiting intestinal perforation without peritonitis and exophytic growth without interfering the luminal patency. The morphological features of the case presented herein, in contrast to previously reported features in dogs with intestinal LMS, are the first reported morphological characteristics of canine LMS that have similar features to LM and LMS in human beings. Furthermore, especially in the case of giant canine intestinal leiomyosarcoma, the possibility of unfavorable prognosis with regard to size of the tumor should be considered.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.M-YK did the clinical examination and assisted the surgery and followed up the patient after surgery. H-JH was the main surgeon of this study. JL and KM did pathological analysis. M-YK, JL, KM, and H-JH analyzed the case and drafted the manuscript. All authors have read and approved the final version of the manuscript.This work was supported by Konkuk University in 2021.Authors JL and KM were employed by Idexx Laboratories. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Teaching point: Ectopic breast fibroadenoma is a rare benign neoplasm that may mimic pathological lymph node clinically and on imaging. A 27-year-old female patient presented with a palpable mass and pain in her left axilla ongoing for a month. The patient’s previous medical history was unremarkable. Physical examination revealed a well-defined mass, which was clinically suspected to be an axillary lymphadenopathy or a sebaceous cyst.Figure 1A) with markedly increased vascularity on superb microvascular imaging (SMI) .On ultrasound (US) examination, a well-circumscribed, hypoechogenic nodular lesion measuring 2.5 × 1.5 cm was observed in the left axilla  with a T2 hyperintense nodular lesion in the left axilla . Dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) showed homogeneous contrast enhancement in left axillary mass . Fibroadenoma and lymphadenopathy were considered as differential diagnosis.Magnetic resonance imaging (MRI) revealed bilateral ectopic axillary breast tissue .Due to imaging features of the lesion, core biopsy was not considered, and total excision of the mass was performed for definitive diagnosis and treatment. On gross pathology, a well-circumscribed slightly lobulated mass with tan white fibrotic appereance was observed. Histologically, the mass was composed of glandular and stromal components. Glandular epithelium was benign and appeared slit-like due to compression and distortion by stromal proliferation. Stromal component was hypocellular and no mitotic figures or atypia were detected. Ki-67 proliferation index was 1%, and beta catenin and p53 were negative. The final diagnosis was intracanalicular type fibroadenoma (Fibroadenoma is a common breast mass that accounts for approximately half of all breast lesions in young women. Nevertheless, axillary fibroadenoma developed from ectopic breast tissue is a rare condition. Other causes of axillary mass such as lymphadenopathy, sebaceous cyst or lipoma should be considered as differential diagnosis . ClinicaImaging methods, especially US are helpful for characterizing axillary masses, but only histopathological evaluation concludes the diagnosis. On US, axillary fibroadenoma presents as benign-looking, well-defined hypoechoic nodule.If the mass does not have typical features of a lymph node, further imaging with MRI may help to identify of origin and further characterization. MRI was useful for revealing bilaterally accessory breast tissue in the present case. Contrast enhancement patterns on dynamic MRI contributes to the differential diagnosis of fibroadenoma of the ectopic breast before histopathological evaluation.


Within the text we describe a 66-year-old male with a history of prostate cancer (PCa), incidentally found to have left-sided hydronephrosis and a left ureteral lesion. Ureteroscopy was employed to visualize the lesion, a biopsy was taken, and a double J stent was placed. The lesion was of prostatic origin and the patient was subsequently started on androgen deprivation therapy (ADT). 6 months following the procedure, the patient's PSA had decreased and his hydronephrosis had resolved. We are the first to report treating a ureteral metastasis from PCa and its associated hydronephrosis solely with ADT and double J stenting, respectively. As the incidence of metastasis to the ureters remains exceedingly rare, disease management for patients with ureteral metastases is often guided by the few published experiences of others. Thus, it is imperative that additional cases be documented in a public domain. The following Case describes an incidence of ureteral metastasis from locally invasive, castrate-resistant prostate cancer that was managed without resection.The patient is a 66-year-old male who presented to clinic for an elevated PSA (3.79 ng/mL in 2014 to 14.95 ng/mL in 2015). Transrectal ultrasound guided prostate biopsy revealed high volume, high-risk disease with 11 of 12 cores positive and a Gleason score of 5 + 5 = 10. He underwent robot-assisted radical prostatectomy that was complicated by a 4 mm rectal laceration. Final pathological staging was pT4N0R1 with positive margins and rectal invasion. The patient was subsequently started on androgen deprivation therapy (ADT) with leuprolide acetate administered every 3 months, and his PSA dropped to a nadir of 1.33mg/mL.Surveillance MRI in 2016 revealed a T2-intense nodular region at the posterior inferior bladder. Additionally, PET scan revealed radiotracer accumulation within a single vertebral body. However, concerns for bony malignancy were low at that time due to the solitary nature of the finding. In late 2017 the patient developed castrate resistant disease due to increasing PSA with a PSA doubling time of 5.6 months. MRI performed in 2018 revealed enlargement of the previously mentioned T2-intense nodular region at the posterior inferior bladder. In late 2018 the patient was referred for enrollment in the NIH Clinical protocol NCT 03315871 for treatment of combination immunotherapy involving vaccines (Prostvac and CV301) and MSB0011359C [an anti-PD-L1 antibody (avelumab) with TGF beta-Trap molecule].In early 2020, a computerized tomography (CT) revealed development of left hydroureteronephrosis  that traCystoscopy was notable for post-prostatectomy changes and a bladder neck mass consistent with his recurrent prostate cancer. Retrograde pyelogram of the left ureter revealed marked hydroureteronephrosis and a torturous ureter. Left ureteroscopy revealed a bulbous mass in the left distal ureter A and B, This biopsy specimen consisted of multiple small tissue fragments characterized by the presence of a cell infiltrate with severe crush artifact. Evaluation of morphology and architecture was precluded by the presence of this severe crush artifact A. An imm6 months following ADT and double J stenting, the patient remained asymptomatic, the patient's PSA showed a substantial decrease, and repeat CT showed no hydroureteronephrosis.Occurrence of ureteral metastasis from prostate cancer remains exceedingly rare, with approximately 50 cases documented over the last century. Gandaglia et al. assessed distribution of metastasis in a cohort of 74,826 patients with metastatic PCa and described the most common metastatic sites as bone (84%), distant lymph nodes (10.6%), liver (10.2%), and thorax (9.1%).Among patients presenting with a ureteral mass, it is common for surgeons to perform nephroureterectomy (NU) rather than diagnostic ureteroscopy with biopsy. Ureteroscopy is often difficult in patients with ureteral strictures, and nephroureterectomy allows for both reduction of disease burden and biopsy to occur within one step. However, as in our Case, we were able to easily access the ureter via ureteroscopy which allowed for visualization both proximal and distal to the lesion, and easy acquisition of a biopsy. Similar to case reports by Gupal et al., in 2009, Schneider et al., in 2012, and Munshi et al., in 2019, we decided against nephroureterectomy due to concerns of post-surgical complications in a patient with extensive extra-prostatic disease burden.As best we can tell, we are the first to report treating a ureteral metastasis from PCa and its associated hydronephrosis solely with ADT and double J stenting, respectively.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The opinions and assertions contained herein are the private opinions of the authors and are not to be construed as reflecting the views of the Uniformed Services University of the Health Sciences, the U.S. Department of Defense, or the U.S. Department of the Army.All authors have made substantial contributions to the acquisition of data, the interpretation of data, and both drafting and revising the article critically for important intellectual content. All authors have granted approval of the final version to be submitted.None.


A 54‐year‐old man had previously undergone curative sigmoidectomy for poorly differentiated adenocarcinoma with a signet‐ring cell component of the sigmoid colon, which was characterized morphologically by stenosis and inelasticity of the colon (linitis plastica). Six weeks after surgery, the patient developed stenosis of the right ureter. Disseminated sigmoid cancer was suspected, and chemotherapy was started. Nine months after initiation of chemotherapy, obstructive jaundice was observed which was due to stenosis of the distal bile duct (BD). Although computed tomography showed no evident metastatic lesion that could cause the stenosis, swelling of the entire pancreas was evident compared to that of 11 months earlier. Endoscopic ultrasound (EUS) also did not detect any focal masses in the head of the pancreas, although there was a diffuse hypoechoic change in the entire pancreas. Histopathology of the stenotic BD and biopsy specimen from the head of the pancreas showed no malignant cells. Two months after the initial endoscopic bile duct drainage, the patient was admitted again for epigastric pain. A second EUS fine needle aspiration (EUS‐FNA) of the head of the pancreas was performed and showed poorly differentiated carcinoma with some signet‐ring cells. This finding provided histological confirmation of a disseminated pancreatic lesion of the previously resected linitis plastica of the sigmoid colon. This is a rare case of disseminated pancreatic lesion from primary linitis plastica of the colon diagnosed by EUS‐FNA. Linitis plastica is described as a scirrhous carcinoma with diffuse thickening and hardening of the bowel wall and characterized morphologically by stenosis and inelasticity of the colon. The incidence of linitis plastic is rare, with a reported prevalence rate of 0.1%–0.2%.A 54‐year‐old male visited our hospital complaining of constipation and small‐caliber stools for 1 month. Colonoscopic examination showed marked narrowing of the sigmoid colon lumen with edematous mucosa Figure . Histolocytokeratin 20, CDX2, SATB2, and SMAD4  + cetuximab regimen. After three courses of the said regimen, lymphadenopathy and urinary tract stenosis markedly improved. During the course of chemotherapy, no obvious recurrence was observed, and the tumor markers remained normal for 9 months. Eleven months after surgery, lymphadenopathy of the right inguinal lymph nodes and obstructive jaundice were noted. Magnetic resonance cholangiopancreatography showed dilation of the bile duct (BD) and the main pancreatic duct (MPD), suggesting a lesion in the head of the pancreas Figure . Althoug4 Figure , suggestLaufman et al first reported primary linitis plastica of the colon in 1951.The reported incidence of patients with colorectal cancer exhibiting a component of signet‐ring cells comprising <50% of the tumor mass is 5%.The usefulness and high accuracy of EUS‐FNA in diagnosing the etiology of several diseases have been widely accepted,The characteristics of pancreatic metastases are reported to be lesions with regular borders, lack of retention cysts, and presence of a nondilated MPD.In summary, this is the first report of a case of disseminated pancreatic lesions of linitis plastica of the colon diagnosed by EUS‐FNA, with characteristic features on CT, MRI, and EUS. Repeated EUS‐FNA might be necessary to make the histological diagnosis because the poorly cohesive cancer cells infiltrate diffusely and do not form masses in the metastatic organs.The authors declare no conflict of interest.None.Supplemental Video. Second endoscopic ultrasound‐guided fine needle aspiration of the head of the pancreas is performed from the descending duodenum.Click here for additional data file.Supplemental Fig. 1. Axial images of computed tomography demonstrating the body and tail of the pancreas (upper) and head of the pancreas (bottom) obtained before resection , 11 months after resection , and at the time of the second Endoscopic ultrasound‐guided fine needle aspiration . (e) Soft tissue infiltration in the retroperitoneal space (arrowhead) and the swelling of the adrenal gland (arrow) are seen. (f) Enlargement of the head of the pancreas (arrowhead) is evident.Supplemental Fig. 2. Endoscopic ultrasound (EUS) images at the first EUS fine needle aspiration.(a) EUS from the descending duodenum shows hypoechoic parenchyma and no well‐demarcated lesion in the head of the pancreas where the main pancreatic duct (MPD) is constricted. (b) EUS from the stomach shows a dilated MPD and hypoechoic parenchyma in the body of the pancreas. *Abbreviations: Ph‐MPD, main pancreatic duct at the head of the pancreas; Pb‐MPD, main pancreatic duct at the body of the pancreasSupplemental Fig. 3. Results of immunohistochemical analysis of the sigmoid colon and the pancreatic lesion. (a‐d) Biopsy specimens obtained by the endoscopic ultrasound‐guided fine needle aspiration (x100). (e‐h) Previously resected specimen (x100)Click here for additional data file.


Forequarter amputation or interscapulathoracalis amputation is a major amputation procedure that involves the entire upper extremity, scapula, and a whole or part of the clavicula. Forequarter amputation is commonly used to control bleeding in malignant tumor cases in which no treatment is available for the extremities.We report a case of forequarter amputation in a 25-year-old patient with synovial sarcoma. Transarterial chemoembolization (TACE) and radiation synovial sarcoma were performed in the patient to reduce bleeding. This technique may also be used for treating synovial sarcoma with massive bleeding.Despite forequarter amputation indications in malignant tumor cases and recurrent cancer cases, the effectiveness of this technique remains unclear. The patient was readmitted with a recurrent mass three months after surgery.In this study, TACE and radiotherapy are effective in controlling bleeding preoperatively and intraoperatively in patients with synovial sarcoma. SS accounts for 5–10% of all forms of soft tissue tumors, which usually affects adolescents and young adults . SarcomaForequarter amputation was first performed in 1808 for treating a bullet wound and first used to treat upper extremity malignancy in 1836 . It is aPreoperative embolization for controlling blood loss in intraoperative and postoperative settings has been reported for use in conjunction with sarcoma resection. However, its use in preoperative amputation has not been described. Transarterial chemoembolization (TACE) is performed before surgery to control the hemorrhage ,11. Embo2A 24-year-old man was admitted to the ER with a large, painful (VAS 8), and recurrent bleeding mass in the right upper chest quadrant, increasing in size for two months before admission. Before the surgery, the mass dimension was 14 cm × 9 cm × 6 cm, with the pathological result of a grade II myxofibrosarcoma. The patient did not suffer from cough, dyspnea, or fever. There was no family history of malignancy in the family. MRI  and CT SThe histology slides were examined, and the morphological features showed spindle cell sarcoma reminiscent of low-grade fibromyxoid sarcoma with extensive necrosis. Immunohistochemical staining was not entirely specific due to extensive necrosis, but as a low-grade fibromyxoid sarcoma, the morphology could still be supported . We perfAfter extensive consultations, a multidisciplinary meeting consisting of oncology surgeons, cardiothoracic and vascular surgeons, pathologists, and radiation oncologists agreed that amputation was the best alternative to treat pain, bleeding, lymphedema, and compromised patient function. A team of oncology surgeons and cardiothoracic and vascular surgeons performed the procedure. Based on a discussion with the patient and his family about the procedure’s radical nature, benefit, and potential complications, they agreed to undergo the operation. He had restricted arm mobility due to mass impact, chronic intractable pain, and lymphedema.Preoperative embolization was advised by interventional radiologists during preoperative consultation. Due to the large tumor size at the proximal area and a previously irradiated bed mass position, we preserved the vascular function (subclavian and axillary vessels) and reduced wound bleeding during surgery. TACE was performed in the tumor artery, and the patient underwent right subclavian and axillary artery angiography with embolization of the right subclavian artery . The TACVascular access from the right femoral artery was achieved with introducer sheath 6 Fr, and a diagnostic catheter 5 Fr was inserted until the tip reached the right subclavian artery. This was continued with the mapping arteriography. Hypervascularization of the feeding artery originating from the superolateral right axillary artery neovascularization branch and the proximal inferomedial right brachialis artery neovascularization branch was demonstrated by this procedure. Then, microcatheter 2,4 Fr was inserted until the tip was selectively located in the neovascularization of these branches, and a chemoembolization agent was inserted. GS particles and microcoils were used in this procedure. The chemoembolization agent used in this procedure was doxorubicin (50 mg) and Lipiodol (10 mL), including the embolization agent, PVA (500–700 microns), and gel foam combination. The operation was performed from the neovascularization branch of the superolateral right axilla artery in the feeding artery and the proximal inferomedial right brachialis artery in the neovascularization branch.Six days after the TACE procedure, we performed extensive surgery on the entire right upper extremity, scapula, and whole clavicula with 235 mL bleeding during the surgery, and the size of the mass was 30 × 24 × 10.5 cm from the right upper quadrant of the chest and shoulder girdle .Fig. 3Pr3Under general anesthesia, surgery was performed with the patient in the full lateral position. Several surgical techniques have been described for performing a forequarter amputation. We used a semi-lateral approach, and the majority of the surgery was performed anteriorly. The patient was in a left lateral decubitus position to reveal the thorax, with the right upper extremity positioned to rotate freely. We made an elliptical incision on the superior apex above the clavicle at one end and proceeded inferiolaterally. Skin flaps were elevated to the anterior midline, superior to the clavicle, inferior to the costal arch, and medial to the midline. The latissimus dorsi and the superomedial border of the mass were the lateral borders of the skin flaps. At the origin of the sternum, we dissected the pectoralis major muscle from the medial as the insertion, which was also invaded by the mass. On the anterior side, the pectoralis muscle was infiltrated by the tumor mass, separating the pectoralis major and minor.The brachial plexus and axillary vessels were exposed anteriorly. The surgical technique involved an incision on the preoperative markings at a distance of 2 cm from the edge of the induration. We then performed anterior vascular exploration by separating the major pectoralis muscle from the clavicle. These were deepened into the musculofascial layers. The platysma and supraclavicular nerves were excised. To allow control of the subclavian vessels, clavicular osteotomy was performed by exposing the clavicle and cutting laterally to the sternocleidomastoid with a Gigli saw. The tendons of the pectoralis major, coracobrachialis, and the short head of the biceps were cut. Dissection was continued to the thoracic wall in order to excise the pectoral muscles, soft tissues, and the ribs’ periosteum. First, ligation of the subclavian artery was performed, and the artery was cut. Thereafter, the subclavian vein was ligated and cut. This was performed to avoid any bleeding from the shoulder’s collateral blood supply. The brachial plexus was proximally ligated and divided.A posterior incision was made, all periscapular muscles were released, and fasciocutaneous skin flaps were developed. The major and minor rhomboid, trapezius, omohyodeus venter inferior, and levator scapulae muscles were then split by electrocautery as they were inserted into the scapula. Moving caudally, we transected the latissimus dorsi and resected it from the chest wall. The exposure was continued to the rhomboid muscle insertions posteriorly and laterally. An axillary incision was made to connect the anterior and posterior incisions. This freed the shoulder girdle and the entire extremity from the trunk. Finally, after the subclavian artery and brachial plexus ligation and transection, the entire forequarter was removed, along with the tumor material, including the scapula, inevitably producing a large tissue defect. Posterior skin flaps were used to close the defect. The dog-ear skin excess was excised. Finally, drains were used to prevent the development of hematoma and wound complications.No significant complications of forequarter amputation were observed, such as the development of a pneumothorax with consecutive respiratory insufficiency. Our patient complained of the minor complication of delayed wound healing, which required local surgical debridement. He also suffered from postoperative phantom pain or local pain with moderate VAS scores of 5–6 that could be overcome with oral analgesics. When the wound healed after two weeks, he was released from the hospital.The pathology findings were consistent with the previous diagnosis of monophasic synovial sarcoma . Three wThe patient seldom experienced phantom limb pain. This is a common sequela of forequarter amputations. The patient received 4 out of 6 cycles of chemotherapy, which was safe. Due to the Covid-19 pandemic, the patient was afraid to go to the hospital. Eleven months after the procedure, the patient died of respiratory failure in his home.4Forequarter amputation is an ablative and radical surgery to remove the entire upper extremity, including the shoulder girdle . AmputatForequarter amputation is a complicated procedure with physical and mental effects due to total functional loss of the limbs and significant optical disfigurement. Locally advanced tumors spreading to the axilla represent indications for forequarter amputation and become irresectable with a limb-sparing procedure . By etioIn the present case, the patient experienced active bleeding from the tumor mass. Bleeding complications typically arise in patients with advanced cancer, with 10% experiencing at least one episode of bleeding ,22. BleeIn neurosurgery, urology, general surgery, head and neck surgery, orthopedics, and oral surgery, preoperative embolization has been identified as essential to reducing intraoperative bleeding. Despite potential complications, including arterial infarction, ischemic event, nerve injury, and local hemorrhage, most have been successfully performed . In patiReducing the risk of bleeding postoperatively for hypervascularized tumors, simplifying tumor manipulation, increasing the chemotherapy response and radiotherapy, and palliative care of pain are the main indications for embolization. When surgery is inappropriate or associated with a higher risk, embolization can also be a therapeutic option for surgery . MoreoveWhen performed by an experienced team with proper embolizing agents, preoperative selective/superselective transarterial embolization of hypervascular malignant soft tissue tumors of the extremities is an efficient and safe procedure. To avoid complications, achieve successful devascularization, and complete resection of a tumor, super-selection and flow control are essential . A relatSynovial sarcoma (SS) is an active tumor of soft tissue with a propensity for local recurrence and a high risk of distant metastasis. Unlike many other sarcomas, in only 10–20 percent of cases, it may invade the adjacent bone. With 5- and 10-year survival rates of 36–76 percent and 20–63 percent, respectively, the prognosis for SS is usually poor. Under 20 years of age, lower tumor stage, tumor size < 5 cm, sufficient excision, and a more distal position of the extremities are factors associated with better prognosis. Poor prognosis predictors include less-differentiated tumor regions, necrosis, and high mitotic activity . BleedinFor decades, radiotherapy (RT) has been used as a non-invasive treatment for bleeding associated with cancer. After only a few fractions of RT, the hemostatic efficacy of radiotherapy is normally visible and is commonly clarified by increased platelet adhesion to the vascular endothelium. By inducing vessel fibrosis combined with tumor remission, the long-term effect could be clarified . AlthougThe pathophysiology of the cancer radiation effect causes significant damage to DNA by inducing malignant damage to endothelial cells, causing signal transduction pathway activation and leading to cell apoptosis . RadiothResearch by Sapienza et al. has shown that palliative radiotherapy is efficient in primary bleeding control . Neverth5For patients with soft tissue malignancies such as synovial sarcoma, particularly tumor recurrence with bleeding manifestation, forequarter amputation is a safe and reliable treatment option. TACE and radiotherapy can be treatment options for patients with malignant bleeding and are effective in controlling preoperative and intraoperative bleeding during forequarter amputation.The authors report no declarations of interest.None declared.Not applicable.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.Erwin Danil Yulian: Concept and design of case report, data collection, drafting, revision, approval of final manuscript.Jacub Pandelaki: Data collection, revision, approval of final manuscript.Evelina Kodrat: Data collection, revision, approval of final manuscript.I Gusti Ngurah Gunawan Wibisana: Data collection, revision, approval of final manuscript.Not applicable.Erwin Danil Yulian.Not commissioned, externally peer-reviewed.None declared.


Mesonephric adenocarcinomas are rare tumors of the female genital tract, thought to arise from embryonic mesonephric remnants, primarily in the cervix and vagina. Conversely, endometrial and ovarian mesonephric adenocarcinomas may have a different pathogenesis, probably originating from transdifferentiated Müllerian carcinomas, as demonstrated by the association of these neoplasms with endometriosis and ovarian serous tumors. For this reason, in the endometrium and in the ovary, they are defined as “mesonephric-like adenocarcinomas”. Some cases of mesonephric carcinomas of the female genital tract have been reported to show a sarcomatous component and have been defined as “mesonephric carcinosarcomas”, characterized by poor prognosis and high metastatic behavior, but this entity has never been described in the ovary. The case herein presented is of a 74-year-old female with abdominal discomfort and a complex ovarian mass. Histological and immunohistochemical analysis showed features of ovarian mesonephric-like carcinoma combined with a low-grade serous component, in support of the theory of a Müllerian origin of these neoplasms. The tumor also revealed foci of chondrosarcomatous differentiation, never before reported in the ovary, showing a similar immunohistochemical profile to the mesonephric-like elements. This work thus describes the first reported case of ovarian mesonephric-like carcinosarcoma. Mesonephric adenocarcinomas are very rare malignancies of the female genital tract, arising in the uterine cervix or, less frequently, in the uterine body, in the vagina or in the ovary ,2,3. TheA 74-year-old female, with a history of abdominal discomfort, was referred in August 2020 to the gynecologic oncology unit of Bari Policlinico hospital by her gynecologist for a complex ovarian mass. In 1973 she underwent right salpingo-oophorectomy for an ovarian serous cystadenoma. All four of the patient’s brothers had a history of cancer . In our patient, transvaginal echography showed a solid-cystic tumor in the left ovary, with a maximum diameter of 5 cm. CT scan confirmed the ovarian mass, also revealing evidence of peritoneal carcinomatosis and suspected omental metastases. Exploratory laparoscopy, with a peritoneal nodule biopsy, was performed for histological diagnosis. Pathology results demonstrated a peritoneal localization of a malignant epithelial neoplasm, with necrosis and a mixed glandular and solid pattern, suspected to be an ovarian poorly differentiated endometrioid adenocarcinoma. After diagnosis, the patient underwent 12 cycles of neoadjuvant chemotherapy (carboplatin and paclitaxel), with a partial regression of the tumor. Subsequently, she underwent hysterectomy with left salpingo-oophorectomy, large-bowel segmental resection, omentectomy and resection of two peritoneal nodules.On gross pathology examination, the left ovary measured 4.5 × 3 × 2 cm, showing an intact, smooth outer surface. The cut section revealed a small unilocular cyst with an adjacent large, solid mass. The left Fallopian tube and the uterus were grossly normal. The omentum presented multiple nodules, the largest of which measured 4 cm. The resected large bowel segment showed a 5 cm nodule on the serosal surface. Histologically, the left ovary showed a serous cystadenoma, undergoing progressive transition to a serous borderline tumor and invasive carcinoma . The invImmunohistochemically, the low-grade serous component showed positivity for CK7 (cytokeratin 7), PAX8 (paired box gene 8), ER (estrogen receptor), PR (progesterone receptor) and complete negativity for Calretinin, CD10, TTF-1  and GATA-3 (GATA binding protein 3) . On the Mesonephric adenocarcinomas are very rare tumors of the female genital tract. They usually arise in the uterine cervix, where it is more common to observe mesonephric remnants, but may originate also in the vagina, uterine corpus and ovary ,2,3. TheThe histological features of these tumors are peculiar. They usually show an admixture of different architectural patterns, such as tubular, glandular (variously sized), papillary, sex cord-like, slit-like, retiform and solid. The tubular and glandular patterns are the most common and often contain typical intraluminal secretions, composed of eosinophilic colloid-like material. The tumor cells show a variable shape and size, usually with a scanty eosinophilic cytoplasm and monotonous hyperchromic or vesicular nuclei ,16. The Moreover, part of the tumor showed, both in the ovary and in the intestinal nodule, a mesenchymal malignant component consistent with a chondrosarcomatous appearance. In literature, some cases of uterine or vaginal mesonephric adenocarcinomas have been reported, associated with a sarcomatous component ,13,14,15Additional studies with larger numbers of cases would be fundamental in order to determine the real origin of these neoplasms and the molecular processes that lead Müllerian neoplasms to transdifferentiate into mesonephric-like carcinomas and, as reported for the first time in this work, into a sarcomatous morphology.The case herein reported sheds light on the similar histological features and behavior of these neoplasms in all sites of the female genital tract, demonstrating that ovarian mesonephric-like adenocarcinomas may also have a malignant mesenchymal component, thus being definable as “ovarian mesonephric-like carcinosarcoma”. Therefore, we can suppose that it is only because of the extreme rarity of ovarian mesonephric-like adenocarcinomas that this sarcomatous transdifferentiation has never previously been reported. Finally, the relation between the sarcomatous component and prognosis will need to be investigated in further studies, and also the prognosis of ovarian mesonephric-like adenocarcinomas, in order to obtain evidence-based treatment guidelines for patients affected by this kind of rare neoplasm.