Fibrofatty bands are composed of adipose tissue and connective tissue and can tangle around the bowel and caused intestinal obstruction. Currently, there is a lack of radiological teaching or guidance on how to identify fibrofatty band in patients with bowel obstruction. The true incidence of fibrofatty band-induced bowel obstruction is likely to have been overlooked. We present a case series of patients with fibrofatty bands with different features and aim to highlight the key radiological findings that may help in the radiological diagnosis. We advocate that these features should be incorporated into the current algorithm for radiologist when assessing scan images of patients with intestinal obstruction. There has been a rise in the number of CT scans performed on patients with small bowel obstruction, partly as a result of the recent National Audit of Small Bowel Obstruction study.5 In our institution, we had noticed that there was an increase in cases of extraluminal band identification for patients who had CT proven SBO. These extraluminal bands are rarely reported in the existing literature and are recognised as fibrofatty band following surgery.6 From our experience, the cohort of patients with fibrofatty bands did not respond to the conservative management alone, and ultimately required surgery. Early detection of these bands may allow better informed clinical decision for surgeons and prompt surgical intervention to avoid waiting from conservative management.5 Fibrofatty bands are more likely to be amenable to a laparoscopic approach and avoid the need for a midline incision, allowing for quicker recovery.CT scan is the preferred modality to aid the diagnosis and assess the severity of obstruction.Upon review of these cases with the radiology team, there are recurring and distinctive radiological features that could help to identify these fibrofatty bands on the CT scan. In this case series, we highlight these features and would recommend them to be integrated into a radiological algorithm upon reviewing the scan for SBO.A 52-year-old male presented with 1-day history of sudden onset right iliac fossa pain. No nausea and vomiting were reported. Three weeks prior to this admission, he had an emergency right hemicolectomy for a perforation related to stricture at terminal ileal disease caused by Crohn’s disease. On examination, his abdomen was tender without gross distension. The only abnormality in his blood results was the elevated white blood cell count. An intravenous contrast-enhanced CT was performed and demonstrated a moderate length segment of oedematous and thickened wall at neoterminal ileum, which was interpreted as recurrent neoterminal Crohn’s ileitis.The patient was then treated with i.v. fluids and analgesia, but the pain was intractable despite the treatment. On second review of the CT scan by the radiologist, it was noted that there was an acute transition from dilated to non-dilated small bowel with a linear fat density band running through the mesentery causing an indentation on the small bowel at the transition point , these fA 49-year-old female presented with 3-day history of lower abdominal pain. She had an absolute constipation for 6 days. Her only previous surgical history was 3 Cesarean sections. Examinations were unremarkable except lower abdominal tenderness. Blood investigations were normal. She was initially referred for an ultrasound scan with no other treatment, however she then developed bilious vomiting and worsening of her abdominal symptoms. A CT abdomen/pelvis demonstrated the presence of dilated, fluid-filled small bowel loops leading to a transition point in the right iliac fossa. A linear fat density structure was seen anteriorly across over the collapsed bowel at the transition point which was in keeping with a fibrofatty band as the cause of the small bowel obstruction . In thisA 76-year-old male presented with several days’ history of progressive worsening acute abdominal pain. He had experienced a few similar episodes previously, but the symptoms had settled spontaneously without any medical intervention. His past surgical history included appendicectomy. Blood tests showed a deranged renal function with mildly elevated inflammatory markers in keeping with acute kidney injury. His lactate level was normal. A CT abdomen/pelvis reported acute small bowel obstruction with small bowel feces proximal to an acute transition point in the distal ileum. A linear fat density band could be seen to traverse the bowel at the transition point suggestive of a fibrofatty band. Surgery was performed and a fibrous band was found and divided. The time from admission to surgery was less than a day. Histology confirmed that the adhesion was composed of fibrofatty tissue . The patAn 87-year-old male presented with 3 days history of sharp, radiating upper abdominal pain. He described constipation, passing only two episodes of small volume hard pellets and vomiting about 1 liter of brown fluid on that day. His past medical history included epilepsy, a cholecystectomy, and a right inguinal hernia repair. He was hemodynamically stable and found to have a mildly distended abdomen with upper abdominal tenderness. A CT scan was performed which reported a fibrofatty band and small bowel obstruction. He underwent surgery and band division. The time from admission to surgery was less than a day. He had a complete resolution of symptoms and was discharged 2 days after his operation.A 35-year-old male was presented with 1 day history of vomiting and increasing abdomen pain. He had laparotomy 3 months ago for a strangulated bowel ischemia that was caused by Meckel’s diverticulum. CT on this admission demonstrated acute small bowel obstruction with a long linear band consisting of linear soft tissue with central fat density traversing the bowel at the transition point, immediately proximal to the small bowel suture line from previous surgery  Supplem. He was Supplementary Material 1.Click here for additional data file.A 27-year-old male who presented with a 1 day history of severe right iliac fossa pain (RIF), no associated vomiting or nausea were reported. The patient continued to complain of discomfort, worse on movement. He did not have any past surgical or medical history. On examination, Rovsig sign was positive with RIF tenderness. Urine dip was unremarkable. The blood results demonstrated a mildly raised CRP 82. This was felt to be in keeping with appendicitis and the patient had a diagnostic laparoscopy without CT scan being performed. The time from admission to surgery was less than a day. At surgery, the appendix appeared macroscopically normal. There was a fibrofatty band adhesion of small bowel mesentery to the abdominal wall causing small bowel obstruction at mid-jejunum . SurgicaThe histology result reported the presence of cellular fibrous connective tissue, collagen, smooth muscle fibers and adipose tissue .5 Identification of fibrofatty bands by radiologist could help to prompt early surgical intervention.In this case series of six patients with fibrofatty band (age ranging from 27–87 years old), all presented with abdominal pain but not all symptoms were typical of small bowel obstruction. Of those, five patients had a history of abdomen surgery, whereas one has no surgical history. Fibrofatty bands are highly elastic and stretchable, so patients with band-induced obstruction are unlikely to settle with conservative management alone. The average time from admission to surgery in this case series was 1.6 days, which was less than the national average time of 3.9 days in the UK 7 with fibrofatty bands being recognied as a type of adhesion which are composed of adipose tissue and connective tissue. When these fibrofatty bands are found in the patients without prior operation, also known as “virgin”, abdomen, they are referred to ‘congenital fibrofatty band’. The exact pathogenesis of adhesion remains inconclusive. Fibrin deposition occurred as part of the normal healing process, however insufficient fibrinolysis at later stage could results persistent and excessive fibrin, which can later transform into fibrocollagenous tissues and form adhesion. The acquirement of fibrofatty bands could be hypothesised as further fibrogenesis process from those residual fibrocollagenous tissues.7 It remains unclear why some individuals are affected by the formation of bands.The occurrence of peritoneal adhesions is well documented in the literature in patients after abdomen surgery,6,8–10 The vitelline duct is part of the omphalomesenteric duct that connects the yolk sac to the primitive mid-gut during the embryonic development, which received its nutrition from the vitelline artery. Vitelline duct usually disappears by 7th −9th week of gestation and failure of its removal, which occurs in 2% of the population, can lead to a variety of congenital anomalies . These congenital remnants are established causes of small bowel obstruction in infancy. However, most patients with fibrofatty band would remain asymptomatic throughout their lives.8 Incidental radiological detection hence is possible.In contrast to the acquired fibrofatty band, little is known for the congenital fibrofatty band. On reviewing literature, the origin of fibrofatty band is thought to be related to the vitelline duct.3,4 There were no apparent precipitating factors triggering the occurrence of SBO in our patients. One previously reported case at our institution was suspected to be precipitated by running a marathon, in this case it is postulated that the rigorous exercise and increase mesenteric vascular flows resulted in entanglement.6The intestinal obstruction occurred when the fibrofatty band wrapped around the intraperitoneal small intestinal cumulating in its symptom’s presentation. The distal ileum seems to be a common site for SBO.5 These are potentially amenable to laparoscopic division, compared to more dense abdominal adhesions from previous surgery, and can guide surgeons’ approach to the patient. Radiological input is important to help identifying the presence of the fibrofatty band as this could influence the decision-making for surgery, allowing better pre-operative planning. Prompt identification potentially aids laparoscopic division of the band with reduced small bowel dilatation. The fibrofatty band has a defined band structure that is potentially easy to identify and divide laparoscopically. Unlike volvulus and hernia, confidently identifying a fibrofatty band on a CT is challenging and may be overlooked by the radiologist, as the density of the tissues within the band is similar to those of the surrounding mesentery and omentum as demonstrated by this cases series.Recent evidence from the National Small Bowel Obstruction audit advises prompt CT for patients presenting with SBO and allows greater opportunity for identification of fibrofatty bands.Careful interrogation of any acute transition point in the context of SBO on all available CT reformats can help identify the pathognomonic linear fat density within a fibrofatty band that will allow confident diagnosis of fibrofatty band on CT. This can help to differentiate fibrofatty band obstruction from other types of adhesive obstruction. Radiological features that can help identify fibrofatty bands on CT include identifying acute transition point in the bowel with central area of fat density at the transition, occasionally a more focal band of well-defined fat surrounded by some soft tissue can be seen to coursing between two abdominopelvic structures, running through the transition point in the bowel and indenting or kinking the bowel.To conclude, recognizing these fibrofatty bands in patients with bowel obstruction is essential to prompting early surgical intervention. There is no focus in the current radiological curriculum to identify the fibrofatty band, which remains as a diagnosis of exclusion. Therefore, we challenge the radiologist to actively look for the fibrofatty band upon reviewing the CT scan and we have highlighted few radiological features l to help detecting thefibrofatty band.Radiologist should actively look for fibrofatty band in the small bowel obstruction using all available CT reformat.The tissues density of the fibrofatty band is similar to the surrounding mesentery and omentum.Compression from fibrofatty band can cause edema in the downstream intestinal loop which can mimic the appearance of Crohn’s disease.The presence of fibrofatty band should prompt surgical intervention.


Wilms’ tumor (WT) in adults is a rare neoplasm. Only a few reports are available in the literature. The tumor often masquerades as renal cell carcinoma (RCC). For accurate reporting, histopathological examination (HPE) plays a vital role in early diagnosis and prompt administration of multimodality treatment helps to improve the prognosis.We comprehensively analyzed five cases of adult WT presenting in the third to fifth decade with flank pain, hematuria, fever, and palpable lump. After complete clinical, biochemical, radiological, and HPE evaluation, tumor was staged and treatment was planned accordingly.Patients with low-stage WT were treated with open radical nephrectomy and chemotherapy. One of the patients diagnosed with inferior vena cava (IVC) thrombus apart from the above treatment also underwent IVC thrombectomy. Another young male presenting with distant metastasis (stage IV) and focal anaplasia on histology received preoperative chemotherapy and then planned for surgery. Unfortunately, the tumor being unresectable, second-line chemotherapy was given but he ultimately succumbed to death. All other patients are on regular follow-up and disease-free.Adult nephroblastoma is a rare clinical entity with hostile behavior. The presence of IVC thrombus is not a contraindication to surgery. Although the management strategy as per pediatric protocol by the inclusion of multimodality approach improves survival, still the overall prognosis in adults is dismal. There is a need for a standardized treatment protocol to encourage a homogenous approach for this rare disease and thereby improve survival. Wilms’ tumor (WT), presumably has originated from primitive metanephric blastema and is named after Carl Max Wilhelm Wilms, noted German surgeon of the 19th century . Large sThis clinical study was conducted in a tertiary care hospital over a decade from June 2010 to August 2020. After approval from the Ethics Committee and taking informed consent, patients were enrolled for the study.An extensive review of the literature was done from articles published over the last 25 years. Various search engines were used to identify relevant articles. The keywords: nephroblastoma, adult wilms tumor, outcome, inferior vena cava (IVC), thrombus, National Wilms Tumor Study (NWTS) group, International Society of Pediatric Oncology (SIOP) were used. With this background, we analyzed five adult Wilms’ tumor patients presenting in the third to fifth decade of life. Four patients were male and one of them was a female. The most common presentation being flank pain, hematuria, fever, and palpable lump . All patAll patients were operated under general anesthesia, with modified chevron incision commencing approximately two fingerbreadths below the costal margin and extending laterally to the midaxillary line. The kidney was mobilized laterally and posteriorly, and the perirenal collateral circulation was ligated. Then renal artery was identified, ligated, and divided, consequently the collateral circulation collapsed making the rest of the dissection easier , 6.In case 4 with IVC thrombus, a plane was then created between the IVC and posterior abdominal wall, small tributaries were identified and ligated. The advantage of creating this plane was to facilitate circumferential control of the IVC. The use of self-retaining liver retractor was of immense help and made the surgery quite effortless. Vascular isolation of the IVC was achieved by placing vascular clamps in the following order: caudal IVC first, then the right renal artery, right renal vein, and cephalic IVC. Extraction of the thrombus was facilitated by a 2–3 cm longitudinal incision on the IVC beginning at the level of the renal vein and extending cranially, encompassing a vessel wall rim of the orifice of the resected renal vein. The tumor thrombus was then “milked” downwards out along with the whole kidney specimen. After extraction of the specimen, the IVC was repaired in a bloodless surgical field with a continuous polypropylene 5-0 suture.Detailed histopathological examination (HPE) was performed in all cases and immunohistochemistry was done as indicated. The staging of adult WT was done similar to pediatric tumors in accordance with NWTSG.All patients were subjected to multimodality treatment according to the stage and histology. Strict follow-up was done with clinical assessment, blood biochemistry, and CT scan of chest, abdomen ,and pelvis biannually for 3 years followed by annual scans thereafter.2) and actinomycin D (15 µg/kg) regimen for 18 weeks. Case 4 with stage II favorable histology received three drugs regimen comprising of vincristine (1.5 mg/m2), actinomycin D (15 µg/kg), and doxorubicin (50 mg/m2) for 24 weeks.Out of five patients, three patients with low-stage disease  and favorable histology underwent open radical nephrectomy, mean duration of surgery was around 110 min and the mean blood loss being 450 ml. Case 1 had a fever and wound infection, Case 3 had paralytic ileus which resolved with conservative management, Case 4 needed a blood transfusion in the postoperative period and had wound infection and dehiscence, apart from that postoperative period was uneventful. Each patient received standard adjuvant chemotherapy. Cases 1, 2, and 3 with stage I favorable histology adult WT received two drugs vincristine (1.5 mg/m2 (d1 = d28). The patient was then planned for radical nephrectomy followed by adjuvant chemotherapy and radiation, but intraoperatively tumor was unresectable. Second line of chemotherapy that consisted of etoposide 200 mg/m2 for 3 days and cisplatin 100 mg/m2 (d1 = d21) was started. After three cycles, the CT scan showed no response to therapy. Within 15 days, patient’s performance status deteriorated and he died 3 weeks after the last cycle.Case 5, a young male with metastatic disease, underwent an initial biopsy which demonstrated unfavorable histology, so upfront chemotherapy was given for 6 weeks, with vincristine 2 mg per week and doxorubicin 50 mg/mCase 4 in our study, with renal mass and IVC thrombus, underwent left open radical nephrectomy with IVC thrombectomy and regional lymphadenectomy, duration of surgery was around 200 min and blood loss was 900 mL. In the postoperative period, he required blood transfusion and secondary suturing of the wound. He was discharged on day 10 with a plan for chemotherapy.The most common presenting symptom in adults includes pain  in 50%–80% of cases, followed by signs like hematuria and abdominal mass in about 30%–60% of patients. Fever, weakness, and weight loss being less common. Seldom adult WT is an incidental finding  or diagnDue to identical imaging characteristics, it is difficult to differentiate a WT from renal cell carcinoma (RCC) in adult patients. Wu et al. , in theiOn T2W MRI it is described as an isointense or hypointense signal in all phases in distinction to many renal tumors  that are heterogeneous and hyperintense on T2W imaging. Therefore, one may distinguish between WT and tumors with hypervascularity based on differences in enhancement . Out of Wilms’ tumor in adults and children have similar histopathological characteristics. The WT1 gene 11p13) is mutated in 10% of tumors. 11p, 7p, 16q, and 1p alterations are also documented. In our study, no genetic markers were tested for classical triphasic histopathological pattern comprising of blastemal, epithelial, and stromal elements is the hallmark , and C. p13 is muPatients with anaplasia have a very aggressive course of the disease as seen in case 5, early age of presentation with clinical and radiological features of advanced disease (stage IV). His Trucut biopsy revealed triphasic pattern with predominant blastemal cells and focal anaplastic cells. He received preoperative chemotherapy, in spite of it, his tumor was not amenable for surgery and later succumbed to death.Anaplasia as identified by multipolar mitotic figures, enlarged nuclei at least three times and hyperchromatic nuclei, is reported in 10% of WT cases. Its recognition and documentation as “focal or diffuse” are very essential. Diffuse anaplasia cases have a higher relapse rate and poorer prognosis as compared to focal anaplasia , 14. ThiAdult WT is diagnosed based on the criteria given by Kilton et al. . These iMasuda et al.  have sugAdditional diagnostics such as immunohistochemical staining for the presence of cytokeratin, vimentin , desmin,Another interesting and rare case (case 4) of a 40-year-old male with clinical and radiological features suggestive of renal mass with venous occlusion secondary to tumor thrombus extending into renal vein and IVC (Level II), a clinical diagnosis of left RCC with IVC thrombus was made. Histopathological evaluation inadvertently revealed findings  consistent with aggressive adult WT.The IVC tumor thrombus may be present in 4%–10% of patients of adult WT identical to RCC but the exact incidence of venous involvement in adult WT is seldom reported and still unknown . These cIn patients with thrombus, (i) invading the wall of the IVC, (ii) extending to intrahepatic IVC, supra hepatic IVC level, or the right atrium, preoperative chemotherapy is beneficial and recommended. In our case, thrombus was limited to infrahepatic level, so preoperative chemotherapy was not offered.As it is a rare disease in adults, standard treatment protocol has not been defined to date. There is a common consensus that a multimodality approach is required in the treatment, involving surgery, chemotherapy, and/or radiotherapy.Two approved protocols for management are SIOP and NWTS. SIOP suggests chemotherapy prior to nephrectomy for tumor shrinkage and intraoperatively less chance of spillage. It also downgrades the tumor, so the overall treatment required is less whereas NWTS recommends upfront nephrectomy to decide further treatment based upon histology and stage of tumor  19, 20), 2019, 2Radical nephrectomy is the gold standard treatment. Nephron sparing surgery is recommended only in some cases  as per SIOP .The SIOP recommends preoperative chemotherapy to decrease the incidence of local and distant recurrence. Some potent drugs used are actinomycin D (ACT), vincristine (VCR), doxorubicin (ADM), cyclophosphamide (ctx), ifosfamide (IFO), etoposide, and carboplatin (as in monotherapy drug combination) , 23. NWTWilms’ tumor is radiosensitive and according to various SIOP trials, it prevents tumor rupture as well as downgrades the tumor stage. Existing guidelines recommend radiotherapy only for advanced WT  and low-stage tumors with unfavorable histology. NWTS and SIOP recommended doses are 10, 15, and 20 Gy, respectively (The NWTS group documented an overall survival rate of 82% in favorable histology of adult WT . ReinharWe reviewed the literature and analyzed the clinical, pathological, treatment, and outcome parameters in various studies and compared these variables with our findings .Long-term follow-up of these patients is of utmost importance because of the risk of relapse and potential side effects of chemoradiation. In our case series, the patient with IVC thrombus received postoperative chemotherapy and is having a disease-free survival at 5th year of follow-up. Amongst the remaining three patients with low-stage disease, one was lost to follow-up, one is still on chemotherapy, and another is on regular follow-up and disease-free to date.Adult WT is a rare entity with mainly case reports in literature. The likelihood of WT should be kept in mind in any adult presenting with flank pain, large tumor mass, and aggressive growth. Being so rare, the diagnosis is made solely on histopathology with hallmark triphasic pattern. From our study, we concluded that there are no established protocols for treatment, still it is curable if treated according to pediatric strategy, including multimodal approach. The presence of IVC thrombus along with its parasitic vasculature and multiple collaterals make the procedure technically challenging but is not a contraindication for surgery and can be managed safely with improved surgical techniques.All WT patients should be registered to international databases which will immensely assist in the research and development of future management guidelines for this rare entity.


Small bowel obstruction (SBO) secondary to pelvic inflammatory disease (PID) is a rare complication only reported on a few occasions. We presented a 38-year-old female with an acute abdomen secondary to PID diagnosed via CT and MRI abdomen. The patient was treated in a conservative manner and recovered with no further complications. In our case, the learning point is the consideration of such an etiology in women with no previous surgical history presenting with an acute abdomen. Pelvic inflammatory disease (PID) is an infection of the female upper genital tract . It is vIUD placement is the most commonly used method of reversible contraception globally and is used by an average of 23% of females using contraception, with a range of <2% to >40% based on the country . Risk faOn the other hand, small bowel obstruction (SBO) is a common surgical emergency defined as the disturbance of the normal flow of intraluminal content secondary to either mechanical or functional factors ,8 This lAlso, acute SBO accounts for 2% to 4% of emergency department visits, with 15% of admissions and 20% of emergency surgical operations for abdominal pain ,11. We rA 38-year-old female with a past medical history of menorrhagia and post-coital bleeding presented with severe abdominal pain. This began one day prior to admission and was associated with a three-week history of constipation. The patient did not have a significant surgical or gynecological history. However, she is sexually active and using an intrauterine device (IUD) for protection. Physical exam showed normal vital signs, and the abdominal exam revealed diffuse distention with hyperactive bowel sounds with no signs of peritonitis. Blood workup was remarkable for an elevated WBC of 18.9. Otherwise, liver and renal function tests, erythrocyte sedimentation rate, and C-reactive protein levels were normal. Plain abdominal X-ray findings were consistent with subacute SBO. A CT abdomen was performed showing dilatation of the large bowel with a transition point in the sigmoid colon. Distal to this there was thickening of the distal sigmoid colon and rectum with surrounding mesorectal and presacral fat stranding. Multiple bilateral pelvic cystic lesions were identified which were suspicious for abscesses . The fallopian tubes were distended and enhancing, indicating pyosalpinx, with evidence of a tubo-ovarian abscess on the left side. The rectum and sigmoid were thickened and enhancing, with dilatation of the proximal sigmoid in keeping with bowel obstruction. Adjacent to the transition point was an abscess, which was inseparable from the mural surface. Incidental note was made of a small endometrioma in the right ovary, with normal appearance of the bladder, uterus, and cervix Figures , 5. The patient was treated conservatively with nil by mouth, intravenous (IV) fluids, and nasogastric tube (NGT) decompression. The IUD was removed and a culture was done which showed a negative result. Broad-spectrum antibiotic therapy (doxycycline and ceftriaxone) was given. As the patient was clinically well, she was discharged in a stable condition and a repeat MRI was completed as an outpatient after completing her course. This showed resolution of the pelvic abscesses, with improvement in the sigmoid colon and rectal. Minor residual diffuse soft tissue enhancement remained Figure .We presented a 38-year-old lady presenting with SBO secondary to PID, a rare etiology leading to bowel obstruction. This case has been scarcely described in the past, with cases reported on only a few occasions ,13. CT aFurthermore, an MRI of the abdomen showed fallopian tubes were distended and enhancing, indicating pyosalpinx, with evidence of a tubo-ovarian abscess on the left side. The rectum and sigmoid were thickened and enhancing, with dilatation of the proximal sigmoid in keeping with bowel obstruction. While imaging has minimal usage in the diagnosis of PID, there is usefulness in assessing complications related to it ,16.Our patient was treated conservatively, the IUD was removed, and broad-spectrum antibiotic therapy (doxycycline and ceftriaxone) was given. Non-surgical treatment has shown to be an acceptable form of therapy with an overall success rate of 65% to 80% . The antIn summary, SBO secondary to PID is a rare but significant complication. It should be considered in females of reproductive age with no significant surgical history presenting with an acute abdomen.


Here, we document a rare and unique presentation of an accessory tragus (AT). A 3-year-old male presented with a 2-cm congenital post-auricular mass on his right side. Upon resection and histologic examination, the mass demonstrated histologic features consistent with an AT. To the best of our knowledge, this is the first reported case of an AT presenting posterior to the auricle. An accessory tragus (AT) is a benign congenital malformation caused by an aberration of the first pharyngeal arch. This abnormality can occur as an isolated finding or with a syndrome, with the most common association being Goldenhar syndrome. AT can also be associated uncommonly with VACTERL syndrome, Wolf-Hirschhorn syndrome, and Townes-Brocks syndrome. Accessory tragi most often occur in the preauricular region anterior to the tragus but also commonly occur within the triangular area between the oral commissure and the anterior auricle . Other rA 3-year-old male was referred to a pediatric otolaryngologist by his pediatrician for a mass behind his right ear. The mass was noticed at birth and had been increasing in size. The mass was not painful, had no drainage, and the patient had no signs of hearing loss. The child had an uncomplicated pregnancy and a full-term delivery. The patient did not have any congenital syndrome. A complete review of systems was obtained and found to be negative. On physical examination, the pediatric otolaryngologist described the mass as a 2-cm fibroma behind the right ear that was soft and mobile Figure . The masSix months later, the patient underwent elective excision. The post-auricular mass was excised under monitored anesthesia care, and the operative findings were consistent with the diagnosis of a fibroma Figure .The operative specimen was submitted to pathology. Histologic examination, as shown in Figure Figure The posterior location of the AT found in this case is rare and unique. Embryologically, the anterior auricle develops from the first pharyngeal arch, which originates at the oral commissure . This stGiven the clinical examination findings, a fibroma was initially the presumed diagnosis. However, histologically, the complement of fibroadipose tissue and vellus hair follicles with cutaneous adnexal tissue was typical of an AT . Of noteTo the best of our knowledge, this is the first reported case of an AT presenting posterior to the auricle. Accessory tragi most commonly present anterior to the tragus at various locations between the anterior auricle and the oral commissure or in the supraclavicular region. This case report, however, is unique because we observed an unusual presentation of an AT posterior to the auricle, which has not been described in the literature yet. The clinical findings of an AT can mimic other benign skin masses, but histological analysis can lead to a diagnosis. In the future, when patients present with congenital post-auricular masses, an AT may be considered in the differential diagnosis.


Suture granulomas are localised inflammatory reactions that develop at the site of retained suture material. They are a rare surgical complication that is sometimes radiologically challenging to diagnose, especially if the intra-abdominal is communicating with the anterior abdominal wall.The case reported here was a 22-year-old female who presented with right iliac fossa pain 5 months post-appendectomy, which turned out to be due to a suture granuloma. Ultrasonography and CT with and without contrast misdiagnosed the lesion as an abscess or less likely as neoplasm. Conclusive diagnosis was based upon histopathological examination of tissue obtained by biopsy.When reviewing the images of patients who present with post-operative surgical complications, it is crucial to consider suture granuloma as a distinct possibility. A definitive diagnosis saves the patient from undergoing unnecessary extensive surgeries and improves the patient experience. Definitive management is usually by appendectomy. Different surgical techniques and incisions have been developed to improve the outcome and minimize post-operative complications. A post-operative abdominal wall mass in the region of McBurney’s incision is one of the recognised complications that follows an open appendectomy. Different post-operative abdominal wall mass conditions include post-operative suture granulomas, haematomas, keloids, hernias, abscesses and abdominal wall tumours.2 Suture granulomas can be superficial, with early onset, or deep, with later onset. They might develop months or even years after an intervention and can develop anywhere in the body. They can be asymptomatic, but sometimes become palpable and tender, mimicking a tumour, an abscess or a perforation. Suture granulomas have been reported in the conjunctiva post pulley fixation suture, in the surgical bed in the anterior compartment of the neck post thyroidectomy, in the left lower lung lobe post left basal segmentectomy, in the abdominal wall with intra-abdominal extension post appendectomy, on the antimesenteric side of the intestine post small bowel resection and in the scrotum post varicocelectomy. Nevertheless, suture granulomas generally occur very rarely as surgical complications.Suture granulomas are localised inflammatory reactions that develop at the site of retained suture material. They develop due to suture antigenicity and/or the presence of bacterial infection. Braided silk and Dacron are the most reactive suture materials; however, any suture material can cause a reaction.3 collection with a hyperechogenic structure impeded in it with a rail-like morphology. Sometimes, some vascularity can be identified using colour Doppler. Despite the unique presentation on ultrasonography images, diagnosis is often missed and finally determined by incisional/excisional biopsy and histological correlation.2 Other imaging modalities can be used for a definitive diagnosis, such as contrast-enhanced CT or positron emissiontomography scans.Imaging plays a major role in the diagnosis of suture granulomas, and ultrasonography has been used as a first-line investigation technique. Using ultrasonography, suture granulomas exhibit a characteristic feature of a hypoechogenicThis report presents a case of a patient with a suture granuloma with intra-abdominal extension that showed symptoms 5 months after appendectomy.A 22-year-old Middle Eastern female patient presented to the local hospital with a 1-week history of moderate constant right iliac fossa pain, 5 months post-open appendectomy. Clinically, the patient described having mild continuous right iliac fossa pain that showed some tenderness to touch on clinical examination. She had no fever, no nausea or vomiting and no weight loss. Clinical examination showed no rebound tenderness. Regarding her labs, inflammatory markers, including white cell count and C-reactive protein, were at the higher end of the normal range.Radiologically, ultrasonography was performed, followed by non-contrast CT abdomen scanning and then contrast CT enterocolonography. Ultrasound (5–13 MHz linear transducers) showed a hypoechoic lesion with hyperechoic foci, averaging 4 × 5.4 cm in maximum axial dimensions. The lesion extended into and was continuous with the related subcutaneous layer of the skin, and on colour Doppler, no vascularity was detected. A differential diagnosis of either an inflamed appendectomy stump or an intra-abdominal abscess was made. However, these findings were not consistent with the presenting complaint, so the decision was then made to proceed with a non-contrast CT abdomen scan.The CT These findings were not conclusive; thus, further imaging was needed. Given the close relation of the mass to the caecum and the history of appendectomy, the decision was made to proceed with CT enterocolonography rather than CT abdomen with contrast. CT enterocolonography provided better visualisation and assessment of the caecum and its relation to the mass. It was also useful to exclude the possibility of stump appendicitis. The scan was performed 2 days later. Axial cuts were taken following oral administration of neutral contrast, a water enema and intravenous contrast injection. The right iliac fossa showed a heterogeneous tumefaction with cystic component measuring 57 × 47 x 57 mm at its maximum dimensions, and enhancing wall with multiple enhancing septations as well as calcific foci within the lesion. The lesion extended to the right lower anterior abdominal wall. This was associated with related fat stranding and oedematous changes of the cecum. Abdominal organs, including the liver, hepatic biliary radicles, pancreas, spleen, kidneys and suprarenal glands were normal and dense, with no focal lesions identified. The impression reported was an intraperitoneal loculated collection with abscess formation and typhlitis rather than a neoplastic process.As per the multidisciplinary team’s advice, the patient underwent surgical excision of the mass. A sample was sent to the histopathology team for pathological correlation. Further planning for the management of the patient was performed.The excised sample was examined by an experienced pathologist who reported that sections through the lesion demonstrated well-formed non-caseating granulomas made up of plump epithelioid histiocytes. These structures were surrounded by variable amounts of lymphocytes and plasma cells and were associated with robust surrounding fibroplasia. In the centre of the reaction, suture material was identified as particulate refractile blackish matter; this finding was in line with inflammatory suture granuloma. No neoplastic lesions or abscess formation were identified. An established diagnosis of suture granuloma was then made, and the patient was reassured.The patient recovered very well after the surgical excision of the granuloma. Her pain had improved, and no further mass was identified during the 6 month follow-up appointment.2,4 These granulomas are mostly associated with non-absorbable sutures.5 Suture granulomas have been reported at various times following surgery. Their duration ranges from a few days to many months or even years following surgery.1 The histopathological nature of the granuloma depends on the material of the suture entrapped and the reaction of the body towards it.4 Clinically, suture granulomas do not have typical presentations; they can be asymptomatic and are sometimes found incidentally, and symptoms depend on granuloma site, extent and size. In one case, suture granulomas appeared as a recurrent tumour on follow-up CT scans post colorectal tumour resection.6 External factors, such as exposure to radiation, have been reported to increase the likelihood of suture granuloma.7Suture granulomas are groups of cells that cluster at or near the site of surgical sutures as a part of the body’s response to foreign material.8 11 years post-operatively, Ichimiya et al9 25 years post-operatively and Augustin et al1 12 years after appendectomy.The present case represents a rare complication of a suture granuloma with intra abdominal extension from the abdominal wall that occurred 5 months post appendectomy. A search of literature published within the last 20 years revealed only 3 similar reported cases: Matsuda et al1With the development of different surgical incisions and appendectomy techniques, some post-operative complications have arisen, including post-operative abdominal wall mass in the region of McBurney’s incision. These complications may occur early or late after surgery. Late complications are considered rare and can include adhesive intestinal obstruction, incisional hernia and suture granuloma. Most of these complications can present as an abdominal mass.1Thus, when encountering a post-appendectomy abdominal mass, a list of differential diagnoses should be considered. The mass could be primary or related to the appendectomy or to any other pathologic condition in the area. Therefore, it is of crucial importance to do a thorough clinical examination and history taking, all while employing radiological techniques, including abdominal ultrasound and contrast-enhanced multislice CT scan, to reach the correct diagnosis.In the present case, the suture granuloma diagnosis had been missed on three imaging modalities, reported by three different radiologists with different levels of expertise ranging from senior registrar to consultant. This illustrates the pressing need to keep suture granulomas in mind as a differential diagnosis for patients presenting with post-operative complications.The patient’s contrast-enhanced CT abdomen scan was performed at an imaging centre that did not share the imaging data with our local picture archiving and communication system. Therefore, we had access to the written report provided by the patient but not to the image itself.Clinicians should include suture granulomas in the differential diagnosis when imaging studies identify intra-abdominal masses in patients with post-operative abdominal complications at the operative site.Ultrasonography should be the first methodology used in the diagnosis of suture granulomas. It is the least invasive technique and minimises radiation exposure and patient anxiety.


Renal carcinoid tumors are exceedingly rare. These neuroendocrine masses are most frequently found in the gastrointestinal and respiratory tracts. A renal carcinoid tumor has only been documented in around 100 cases. In this article, we report two additional cases in female patients ages 53 and 63. Both tumors were found incidentally on computed tomography scans. Both women underwent radical nephrectomies. Neither has shown evidence of metastasis nor relapse to date; however, the 63-year-old woman was lost to follow-up. In conclusion, upon discovery of the asymptomatic renal mass, renal carcinoid should be a consideration in the differentiation, and if suspected, may be treated with radical nephrectomy as was done in our hospital. Carcinoid tumors are a rare subset of neuroendocrine tumors with an incidence of 38 for every 1 million persons in the United States . CarcinoThe paucity of cases, indolent nature of the disease, and illusive findings on imaging complicate the diagnostic process and cause many such cases to go misdiagnosed . OverallCase 1A 63-year-old female with a past medical history of clinical-stage, IB-grade-2 endometrial adenocarcinoma, status post-total abdominal hysterectomy, and bilateral salpingo-oophorectomy was referred for evaluation of an incidental left renal mass found on surveillance computed tomography of the abdomen and pelvis (CT A/P).On presentation, she denied constitutional symptoms, gross hematuria, flank pain, and lower urinary tract symptoms. The CT urogram scan of the abdomen and pelvis demonstrated a 3.8-cm heterogeneously enhancing lesion of the left lower renal pole Figure . A smallGross pathologic examination of the specimen revealed a 3.5 × 3 × 2-cm yellow-tan mass in the lower pole involving both cortex and medulla. No renal sinus or vascular involvement was seen . Following a discussion with the patient regarding observation with repeat imaging in six months versus biopsy, the patient opted for surveillance.Over the course of the following year, the LNs continued to enlarge, with the largest measuring up to 3.7 cm. Fine-needle aspiration of an enlarged celiac LN revealed benign hepatocytes and mixed lymphocytes. The patient was followed conservatively with a CT scan every six months for 30 months due to the benign nature of the findings. A positron emission tomography (PET)/CT scan was performed and there was mild uptake noted in the upper abdominal nodes, which was felt to be non-specific; however, low-grade lymphoma could not be excluded as there was no evidence of a metastatic carcinoid tumor. The patient was then lost to follow-up.Case 2A 53-year-old female was referred for evaluation of a 7-cm right, intrapolar enhancing renal mass found incidentally on workup for right upper quadrant abdominal pain. Past medical history included hypertension, hyperlipidemia, type II diabetes, and lifelong tobacco use. The patient denied constitutional symptoms, flank pain, gross hematuria, and lower urinary tract symptoms. CT A/P demonstrated a 7-cm prominently solid but enhancing dorsal right mid renal lesion with no evidence of osseous, adrenal, or hepatic metastasis or renal venous invasion or retroperitoneal lymphadenopathy Figure . A CXR wGross pathology revealed a well-demarcated tan solid tumor of the upper pole measuring 6.0 × 6.5 × 3 cm. The tumor appeared to reveal variable parenchyma morphological expression in both growth patterns and cytomorphology. Immunohistochemical stains were positive for CD56 and synaptophysin with membrane-bound, electron-dense neuroendocrine granules consistent with primary renal carcinoid  challenges in diagnosis and management. At the time of presentation, case 1 was asymptomatic with an incidental enhancing mass on the lower pole of the left kidney, which was subsequently misdiagnosed as RCC. Upon further pathological workup, a diagnosis of PRCT within the background of clear-cell-type RCC was made. Surveillance included six-month CT A/P for 18 months until the patient was lost to follow-up. Alternatively, case 2 presented with right upper quadrant abdominal pain and an enhancing mass on the upper pole of the right kidney measuring nearly twice the size of the first patient’s mass. However, the course of surveillance for this case was more complex. Surveillance for this patient included a four-month post-operative measurement of serum serotonin and urine 5-HIAA in addition to an octreotide scan with subsequent endoscopy and PET scan. Further testing at six months post-operatively included a CT of the chest and A/P, which was repeated annually thereafter. Measurements of serum markers and urine metabolites were also repeated biannually. Neither patient showed evidence of metastatic disease throughout the surveillance period, although one patient was eventually lost to follow-up. These outcomes are consistent with the well-documented favorable prognosis that follows complete resection of PRCT.This case report highlights the variability in presentation leading to difficulty in the diagnosis of renal carcinoid tumors. It is crucial to differentiate this tumor from other renal masses. If a lesion is found within RCC, the management of the patient must be adjusted accordingly. Given the rarity of the condition, there is a lack of follow-up protocols and treatment plans. More research is needed for renal carcinoid tumors.


A 48-year-old, right-handed Moroccan woman with hepatitis C, receiving sofosbuvir 400 mg per day and daclatasvir 60 mg per day, presented 2 years ago a fixed painless flesh-colored nodule at the pulp of the right thumb.There was no functional impairment or history of trauma, but the patient complained of discomfort during thumb movements due to the size of the nodule . The X-rQuestion 1: What is the most likely diagnosis?A.LipomaB.Rheumatoid noduleC.Superficial acral fibromyxomaD.Giant cell tumor of tendon sheath (GCTTS)E.Tuberculous tenosynovitisAnswers:A.Lipoma – Incorrect. Lipomas rarely present on the hand (<1%).B.Rheumatoid nodule – Incorrect. First, the pulp of the thumb is not a location of rheumatoid nodules and the patient had no history of systemic disease or joint symptoms. These nodules are moveable in subcutaneous planes, which was not the case our patient, in whom the nodule was fixed. Finally, the histology of rheumatoid nodule exhibits a central area of necrosis surrounded by palisading epithelioid macrophages enclosed by granulation tissue containing lymphocytes and histiocytes.C.Superficial acral fibromyxoma – Incorrect. Superficial acral fibromyxoma is a rare, slow-growing myxoid tumor in the subungual area with a predilection for the great toe; nail involvement is seen in 50% of cases, usually with hyperkeratosis and onycholysis. Histologically, the tumor is composed of abundant myxoid stroma in the dermis with spindle-shaped cells.D.GCTTS – Correct. GCTTS is the most common benign neoplasm of the hand.E.Tuberculous tenosynovitis – Incorrect. Our patient was asymptomatic , and no caseous granulomas, tuberculosis bacillus, or multinucleated Langerhans giant cells were observed in the biopsy.Question 2: What is the most specific non-invasive test?A.Positron emission tomography (PET)B.UltrasoundC.Magnetic resonance imaging (MRI)D.Computed tomography (CT)E.Skin biopsyAnswers:A.PET – Incorrect. PET with fluorine-18 fluorodeoxyglucose combined with computed tomography (PET/CT) is widely used to differentiate benign from malignant tumors and to detect distant metastasis. However, GCTTS may show high fluorine-18 fluorodeoxyglucose uptake, which can resemble the situation characteristic of a malignant tumor. Therefore, fluorine-18 fluorodeoxyglucose PET/CT has limited diagnostic value, due to its false-positive findings.B.Ultrasound – Incorrect. Sonography is capable of distinguishing solid and cystic masses; however, GCTTS usually appears as a solid, homogeneous, hypoechoic mass. Internal vascularity can be demonstrated by Doppler examination in most cases, but does not have high specificity for GCTTS.C.MRI – Incorrect. MRI typically shows a well-defined mass adjacent to or enveloping a tendon. Characteristically, the mass is hypointense on T1-weighted images. On T2-weighted images, there is usually low signal due to chronic hemorrhage with hemosiderin deposition. The most specific feature of GCTTS is the blooming artefact (hemosiderin deposit) on gradient echo sequences.D.CT – Incorrect. Although it can reveal bone destruction and can be helpful in some cases of giant and infiltrative tumors, it is not the best diagnostic method for tendons and ligaments.E.Skin biopsy – Correct. Histology confirms the diagnosis, revealing foci of hemosiderin-laden histiocytes with a predominance of small stromal mononuclear cells and numerous larger histiocytoid mononuclear cells with eccentric nuclei.Question 3: What is the best treatment option in this case?A.AbstentionB.Surgical excisionC.RadiotherapyD.PexidartinibE.Surgery followed by radiotherapyAnswers:A.Abstention – Incorrect. Although there was no functional impairment, the tumor was increasing in size, causing discomfort. Moreover, some diffuse types of GCTTS tend to be more aggressive and are capable of malignant transformation.B.Surgical excision – Correct. Complete local excision is the treatment of choice. The main concern regarding this treatment is related to the high recurrence rates. Besides incomplete excision, there is no consensus concerning the effect of other risk factors on recurrence.C.Radiotherapy – Incorrect. The use of radiotherapy is limited, it is purported to be useful for controlling infiltrative cases and preventing recurrence.D.Pexidartinib – Incorrect. Pexidartinib was approved by the Food and Drug Administration in 2019 for adult patients with symptomatic tenosynovial giant cell tumor associated with severe morbidity or functional limitations and for surgically unresectable pigmented villonodular synovitis (large variant of GCTTS),E.Surgery and radiotherapy – Incorrect. There is no indication for radiotherapy after surgery in this case. In fact, it is the first episode in our patient and the tumor was encapsulated and disconnected from the tendon.None declared.


Adult intussusception during the perioperative period is defined as an extremely rare condition, especially when it emerges within short intervals of laparotomy, which may be explained as an unphysiological peristaltic function of the bowel without any lead points. Accurate diagnosis and therapeutic schedule predict a satisfactory outcome. Here, we introduce the case of a 32-year-old man who had symptoms of abdominal pain, no gas emission, and defecation shortly after liver transplantation. Intussusception was definitely diagnosed by abdominal CT, and then reduction was operated successfully by three-dimensional laparoscopy-assisted operation. There were no other complaints, and no secondary lesions were detected during the postoperative rehabilitation process in the hospital and over a follow-up period of 6 months. Relevant literature has been summarized subsequently. A promising minimally invasive surgery along with minimal secondary trauma was presented by laparoscopy in this rare case, providing the potential remedy for perioperative intussusception in the adult. Adult intussusception is a rare entity and defined as the invagination of partial intestinal segment into an adjacent segment of the bowel . In a reWe present the case of a 32-year-old man who has just undergone liver transplantation for acute liver failure and decompensated liver cirrhosis. Chief complaints of slight abdominal distention and cramp pain in the left lower quadrant were referred during the postoperative period of 15 days. The patient had no other malaises of nausea, vomit, and bloody tool, only performed with descending frequency and shape alteration of defecation. Physical examination showed an apparent inverted T-shape surgical incision. Then, abdominal palpation of the left lower quadrant showed slight tenderness but there was rebound, muscle rigidity, or abdominal mass. An abdominal CT scan was completed few days later, which disclosed the sign of proximal enterostenosis instead of direct intestinal intussusceptions based on partial air-fluid level . Conservvia laparoscopy had been completed , subacute 4–14 days), and chronic (>14 days) symptoms, most of which are involved in various features of digestive tract obstruction –14 days,. Intermi days, suMain etiologies of pediatric and adult intussusception are attributed to be idiopathic or underlying intestinal lesions associated with anatomic or infectious factors, postoperative adhesion, and other benign or malignant neoplasms , 6, 7. AThe diagnosis of intussusception in adults relies more on imaging techniques, because of untypical manifestations and latent structural lesions, which are usually relevant to the clinical outcomes of this emergency. Ultrasonography has unique advantages in diagnosing and screening the disease in children, treated as a non-radiation intervention with accuracy of 49.2–100% , but phyRestoring the physiological properties and function of bowels has been deemed the ultimate intention, and there are distinct differences with regard to the treatment of pediatric and adult intussusception. Hydrostatic reduction, namely enema reduction, is still recommended for idiopathic intussusception in children with an 80–85% success rate . In contIn conclusion, adult intussusception during the perioperative period of liver transplantation is extremely rare, and it easily involves misdiagnosis and then gets worse results. Therefore, definite diagnosis through abdominal CT and relief of obstruction performed by laparoscopy exerts a positive influence on clinical outcomes. Although the patient has attained a good prognosis so far after laparoscopy-assisted reduction, a longer follow-up period and concrete evidence, such as imaging assessment, will be essential to demonstrate no recurrence and other secondary lesions.The original contributions presented in the study are included in the article/Written informed consent was obtained from the patient for publication of this case report.QG wrote the original manuscript. SY offered some further advice for revision. XL mainly contributed to laparoscopic operation and introduction of the case. Collection of patient information and literature was performed by QG, CC, and YL. JY gave guidance in the submission of this study. All the authors read and approved the final manuscript.The 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.


The equine prepuce is characteristic for having two infoldings that allow for substantial accommodation of the penis during detumescence and permit erection. Segmental posthetomy of the equine prepuce is a well described technique indicated for penile sheath injuries or lesions  that do not involve the underlying penile tunics. This surgical technique can be performed with variable extent of excision . The authors describe their experiences and results with different levels of preputial resection for treating four Equidae stallion patients with different preputial/pathologies.Segmental posthetomy, also referred to as circumcision, reefing or posthioplasty, consists of removing a circumferential segment of the internal preputial lamina  followed by end-to-end anastomosis of skin edges. The purpose of this case series is to describe the successful outcome of segmental posthetomy for treating different diseases involving the internal or/and external preputial fold, while restoring the normal telescopic function. In this paper, we report the first case of complete degloving injury of the equine penis in the literature (case 1) and describe three different common lesions of the equine prepuce/penis . The amount of prepuce (safe minimums) that can be removed from a stallion without disrupting the proper telescopic function of the internal/external preputial fold and normal copulatory ability, has not been established. In this case series, all Equidae stallions maintained the telescopic function after preputial surgical resection. However, the surgeon must carefully evaluate every single case, especially when performing the Adam’s procedure. The equine prepuce or penile sheath has a double integumentary fold that covers the free part of the retracted penis: the external preputial fold or external lamina and the internal preputial fold or internal lamina . Each inSegmental posthetomy, also referred to as “circumcision”, “reefing” or posthioplasty , consistThis surgical technique is recommended for removing granulomas, scar tissue or chronic thickening of the preputial membrane that prevents retraction of the penis . It is aThe aim of this case series is to describe the successful use of segmental posthetomy in four stallions for the treatment of different diseases involving the internal and/or external fold of the prepuce, while preserving the normal telescopic function.All clinical cases were referred to the Veterinary Teaching Hospital of the University of Teramo .A 4-year-old Sardinia donkey stallion was referred with a history of injury of the penis of 4 h duration approximately. A complete circumferential avulsion of the integument at the level where the inner lamina of the external preputial fold inserts on the preputial orifice was detected at physical examination .A 14-year-old Pura Raza Espanola (PRE) stallion was admitted with a history of a wide mass against its penile sheath of 6 months duration. On admission, the physical examination of the external reproductive tract highlighted the presence of phimosis, caused by a firm circumferential swelling at the level of the outer lamina of the internal preputial fold and the preputial ring .By administering xylazine (0.5 mg/kg intravenously (IV)) and applying traction, the free portion of the penis could be extracted and extended through the acquired stenosis of the preputial ring, and the inner lamina of the internal preputial fold could be examined, to assess that it was not involved .A 5-year-old Murgese stallion was referred with a mass over his penile sheath. Physical examination of the external reproductive tract showed a hyperkeratotic proliferative-verrucous neoformation, with ulcerated and infected tissue, surrounding the outer lamina of the internal preputial fold and the preputial ring . There wA 16-year-old Pura Raza Espanola (PRE) stallion was referred with a history of injury of the penis of approximately 2 months duration. On admission, a necrotic and ulcerated wound (3–4 cm deep) that involved skin, subcutis and part of the bulbo-spongiosus muscle between the free portion of the penile body and the inner lamina of the preputial fold was detected at physical examination ; the ureIn all cases the animals were premedicated with acepromazine (30 μg/kg IM) and sedated with medetomidine (7 μg/kg IV); general anesthesia was induced with ketamine (2.2 mg/kg IV) and diazepam (0.06 mg/kg IV) and maintained with isoflurane and a constant rate infusion of medetomidine (3.5 μg/kg/min IV); all equines were positioned in dorsal recumbency.bis in die (BID)), gentamicin (8 mg/kg IV semel in die (SID)) and phenylbutazone (2.2 mg/kg IV BID).Perioperative treatment included the intravenous administration of cefazolin  was attempted .On day 12 from the first surgery, failure of the primary closure occurred , and a sDistally and proximally to the lesion, two parallel incisions, through the preputial epithelium were made -Blue; thThe integument between the incisions was excised. The subcutis and the skin were sutured with a combination of no. 2-0 and 0 sutures  in a simple interrupted pattern, in two different layers .A circumferential preputial resection  and anastomosis with the horse under general anesthesia were performed.Distally and proximally to the lesion, two parallel incisions, through the preputial epithelium were made -Green. TThe excised mass measured 18 × 10 cm and weighed 560 gr .The integument between the incisions was excised. The subcutis and the skin were sutured with a combination of no. 2-0 and 0 sutures  in a simple interrupted pattern, in two different layers.A circumferential preputial resection  and anastomosis with the horse under general anesthesia were carried out.Distally and proximally to the lesion, two parallel incisions, through the preputial epithelium were made -Green. TThe excised mass measured 22 × 11 cm and weighed 600 gr .The integument between the incisions was excised. The subcutis and the skin were sutured with an absorbable monofilament material no. 2-0 or 0  in a simple interrupted pattern, in two different layers.A debridement of the necrotic and ulcerated penile wound of the bulbo-spongiosus muscle between the free portion of the penile body and the inner lamina of the preputial fold was performed; the bulbo-spongiosus muscle defect was apposed by simple interrupted sutures of a no. 2-0 absorbable monofilament material .A limited circumferential preputial resection  and reconstruction with the horse under general anesthesia were performed . DistallThe integument between the incisions was excised. The subcutis and the skin were sutured with an absorbable monofilament material no. 2-0 or 0  in a simple interrupted pattern, in two different layers.Follow-up was obtained via telephone interview with owners and referring veterinarians.per os (PO) SID) for 3 days and application around the surgical site with Hypermix® , Italy.) The donkey appeared comfortable when it shafted out to urinate and had normal penile erections. He was discharged 35 days after the second surgical procedure with the preputial integument wound almost completely healed.Post-operative management included the administration of antimicrobial therapy  for 5 days, anti-inflammatory therapy  The horse appeared comfortable when it shafted out to urinate, and it was discharged 7 days after the surgery. Complications included a mild subcutaneous oedema/hematoma and a mild colic syndrome (within 12 h of anesthesia), which resolved with medical treatment consisting of a single administration of flunixin meglumine 1.1 mg/kg IV.Post-operative management included the administration of antimicrobial therapy  for 5 days, anti-inflammatory therapy (suxibuzone 3.3 mg/kg PO SID) for 3 days and application around the surgical site with ReparilFollow-up consultation after 6 months verified that the horse returned to work. A breeding career had not been planned for this stallion yet, however the stallion had a normal penile erection.Post-operative management included the administration of antimicrobial therapy  for 5 days and anti-inflammatory therapy (suxibuzone 3.3 mg/kg PO SID) for 3 days. Complications included a mild colic syndrome, which resolved with medical treatment in the following days, and a partial suture dehiscence, which healed by second-intention healing with minimal granulation tissue.No recurrences occurred over the following 2 years and the stallion was regularly employed for reproduction.Post-operative management included the administration of antimicrobial therapy  for 5 days, and anti-inflammatory therapy (suxibuzone 3.3 mg/kg PO SID) for 3 days.Recognized post-operative complications were a mild abdominal pain (within 24 h of anesthesia), which resolved with a single administration of flunixin meglumine 1.1 mg/kg IV SID and a partial suture dehiscence, which healed by secondary intention healing. The horse was discharged 10 days after the surgery.The long-term follow-up reported that the horse, 4 years after the removal of the mass, was in good clinical condition and returned to show jumping competitions, but had not yet been used for breeding; however, he appeared comfortable when urinating and had normal penile erections.The resected portions of tissue were submitted for histopathology in cases 2–4. Histopathological results are detailed in Circumferential or extensive lesions of the prepuce, that could not be treated with a simple excision, were removed surgically through a more or less extensive posthetomy. Lesions with varying etiology and different extension were treated with success, without recurrences, and with preservation of the telescopic function.Traumatic injuries of the penis and prepuce occur during breeding when attempting to mate across the fence or from a variety of sources ,5,6. TheHabronema. The preputial ring and urethral process are the most commonly involved genital sites [Cutaneous habronemiasis is a granulomatous disease caused by larval infection of al sites . HabroneThe outer lamina of the internal fold was involved in case 3, while the outer lamina of the internal fold and the preputial ring were involved in case 2. A successful extensive posthetomy was performed in case 2 and the horse returned to his intended use.In case 3, a diagnosis of sarcoid was made histologically. Sarcoid is the most common tumor of the horse and affects horses of all ages. The clinical appearance of this tumor ranges from small single nodules to very aggressive and extensive involvement of the penis and inner lamina of the internal preputial fold . In caseIn the literature, there are no treatments for equine sarcoids that are accepted as the gold standard . ApproxiIn case 3, segmental posthetomy represented a viable treatment for a large sarcoid located on the outer lamina of the internal fold. A 2-year follow-up proved that no recurrence occurred, and the stallion was regularly employed for reproduction.Squamous cell carcinoma (SCC) is the most common neoplasm of the penis and prepuce. According to the literature, geldings develop squamous cell carcinomas more often than stallions, and horses with nonpigmented genitalia are more commonly affected than those with pigmented genitalia . ConversThe histological examination of the resected tissue (case 4) highlighted a grade I SCC  that invaded the penile epithelium and subepithelial tissue. According to the Van den Top algorithm, posthioplasty or local excision were possible treatments, however the choice of therapy for case 4 was not based on this classification because the stallion had a traumatic injury history, and it was treated with the aim of preserving the function of the external genitalia. Despite that the exeresis was not performed as in a case of neoplasm, histopathology showed 2 cm of clean margins.For such lesions the prognosis is guarded since recurrences and new lesions are common . After eDepending on the nature and extent of the lesion, the amount of prepuce removed in this case series was variable. More specifically, the distal portion of the inner lamina of the internal fold (case 4), the outer lamina of the internal fold and preputial ring , or the inner lamina of the external fold, outer lamina of the internal fold, preputial ring and proximal portion of the inner lamina of the internal fold (case 1) were removed.Partial suture dehiscence  can be managed by second intention healing without compromising the cosmetic and functional result.Post anesthetic colic (PAC) was recognized within 12 h (case 2) and within 24 h after anesthesia (case 4). In the literature, PAC is also correlated with nonabdominal procedures ; the mosIn veterinary literature, posthetomy is suggested for removing the internal preputial lamina ,15,16,17The amount of prepuce that can be removed from a stallion without disrupting proper telescopic function of the internal preputial lamina and normal copulatory ability has not been established. In this case series the animals were all Equidae stallions that preserved telescopic function and had normal penile erections after surgery. To our knowledge, this is the only report of segmental posthetomy in stallions.


There was local recurrence in one patient who underwent radical orchiectomy for the sarcoma one year ago. In addition, the CT scans showed no occurrence of distant metastasis. The two patients underwent radical inguinal orchiectomy or resection of the recurrent tumors with nerve-sparing retroperitoneal lymph node dissection. Histologic examination revealed embryonal RMS (eRMS) without lymph node metastasis. We highlight the importance of multi-disciplinary participation for paratesticular RMS detection and preoperative ultrasound-guided needle biopsy (UNB) for rapid confirmatory diagnosis. Complete surgical resection coupled with chemotherapy and radiotherapy is the main treatment option for the paratesticular RMS. In addition, sperm cryopreservation treatment and endocrine follow-up could increase the overall survival and quality of life of the patients.Paratesticular rhabdomyosarcoma (RMS) accounts for only 7% of all the RMS cases. Due to the limited available data, there is no consensus on the diagnosis and management of the paratesticular tumors. Here, we interrogated two paratesticular RMS cases in 25 and 27-year-old men presenting with painless and rapidly growing mass in the scrotum. Whereas the data showed no upregulation of tumor markers such as  Scrotal ultrasonography demonstrated an irregular and isoechoic mass within the left hemi-scrotum, while the testicular size was normal. In addition, Color Doppler ultrasound showed significant vascularity within the mass and a resistance index (RI) of 0.71, indicating a high probability of a tumor. On the other hand, magnetic resonance imaging (MRI) showed that the soft tissue mass in the left scrotum was closely associated with the epididymis and had gradual enhancement after contrast suggesting that the lesion might be arising from mesenchymal tissues , carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), th month, CT scan in the 12th month, and positron emission tomography-computed tomography (PET/CT) in the 24th month. Over the 24-month follow-up period, he remained free from local recurrence and distant metastases. The last physical examination showed restoration of his erectile functions as well as serum endocrine hormones such as follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen (E), and testosterone (T). However, two semen examinations indicated oligospermia.Based on the staging evaluation by Intergroup Rhabdomyosarcoma Study Group , the casβ-HCG and LDH showed no significant abnormalities. Besides, a scrotum echography showed a heterogeneous mass above the left groin and pelvis. In addition, chest, abdominal and pelvis CT and MRI scans showed an irregular lesion above the left groin and pelvis  and no adjuvant therapy was administered post-surgery. On physical examination, a surgical scar in the left inguinal region and a 4.0 × 5.0 cm mass localized above the inner ring of the inguinal canal were palpable. This mass was hard and immobile, growing into the pelvic cavity  can be a useful alternative in the diagnosis . The scrThe two cases lacked specific clinical manifestations but presented to the hospital due to left scrotal or inguinal swelling in a month. Thus, the lesions had rapid growth. In addition, both cases lacked any serum tumor markers, such as CEA, AFP, β-HCG and LDH showing no significant abnormalities. Besides, the scrotal US demonstrated irregular and isoechoic mass, while the Color Doppler US image showed significant vascular signals. Both the CT scan and MRI showed localization of the tumor in the paratesticular region, with no definite distal metastasis. Thus, to improve diagnosis precision, we suggest that adolescents should be educated about self-examination. A thorough physical examination is necessary at the discovery of the painless scrotum or inguinal enlargement. Besides, US and MRI should be the main methods to examine localization of the lesion. They are simple and do not emit any radiation. Further, we recommend preoperative UNB for rapid confirmatory diagnosis. Some previous case reports did not present preoperative diagnosis of the paratesticular RMS prior to the first surgery and underwent simple resection of the lesion. The cases underwent remedial radical operation after post-operative pathologic reports. In recent years, testicular and epididymal puncture has been accepted as a safe and reliable diagnostic method, which is not associated with the risk of tumor needle implantation or tumor metastasis . In our According to the international RMS classification, the common histological subtypes are alveolar, embryonal, botryoid embryonal, spindle cell embryonal, and anaplastic . EmbryonHistopathologically, the two cases showed a pale profile of gross specimen with fish-like appearance. Microscopically, the tumor comprised of a significant number of rhabdomyoblasts with elongated eosinophilic cytoplasmic tales, commonly referred to as tadpole cells or strap cells. In addition, there were cases of cross-striations within the cytoplasm. The lesion presented a storiform growth pattern with abundant collagen between the tumor cells. It showed an arrangement of tumor cells in bundles with a low to moderate amount of collagen, resembling a leiomyosarcoma. Immunohistochemical findings showed the expression of MyoD1, Myogenin and Desmin in the tumor cells, while keratin and CD34 were negative. On the basis of these findings, a final diagnosis of spindle cell variant of the rhabdomyosarcoma was conducted. The peripheral resection margin and both seminal vesicles did not show presence of tumor cells. Besides, there was no vessel or perineural invasion.The RMS prognosis is related to age, histology, lesion site, and tumor diameter , 17. TheWe, therefore, suggest that there should be a MDT discussion among specialties from the surgery department, endocrinology department, reproductive center and other departments after confirmation of the eRMS. A comprehensive and individualized, but optimal, treatment plan should include tumor resection and preservation of sexual and reproductive functions of the male patients.Surgical excision should be extensive and thorough. Paratesticular RMS often extends beyond the visual margin, and therefore microscopic examination of the excision margin might yield positive results. Therefore, surgery should be performed with extensive and thorough excision, and a precise circumstantial histopathological examination should be performed to determine the presence of microscopic tumor residues. For the patients with a high risk of local recurrence or positive margin, it is recommended to undergo reoperation of the positive margin area or perform adjuvant radiotherapy , 21. AltNevertheless, the role of RPLND has always been controversial , 23 and Moderate chemotherapy and radiation therapy are also recommended. On the basis of imaging and histopathology, patients with stage I clinical stage were treated with the standard VAC regimen , which was effective in the treatment of pediatric rhabdomyosarcoma . RetrospParatesticular RMS often occurs in children and young adults and usually has a better prognosis and higher survival rate after radical tumor resection, compared with other RMS . PreviouWe suggest sperm cryopreservation before chemoradiotherapy to prepare for artificial insemination and assisted reproduction as in Case 2. Secondly, retroperitoneal lymph nodes should be treated with a higher dose (30 Gy) radiotherapy instead of RPLND to avoid possible complications of surgery. In addition, long-term follow-up of hormone function tests and personal mental health is required. For instance, in Case 2, spermatogenic Chinese medicine named Guilingji, HCG treatment scheme and sildenafil were administered 3 months after the surgery. Indeed, the patient gradually restored his erectile function after 9 months following the surgery. Besides, his semen returned to normal after 39 months following the operation, aiding the early recovery of male sexual function and quality of life.Due to the rapid growth of adult paratesticular RMS, there is need for timely confirmatory diagnosis and comprehensive treatment plan. Preoperative ultrasound-guided needle biopsy is an available option for rapid diagnosis. Besides, extensive and thorough surgical excision is key to the treatment. Radiotherapy or retroperitoneal lymph node dissection used based on the tumor clinical stage. The adult chemotherapy regimen can refer to pediatric VAC regimen. Sperm cryopreservation should be performed before radiotherapy and chemotherapy. Treatment and follow-up of reproductive endocrine function after surgery can significantly improve the quality of life.The studies involving human participants were reviewed and approved by Jinhua Hospital Affiliated to Zhejiang University School of Medicine. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article.ZWZ and YX collected all the clinical and pathological data. YZ analyzed and interpreted the patient data and was a major contributor in writing the manuscript. ZSZ revised the final manuscript. All authors contributed to the article and approved the submitted version.This work was supported by grants from Zhejiang Provincial Technological Research Project for Public Welfare (grant number LGF18H050006).The 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.


Neuroendocrine tumors (NET) are a small fraction of overall gastrointestinal (GI) malignancies. Recently the incidence of NETs has increased due to advancements in diagnostic modality. While solid tumors are easily visible on routine endoscopy, identifying endocrine tumors can be difficult, and low incidence and non-specific presentation can be easily missed on upper gastrointestinal endoscopy (UGIE). The management differs based on the type of tumor and location, but the overall prognosis is good. We present a 59-year-old male with multiple NETs throughout the GI tract, diagnosed on repeat esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) showing multiple gastric folds. A biopsy of multiple nodules was taken to diagnose type I NET with grade 2 differentiation finally. The mucosal nodules were resected with a band ligator, and surveillance endoscopy was recommended. Neuroendocrine tumors (NET) arise from neuroendocrine cells that feature nerve cells and hormone-producing endocrine cells. These tumors can be functional or non-functional based on their hormone-like substance-producing capabilities, but all of them are considered cancerous. Nearly 175000 people live with NETs in the United States, with 12000 anticipated incidence each year .A 59-year-old male with a significant past medical history of type II diabetes mellitus, essential hypertension, dyslipidemia, hypothyroidism, obstructive sleep apnea, deep vein thrombosis, and coronary artery disease status post stent placement to the left anterior descending artery (LAD) presented for outpatient endoscopic evaluation after being found to have iron-deficiency anemia. Earlier labs demonstrated decreased hemoglobin, decreased mean corpuscular volume (MCV), low Iron, and low ferritin with increased total iron-binding capacity, for which he was placed on an oral iron supplement. The patient's family history was significant for colon polyps with many siblings. Given the patient's family history and no hemoglobin improvement on the iron supplement, esophagogastroduodenoscopy (EGD) and colonoscopy were scheduled to evaluate the anemia further.Initial esophagogastroduodenoscopy (EGD) findings showed a normal esophagus and duodenum; however, they noted an enlarged gastric fold figure . ColonosA repeat EGD was ordered with endoscopic ultrasound (EUS) to evaluate the enlarged gastric fold accurately. EUS findings showed a single 4 mm mucosal nodule in the gastric body and a 5 mm mucosal nodule in the duodenal bulb. Last enlarged gastric fold was again identified on EUS figure  and precThe repeat histopathology of the enlarged gastric fold showed chronic atrophic gastritis and reactive gastropathy. The biopsies of the gastric body and duodenal bulb nodules showed well-differentiated type I NET (grade 2 of 3). The immunohistochemical analysis of tumor cells was positive for chromogranin A enterochromaffin-like cells (CgA ECL). Further labs showed increased gastrin, elevated parietal cell antibody, and decreased Vitamin B12 level. Hormone-producing tumor markers 5-Hydroxyindoleacetic Acid (5-HIAA) and morning cortisol were within the normal limit. CT chest/abdomen/pelvis showed no evidence of metastatic disease. Additionally, genetic testing was negative for multiple endocrine neoplasia type 1 (MEN1) syndrome.After three months, a surveillance EGD with EUS illustrated an additional three 4 to 6 mm mucosal papules (nodules) within the gastric body and a single 6mm mucosal nodule in the duodenal bulb. With Roth net retrieval, all four mucosal nodules were resected via band ligator and snare mucosal resection. The patient was started on Vitamin B12 injections. The patient's hemoglobin was improved on follow-up, and surveillance of EGD with EUS was recommended every six months.Neuroendocrine tumors (NETs) may arise in different organs, including the gastrointestinal tract, pancreas, lungs, gallbladder, thyroid gland, testes, ovaries, and skin. A small percentage of NETs are associated with inherited syndromes such as Multiple endocrine neoplasia type 1 (MEN1), Neurofibromatosis type 1 (NF-1), and Von Hippel-Lindau syndrome. Gastric NETs are differentiated into four types based on their clinicopathological characteristics. Gastric NETs type I to III comprise enterochromaffin-like cells (ECL), while type IV consists of endocrine cells.70% to 80% of Gastric NETs are type I tumors that are associated with pernicious anemia, chronic atrophic gastritis (CAG), including autoimmune gastritis (AIG), and Helicobacter pylori-associated atrophic gastritis . CAG cauType I Gastric NETs have no specific symptoms; thus, they are found incidentally on EGD. However, the hormone-producing tumor may present with diarrhea, facial flushing, hyper or hypoglycemia, and GI ulcers. Type I Gastric NETs are multiple, less than 10 mm in diameter, and usually found on the gastric fundus or corpus ,5. On enNational Comprehensive Cancer Network (NCCN) guideline version 2.2021 for management of NET patients suggests baseline EUS if clinically indicated, vitamin B12, and gastrin level check . FollowiGastric NETs are difficult to diagnose; as it is asymptomatic and often missed on endoscopic evaluation. EGD with EUS can be a superior approach to diagnose NETs, and it is wiser to take multiple biopsy samples under EUS guidance during EGD to identify NETs. Here we present an interesting case of a middle-aged male who was found to have gastric and duodenal neuroendocrine tumor during repeat endoscopic evaluation for iron-deficiency anemia. This case emphasizes the importance of keeping NETs in differential while evaluating iron-deficiency anemia and the necessary evidence-based surveillance.