Schwannoma is the most common mediastinal neurogenic tumor, while schwannoma originating from mediastinal vagus nerve is rare.This article reported one case of schwannoma originating from vagus nerve in the right superior mediastinum. The mediastinal schwannoma was completely resected through a right-sided video-assisted thoracoscopic thoracotomy. Histologic examination clarified the diagnosis as schwannoma.Chest CT scan and MRI can be used to determine the location of mediastinal schwannoma and its relationship with adjacent tissue. Histologic examination showing distinctive feature of Antoni A areas and Antoni B areas can help clarify the diagnosis. Complete surgical resection is the first-line treatment option for mediastinal schwannomas. Schwannoma is a benign tumor originating from the neural sheath Schwann cells, with approximately 9% of which occurring in the mediastinum . SchwannA 32-year-old asymptomatic woman with a mediastinal mass found by CT scan 2 years ago was admitted to our hospital. Physical examination and laboratory tests showed no significant abnormalities. Contrast-enhanced chest CT scan revealed a sharply marginated mass, 24 × 33 mm in size, in the right superior mediastinum Fig. . A rightMediastinal schwannomas usually occur in the posterior mediastinum arising from intercostal nerve, sympathetic chain or posterior root of spinal nerve, while those originating from intrathoracic vagus nerve are rare . When thMediastinal schwannomas present grossly as solitary and well-encapsulated tumors, which have a sharp border with the adjacent soft tissue. Nerve of origin usually present at the periphery of the tumor, instead of penetrating the tumor. CT scan can be used to determine the location of mediastinal schwannoma and its relationship with adjacent tissue. MRI can help better determine the relationship of a mediastinal schwannoma with adjacent vascular structures . Under mThere are several special variants of schwannoma that have been described in the mediastinum. Ancient schwannomas have a high frequency of regressive changes, such as fatty degeneration, cystic formation, hemorrhage, and calcification, which may grow to unusually large size. This variant of schwannoma still maintains its strong diffuse S-100 positivity by Immunohistochemistry, which helps distinguish it from malignant schwannomas . MelanotComplete surgical resection is the first-line treatment option for mediastinal schwannomas. Video-assisted thoracoscopy (VATS) technique has been gradually accepted as a safe and reliable access for resection of mediastinal schwannomas, which can reduce surgical trauma, accelerate postoperative recovery, while permit good exposure of the mediastinum. However, for tumors with more than 6 cm in size, or located at the costophrenic angle or thoracic apex, open approaches such as thoracotomy, sternotomy, supraclavicular excision or posterolateral thoracotomy are more appropriate . It has In this case, the essential of the operation was to expose the tumor clearly and to resect it completely, without injuring the vagus nerve. In order to achieve those purposes, we chose a 3 cm uniport through the 4th intercostal at midaxillary line to perform the video-assisted thoracoscopic thoracotomy. Electrocantery and aspirator were used to separate the capsule of the tumor and expose the vagus nerve clearly. After the pedicle of the tumor was adequately exposed, ultrasonic scalpel was used to divide the pedicle and complete the resection.Schwannoma is a benign tumor originating from the neural sheath Schwann cells, which is the most common mediastinal neurogenic tumor, while schwannoma originating from mediastinal vagus nerve is rare. Chest CT scan and MRI can be used to determine the location of mediastinal schwannoma and its relationship with adjacent tissue. Histologic examination showing distinctive feature of Antoni A areas and Antoni B areas can help clarify the diagnosis. Complete surgical resection is the first-line treatment option for mediastinal schwannomas.


Diagnosis in children with physical and intellective anomalies is very challenging because of the wide spectrum of causes. Array-based comparative genomic hybridization (CGH) has acquired an important role in pediatric diagnostic work up. Interstitial deletion of the long arm of chromosome 12 are rare. To date, deletions including the 12q21 region were reported in only 13 patients. The main features are development delay, eyes and central nervous system anomalies, and heart and kidney defects. We describe a 3-year-old boy with a de novo 15 Mb deletion at 12q21.1q21.32, never reported in the last cases. By screening the critical region and reviewing the literature, we identified SYT1, PPP1R12A, and CEP290 such as pathogenetic genes. Diagnosis in children with physical and cognitive impairment is very challenging because of the wide number of etiological events. Array-based comparative genomic hybridization (CGH) has acquired an important role in diagnostic work up allowing a better definition of the diagnosis. Deletions in the 12q21 region has been rarely reported and so far only 13 cases with this anomaly have been published. We report a 3,1/2years-old boy with development delay, craniofacial dysmorphism, strabismus, muscle mass hypotrophy, pectoral muscle asymmetry, scoliosis, and dysmorphic corpus callosum at the brain MRI. The CGH microarray disclosed a novel 15 MB deletion in the 12q21.1q21.32. Genetic analysis in the parents were normal.The proband, a 3.5-year-old boy, is the second child of unrelated parents. The family history is unremarkable. He was born at term by caesarean section for breech presentation, with a weight of 2,700 g. He did not have jaundice or asphyxiation. No teratogenic drug exposures were reported with normal neonatal period. Parents reported a failure to thrive with a regular progression in weight and height, always under 3rd centile. Developmentally, he achieved head support at the age of 5 months, he was able to sit unsupported at the age of 9 months, and walked unsupported at 30 months. His examination reveals prominent forehead, hypertelorism, strabismus, triangular face, low set ears, hypoplastic nostrils, and micro- and retrognathia . We notSYT1,PPP1R12A, andCEP290genes.The first to describe an interstitial deletion of the long arm of chromosome 12 was Meinecke's in the 1987, describing a syndrome with multiple malformations including cleft lip and palate and cardiac abnormalities in 12q13.3q21.1 deletion.2+sensors in the process of vesicular trafficking and exocytosis.We compared the phenotype with the data available in the publica database DECIPHER . The maPPP1R12A encodes a regulatory subunit of myosin phosphatase. This enzyme is recently associated in the cellular processes such as cell cycle, gene expression regulation, neurotransmitter release, and even embryonic development.We suppose also CEP290 as one of the main genes for our child. In the literature, there are suggestive evidence in autism reports . Althou


Hypertrophy of the tensor fascia lata muscle is a rare entity that may be observed in patients presenting with a palpable mass in the antero-lateral aspect of the proximal thigh area. Imaging confirms the diagnosis of such a rare entity. This case report highlights a case of isolated hypertrophy of the tensor fascia lata muscle with no identifiable etiology. Biopsy and surgical intervention were not needed due to the interval stability throughout a three-year period. The orthopedic oncology team reassured the patient and followed up the patient annually.  Palpable lump in the anterolateral aspect of the thigh has broad differential considerations including neoplastic, benign entities, and tumor mimickers. Isolated hypertrophy of the tensor fascia lata (TFL) muscle is considered in the latter category. Tensor fascia lata hypertrophy is a rare benign clinical entity that may be considered a differential in patients who complain of swelling and pain in the anterior thigh ,2. The TA 67-year-old female known case of type 2 diabetes mellitus presented to our hospital complaining of left hip swelling. She noticed the swelling three months prior to her presentation. It was associated with mild pain. The patient has no numbness or weakness or any constitutional symptoms. Physical examination revealed a mass over the TFL, and it was noted to be deep to the fascia. The mass was mobile, oval-shaped, soft to firm with no tenderness. The patient has no history of trauma or surgery in that area. Axial MR T1 nonfat saturated and T2 fat-saturated images Figures , 1B and The images Figures , 2 demonThe patient was monitored by the orthopedic oncology team and was reassured after confirming stability for three years. A yearly follow-up regimen is currently in place for the patient.Muscle hypertrophy involves an increase in muscle volume based on an increase in the number and size of muscle fibers. In contrast, in pseudohypertrophy, the increase in volume occurs because of the infiltration of fat and connective tissue into the muscle belly . ImagingTensor fascia lata muscle hypertrophy is a rare pathology, with only a few cases published in the literature. Imaging with MRI studies would demonstrate diffuse enlargement of TFL muscle, with preservation of its morphology and signal characteristics .A case report conducted by Cedric De Clercq et al., has found a patient with bilateral tensor fascia lata hypertrophy. Differential diagnoses of muscle hypertrophy include exercise, denervation, radiation, and myopathies . In our Moreover, two cases of unilateral TFL hypertrophy were present at Hospital Universitario de Fuenlabrada. Both patients were treated with conservative treatment and clinical observation due to the absence of growth and physical limitation . A case reported a 68-year-old man with no relevant medical history presenting with asymptomatic swelling gradually increasing in size. The TFL hypertrophy was secondary to an abductor tendon tear [Many cases reported have described an underlying cause, such as a tear following an injury, radiculopathy, or post-surgery. However, our patient did not have any signs of weakness, and based on her MRI the hypertrophy has been stable since her diagnosis. Given the interval stability over three years, biopsy and surgical intervention were not required. The patient was reassured and kept on regular annual follow-up.Tensor fascia lata hypertrophy is a rare entity that may simulate a soft tissue tumor. Patients may present with symptoms such as pain and swelling in the anterolateral proximal thigh area. MRI imaging features, in conjunction with the clinical assessment and regular follow-up would help in reaching the correct diagnosis. To avoid the need for invasive procedures, it is essential to understand the imaging characteristics of tensor fascia lata muscle hypertrophy.We report a case of tensor fascia lata muscle hypertrophy without an identifiable etiology. Imaging characteristics demonstrated interval stability throughout a three-year period; hence, neither a biopsy nor surgical intervention was required. The patient was reassured by the orthopedic oncology team and is currently undergoing yearly follow-up.


The owner referred that the day after the dog undergo blood transfusion, and started antibiotic and corticosteroid therapy. A week later hematological parameters were quite improved, but anemia was still present . No other medical reports were available.A 10‐year‐old male Italian Volpino crossbreed dog was referred for a second opinion for not‐responsive anemia. The dog had a history of travel across Europe, including Spain. A month before, the dog was visited in the Canary Islands for lethargy, dysorexia and vomit lasting for about 2 months with a worsening in the last week. The Complete Blood Count (CBC) revealed severe normocytic normochromic anemia . Urinalysis revealed low specific gravity  and significant proteinuria . A Leishmania infantum IFAT (IgG) titer was positive at a dilution <1:1280 (RI < 1:80) while IgM titer was negative.Additionally, a new CBC confirmed a persistent severe slightly regenerative anemia [RBC 2.45 × 10Leishmania spp. antibodies, the dog was considered sick (stage C) according to a proposed clinical classification scheme and underwent treatment with meglumine antimoniate.Due to cytological identification of amastigotes and the high titer of anti‐The skin lesion underwent to size reduction within few weeks, before a new move of the dog owner.3Leishmania infantum (Leishmania donovani complex).Leishmaniasis is a common canine vector‐borne disease endemic in central and western Mediterranean basin whose causative agent is Canine cutaneous histiocytoma is a common benign neoplasm occurring as a solitary, alopecic, dome‐shaped lesions often undergoing spontaneous regression. Although histiocytomas occur in dogs of all ages, they are usually found in patients <3‐years‐old. In our case, macroscopic and cytologic features were consistent with histiocytoma, although the age was not typical.Leishmania amastigotes were found in the background and also in the cytoplasm of some neoplastic histiocytic cells and, to our knowledge, this is the first report of this coexistence. Interestingly, in the literature only a case report describing the presence of Leishmania amastigotes in a histiocytic tumor, in particular a human fibrous histiocytoma, is reported.Nodular lesions are uncommon in canine leishmaniasis and are usually characterized by pyogranulomatous inflammation associated with moderate to severe lymphoplasmacytic infiltration. In our case, Leishmania and neoplasia has been reported in humans and animals: in dog Leishmania and neoplasia have been documented in a variety of neoplastic conditions including lymphoma, cutaneous transmissible venereal tumor, splenic hemangiosarcoma, soft tissue sarcoma, and adrenocortical adenoma. In some tumors, such as transmissible venereal tumor, sarcoma, small‐cell lymphoma, adrenocortical adenoma and perianal adenoma, amastigotes were identified not only in the macrophagic cells but also within the neoplastic cells, as occurred in the case presented.The coexistence of The relationship between parasites presence and neoplasia is not yet clearly understood, although it is evident that leishmaniasis can directly or indirectly affect the presentation, diagnosis and course of malignant disorders. Among the proposed theories, the chronic inflammation induced by the parasites, the leishmaniosis interference with the local systemic immune system, and a direct involvement of leishmaniosis in the pathogenesis of cancer are those considered most relevant.Leishmania spp. could be due to two of these proposed mechanisms. In the first scenario, the coexistence was consequent to the inoculation of amastigotes by the phlebotomine vectors in a pre‐existent neoplastic lesion confirming the nonspecific tropism of the parasite.Similarly to that reported, in our case, the pathogenesis of the coexistence between neoplastic cells and The second possible explanation is that the interference of the inoculated pathogen with the local immunity ultimately led to histiocytic tumor development.Leishmania spp. to coexist within neoplastic cells, although the exact pathogenesis of such finding is not yet completely known.This finding confirms the well‐reported ability of 4Leishmania spp. amastigotes have been identified in several benign and malignant neoplastic lesions in humans and dogs; among these, canine histiocytoma has now to be considered.The authors declare no potential conflict of interest.


Intestinal malrotation is a rare congenital disease caused by abnormal intestinal rotation and fixation of the intestinal tract in the early embryonic state. Adult cases are rare. A laparoscopic Ladd procedure for adult intestinal malrotation is increasingly reported, but owing to the rarity, some important aspects of the disease and its treatment may be overlooked. Three adult cases of intestinal malrotation that underwent surgery at our hospital between January 2019 and October 2020 were retrospectively examined about patient backgrounds, short-term results, and complications. All patients were male, median age was 54.6 years, and the complaints were abdominal pain and/or distention. No midgut volvulus was observed. The laparoscopic Ladd procedure was performed for all cases. One patient underwent reoperation (duodenoduodenostomy) because of impaired passage of the duodenal descending section due to postoperative pancreatic fistula. The postoperative courses of the other two patients were good. No recurrence of symptoms was observed in any of the cases. The reason for reoperation in one of the cases is considered to be pancreatic injury when the severe curve from the duodenum to the upper jejunum near the pancreatic head was straightened. Correction of the curve is important to improve passage disorder of the duodenum, but special care is required to avoid organ damage, especially during a laparoscopic procedure with forceps. The laparoscopic Ladd procedure for adult intestinal malrotation is recommended if there is no midgut volvulus; it is minimally invasive and a comparatively simple technique, but surgeons should take special care to avoid organ damage. Intestinal malrotation is a rare congenital disease caused by abnormal intestinal rotation and fixation of the intestinal tract from the duodenum to the transverse colon in the early embryotic stage . The freLadd procedure is the generally performed treatment for intestinal malrotation. Any midgut volvulus is released; then, the abnormal band between the duodenum and the colon (Ladd's band) is resected. The base of the small intestinal mesentery including the superior mesenteric artery (SMA) is opened, followed by appendectomy and rearrangement of the intestinal tract . LaparosA 35-year-old male felt right abdominal pain from the previous year. The pain reportedly occurred once or twice per month. Intestinal malrotation was detected on computed tomography (CT) at another hospital, but treatment was not performed. Abdominal pain did not improve, so he was referred to our hospital. CT showed absence of the duodenal horizontal section. The jejunum transitioned directly from the duodenal descending section, and both were confirmed as a mass in the right-upper abdomen under the right colonic mesentery. The colon was recognized to be in a normal position. CT showed the features of the intestinal malrotation, and the patient was admitted to our hospital on the same day Figures .Upper gastrointestinal (GI) series confirmed the duodenal descending section and the jejunum as a mass in the right-upper abdomen . PreoperThe surgery was performed by five ports under general anesthesia. The first 12 mm port was inserted from the umbilicus, and the other four ports (5 mm) comprised upper and lower parts on both sides of the abdomen.In operative findings, the small intestine was recognized under the abnormal adhesive retroperitoneal band and the right colon mesentery. The duodenum and the jejunum were released from the mesenteric pressure after dissection of the band by laparoscopic coagulating shears (LCS). The outside adhesion of the right colon was all resected by LCS, and the small intestine excluded on the dorsal side came out from the thickened tissue at the right-lower abdomen which had formed between the colon mesentery and the retroperitoneum. The thickened tissue was like “hernia defect,” and it was resected. The narrowed base of the small intestinal mesentery including SMA was widely opened, and appendectomy was performed. Finally, the small intestine was replaced at the right side, and the colon was at the left side. No fixation of the intestine to the retroperitoneum was performed Figures .Meals were started on postoperative day (POD) 2, although vomiting occurred on POD 5. A nasal gastric (NG) tube was inserted. On POD 6, upper GI series was performed and passage disorder of the duodenum was observed .Paralytic duodenal peristalsis was considered to be the reason for the passage disorder, so conservative treatment was performed. However, 1 or 2 L of enteric content from the NG tube was continuously observed every day. Esophagogastroduodenoscopy (EGD) was performed on POD 15. The scope could not pass through the duodenum because of the external compression Figures . A conseDuring reoperation, there was stenosis of the duodenal descending section. A local saponification was observed around it. The duodenal passage was judged to be impaired due to pancreatic fistula. The stenosis and the inflammation were very severe, so lysis was not thought to be possible. The proximal and distal sides of the stenosis were therefore anastomosed by Albert-Lembert method (side-to-side duodenoduodenostomy). The postoperative course was good, and the patient was discharged on POD 32.A 71-year-old male underwent appendectomy for acute appendicitis at fourteen years of age. Eight months prior to the current presentation, he had abdominal pain for the first time after a meal which continued intermittently thereafter. When the same symptom appeared to worsen, he visited the emergency department of our hospital. CT and upper GI series revealed similar results to those of Case 1. The patient was admitted to our hospital on the same day. Preoperative diagnosis was the same as Case 1, and surgery was performed. The operative procedure was almost the same as that in Case 1. The patient was discharged on POD 10.A 58-year-old male had right abdominal pain after meals over a ten-year period. He went to other hospitals, but there was no accurate diagnosis. From two months before visiting our hospital, epigastric pain and appetite loss appeared, and he lost 4 kg in weight. The pain got worse, so he visited the emergency department of our hospital. The findings of CT and upper GI series were similar to those of Cases 1 and 2. Under the same diagnosis, surgery was performed. The operative findings and procedure were almost the same as those in Cases 1 and 2. The patient was discharged on POD 7.In our cases, all three patients were male with a median age of 54.6 years. The period of complaints ranged between eight months and ten years. There was no midgut volvulus, and a laparoscopic Ladd procedure was performed for all cases. The postoperative courses were good, with the exception of Case 1.Intestinal malrotation, especially in adults, is rare , 3, so aThe treatment for intestinal malrotation is generally the Ladd procedure . ImportaIn our cases, the clinical symptoms were thought to have been caused by the duodenum and the jejunum being compressed by the abnormal retroperitoneal band and the right colonic mesentery. The band is connected to the adhesion between the prepancreatic fascia and the colonic mesentery. There is also a severe curve between the proximal side and the distal side of the duodenal descending portion because of the adhesive compression. This adhesion is considered to be more severe in adult cases than in infant cases because of the longer period of illness. The curve otherwise remains the same; the duodenal passage disorder does not completely improve. Not only resection of the abnormal band but also straightening of the curve is therefore necessary. It is important to perform this resection and straightening carefully in order to avoid organ damage, such as to the duodenum or the pancreas. Resection of the abnormal band and straightening the curve were performed in all of three cases. In Case 1, however, postoperative stenosis of the duodenal descending section occurred because of pancreatic fistula. The pancreas head was thought to be damaged when resecting the adhesion between the prepancreatic fascia and the right colon mesentery. In operative findings, the bleeding was recognized at the pancreatic head . Two facOpening the base of the small intestinal mesentery is also thought to be important. The narrow base of the small intestinal mesentery could lead to the patient having subsequent midgut volvulus and obstruction with potential vascular catastrophe . The fren = 10) and a laparoscopy group (n = 11); three patients in the laparoscopy group were converted to open surgery [Due to the widespread use of laparoscopic surgery, there has been an increase in reports of laparoscopic Ladd procedure for intestinal malrotation. Owing to its rarity, adult cases are almost always reported within case reports, but there have been several retrospective studies for large numbers of laparoscopic Ladd procedure for adults –12. Matzroup n = ; three proup n = ; three proup n = ; three pSeymour and Anderson reported seven cases of laparoscopy; this included no cases of laparotomy but three cases with midgut volvulus . No patin = 13) and laparoscopy (n = 9); three patients in the laparoscopy group were converted to open surgery [Fraiser et al. compared laparotomy ( surgery . In the  surgery . There w surgery . Three p surgery . One of  surgery . The reaIn conclusion, a laparoscopic Ladd procedure for adult intestinal malrotation is recommended because it is minimally invasive and has shorter LOS compared with laparotomy. However, in an emergent case, such as with intestinal necrosis or midgut volvulus, laparotomy should instead be selected. Careful technique is required due to the risk of organ damage.


A 46-year-old female patient came to the Dermatology outpatient clinic complaining of asymptomatic breast lesions for ten years. She reported a weight gain of approximately 50 kg during this period and reported being an active smoker with a tobacco load of 42 pack/year. Dermatological examination showed erythematous to violaceous reticulated lesions on both breasts. Some areas showed shallow ulcerations .Figure 1Histopathology revealed a rectified epidermis and proliferation of small vessels, more intense in the upper dermis, but extending to the middle dermis without cell atypia . The imma)Kaposi's Sarcomab)Low-grade angiosarcomac)Diffuse dermal angiomatosis of the breastd)CalciphylaxisBased on the clinical-pathological correlation, a diagnosis of diffuse dermal angiomatosis of the breast was made. Laboratory tests including ANF, lupus anticoagulant, anticardiolipin, anti-beta-2 glycoprotein, C and S proteins were normal. The CT angiography excluded venous or arterial thrombosis. The patient lost 20 kg in one year and there was complete regression without any medical or surgical treatment . DespiteDiffuse dermal angiomatosis of the breast (DDAB) is a poorly described entity that affects exclusively middle-aged, obese women with macromastia and who are smokers.The pathogenesis likely involves tissue ischemia leading to an increase in endothelial growth factors and neoangiogenesis.The management of DDAB requires treatment of the underlying cause of tissue ischemia. The investigation to exclude the causes of ischemia is mandatory. Advice on weight loss, smoking cessation, and control of cardiovascular risk factors such as hypertension or hyperlipidemia are essential. Drug therapy includes the use of isotretinoin, anticoagulants, acetylsalicylic acid, pentoxifylline, and oral corticosteroids, but responses are variable.None declared.Bruno de Castro e Souza: Drafting and editing of the manuscript; critical review of the literature.Esio Pessoa Caracas de Souza: Collection, analysis, and interpretation of data; drafting and editing of the manuscript; critical review of the literature.Neusa Yuriko Sakai Valente: Design and planning of the study; drafting and editing of the manuscript; critical review of the literature; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied case.José Antonio Sanches: Design and planning of the study; drafting and editing of manuscript; critical review of the literature; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied case.None declared.


Herein, we have presented the clinical features of meningioangiomatosis associated with meningioma, which is considered to be a rare neoplastic lesion. Magnetic resonance spectroscopy (MRS) demonstrated a remarkably decreased N-acetylaspartate peak and an increase in the choline peak of the lesion, suggesting neuronal injury and active cell proliferation. These findings substantially differed from those observed in the case of pure meningioangiomatosis. Meningioangiomatosis (MA) is regarded as a benign hyperplastic tumor-like lesion characterized by meningovascular proliferation, with seizures being the most common clinical symptom. It occurs sporadically in children or young adults, accounting for ~80% of all cases . HoweverMagnetic resonance spectroscopy (MRS) was found to be particularly useful in this case because it demonstrated a remarkably decreased N-acetylaspartate (NAA) peak and increased choline (Cho) peak of the lesion, suggesting neuronal injury and active cell proliferation. However, to the best of our knowledge, only two cases of MRS for pure MA have been reported to date , 6. To aAn 8-year-old boy experienced paroxysmal dizziness for 5 years. Six months prior to admission to our hospital, he experienced intermittent tremors in the right upper extremity without any obvious predisposing factors. Gradually he developed generalized tonic-clonic seizures accompanied by right arm stiffness, generalized convulsion, aphasia, and tilting of the head and eyes.He was admitted for diagnosis and treatment; no obvious abnormalities were observed upon physical and neurological examination. No personal or family history of neurological diseases was reported, but plain computed tomography (CT) demonstrated a hyperdense lesion with multiple calcifications and proliferating adjacent blood vessels in the left parietal lobe . T1-weigThe patient underwent a left parieto-occipital craniotomy, which revealed an ill-defined mass with a grayish-yellow surface. The overlying dura was determined to be involved, and the surrounding tissues were slightly edematous . Intra-oMicroscopically, the lesion area was poorly circumscribed regarding normal brain tissue, and the presence of diffused proliferation of spindle and oval cells in addition to psammoma bodies was observed in the cortex. Extensive spindle-shaped cells were found to be arranged in a whorled pattern surrounding the vessels, and syncytial cells were present in local regions . No obviImmunohistochemistry revealed epithelial membrane antigen (EMA) positive findings, and the Ki-67 index in the meningioma was 3%. NeuN showed focal neuronal arrangement disorder. Based on these results, the final diagnosis was MA-associated with WHO grade 1 fibrous meningioma. The patient was discharged without any adjuvant radiotherapy or chemotherapy and was seizure-free at the 3-month follow-up. Moreover, the elevated Cho peak decreased over the 3-month follow-up period, and the Cho/Cr and NAA/Cr ratios were 1.08 and 0.00, respectively.The MA is commonly defined as a benign hyperplastic tumor-like lesion in the cerebral cortex, marked by meningeal and vascular proliferation. It has been found to be occasionally associated with MA-M, which is considered to be a neoplastic lesion , highligAt present, the most obvious differences between MA and MA-M reported in the literature include the incidence of seizures and symptom duration , with thThe MRS is a non-invasive imaging technique that can help clinicians identify potentially malignant lesions . The ChoIn this case study, MRS indicated decreased NAA and increased Cho in the lesion, suggesting associated neuronal injury and active cell proliferation. The Cho/Cr and NAA/Cr ratios in the lesion area were 3.94 and 0.43, respectively, and this was in contrast to previous studies on MA that reported only a slight change in MRS. Nomura  reportedin vitro spectrum and in vivo spectrum, respectively (ex vivo high-resolution magic angle spinning (HR-MAS) was not performed then, which can help better interpretation of the in vivo spectrum.According to the previous literature, the spectrum of meningioma can show a peak at 1.47 or 1.50 ppm, which can be assigned to alanine (Ala) ectively . Ala is ectively , 16. Howectively . It is aMoreover, the Cho/NAA ratio in the current case study was 19.12, indicating an invasive malignant lesion . HistopaTherefore, although MRS may help distinguish MA-M before postoperative pathological diagnosis, more clinical data is essential to assess its value in this disease.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by First Affiliated Hospital of Sun Yat-sen University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.LL: collecting the data and drafting the manuscript. FL: critical revisions of the manuscript. All authors participated in the article and approved the final version.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.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.


Management of early-stage cervical cancer (CC) in young women often faces challenges to preserve fertility, as well as to achieve an adequate oncological outcome. Although existing evidence supports a fertility-sparing treatment in the case of tumors <2 cm in diameter, the approach is less clear in bulky early-stage CC. In addition, the outcomes of radical trachelectomy performed by minimally invasive techniques are also highly debatable. Highlighting the high incidences of young women with early-stage CC, the lack of sufficient data raises considerable hindrances towards the proper counseling of this vulnerable patient group. In this report, a case of a young woman with bulky early-stage CC with a strong desire to preserve fertility is presented. A satisfactory oncological outcome was achieved after neoadjuvant chemotherapy followed by laparoscopic radical trachelectomy. Ongoing prospective trials are expected to provide stronger evidence on this topic. Cervical cancer (CC) is ranked as the fourth most common oncological disease among women, with a peak incidence in the younger population—between 35 and 45 years of age . Histori2, had undergone the first Pap smear screening, which revealed atypical squamous cells of undetermined significance (ASC-US). After the repeated Pap smear, 6 months later, a high-grade squamous intraepithelial lesion (HSIL) with human papillomavirus (HPV) type 16 infection was diagnosed. The specimen collected during uterine cervix biopsy showed squamous G3 cervical carcinoma. To determine the spread of the disease, pelvic magnetic resonance imaging (MRI) was immediately carried out, showing cervical tumor, 40 mm in the longest diameter, without clear parametrial invasion; on the left side, pathological obturator lymph node 15 × 10 mm in size was noticed, while obturator lymph nodes on the right side were up to 8 mm in diameter -enhanced fluorescence-guided laparoscopy was carried out, performing paraaortic and obturator lymphadenectomy. The ICG solution was prepared with 25 mg of ICG powder diluted into 10 mL of sterile aqueous water. Afterwards, the cervix was injected with 2 mL of ICG at the 3, 6, 9, and 12 o’clock positions, with 1 mL superficially under the mucosa and 1 mL 1 cm into the cervical stroma. Moreover, the bilateral salpingectomy and ovarian transposition was done. As discussed, the treatment plan with patient after first radiologic staging and interdisciplinary counselling, ovarian transposition, and radical radiotherapy was suggested, due to the bulky CC and suspicion of pelvic lymph nodes metastases. Liver, peritoneum, omentum, and other organs were without visible pathological changes. The uterus was normal in size, and a decent amount of pelvic free fluid was observed in the Douglas pouch. Pelvic examination under infrared light showed ICG dye distribution in pelvic and paraaortic lymph nodes.Removal of obturator and paraaortic lymph nodes were performed. Surgical procedure is shown in Due to the fact that no pelvic metastases were reported, the standard treatment with radical hysterectomy was suggested. However, the patient refused this option, due to the fact that fertility preservation was strongly desired. As a result, 10 days after diagnostic laparoscopy neoadjuvant chemotherapy had been started and 3 cycles of carboplatin/paclitaxel were carried out every 3 weeks, excellent treatment response to the chemotherapy was achieved, with a considerable decrease in tumor size. One month after the third chemotherapy cycle, laparoscopic radical trachelectomy (without uterine manipulator) was conducted. The procedure is shown in Colposcopy with cervical stump biopsy was performed 2 months after radical trachelectomy, obtaining four specimens of up to 0.3 cm in diameter . There wThe patient had undergone Pap smear 6 months after trachelectomy—neither intraepithelial lesion, nor HPV16 infection was found, and the CINtec PLUS cytology test was also negative. Colposcopy and Pap smear were repeated 10 months after trachelectomy, showing the same results as reported above.The patient, 27-years-old, proceeded to the in vitro fertilization (IVF) procedure 14 months after radical treatment. Endometrial scratching and ovarian puncture were performed, and two eggs were collected. They were fertilized with intracytoplasmic sperm injection (ICSI), and one embryo was inserted into the uterine cavity. Unfortunately, the IVF procedure was unsuccessful at that time. The next IVF procedure is planned in the near future.Several data suggested that, for patients with early-stage CC, safety and clinical outcomes were equal for radical trachelectomy and RH  .Currently, a patient’s suitability for the radical trachelectomy is determined by the size of the primary lesion and whether the oncological process has spread to lymph nodes and distant organs. This assessment is performed using colposcopy, MRI, or PET . In addiFSS for CC treatment includes traditional cone biopsy, cervical amputation, and radical trachelectomy, which is under the interest of our report. Radical trachelectomy may be performed by vaginal, abdominal, or minimally invasive (as in our case) approaches . Based oBased on the current knowledge regarding the oncologic outcomes after MIS approach radical trachelectomy, the recurrence rate after laparoscopic radical trachelectomy is 11%, highlighting that, in 40% of these cases, the tumor were sized above 2 cm in diameter. Another MIS-RT study, although with a limited number of patients, reported a combined recurrence rate of 4.2% and rate of deaths below 1%, which made the outcomes similar to open and vaginal approaches . Other aSome authors evaluated fertility and oncological outcomes after neoadjuvant chemotherapy (NACT), followed by fertility sparing surgery  for CC 2–4 cm in size. Meta-analysis, reporting outcomes of 114 patients, showed that, out of 64 pregnancy efforts, there were 49 (76.6%) live births (6 (9.4%) preterm deliveries). Concerning oncological outcomes, 6.1% of patients had relapse, and two patients died of the disease. This study concludes that fertility sparing surgery after NACT is a promising option for CC patients with tumors 2–4 cm in size who wish to conceive . The NatUp until now, nearly 225 cases (39 cases of tumors measuring 2–4 cm) of LRT without NACT have been reported. Disease recurrence was observed in 13 patients (5.7%), and 8 of them have had tumors 2–4 cm in size. These results were comparable to tumors >2 cm treated by VRT . Other aThe fertility and oncologic outcomes of women affected by CC >4 cm (FIGO IB3) who received NACT (platinum-based) and FSS were assessed by systematic review. The 4.5-year DFS was 92.3%, and all the patients survived. Recurrence occurred in two patients who received ifosfamide, instead of paclitaxel, and had residual disease found during the histopathological investigation. Four out of six patients achieved at least one pregnancy, and three out of five showed preterm delivery .At present, there is growing number of evidence of the role of NACT, with a significant reduction of primary tumors seeking safe and reasonable fertility sparing surgery ,6,12. A According to recent studies, the relapse rates after NACT following FSS vary from 6% to 10% for tumors below 2 cm in diameter ,13,14. URecent review by Buda et al. altogether analyzed 114 women with stage IB2 cervical cancer who underwent NACT and FSS, showing that only in 76.7% of cases uterine preservation was achieved . The besIVF is sometimes recommended after radical trachelectomy because of cervical stenosis and other causes of natural pregnancy difficulties. In addition, it was reported that radical trachelectomy may diminish ovarian reserve, since a decreased response to controlled ovarian stimulation had been reported after radical trachelectomy procedures . On top This case report and literature review revealed that FSS approaches and perioperative management in the case of CC needs further research, in order to achieve both the satisfying oncologic outcomes and desired obstetrics results. This strongly applies to the role of NACT seeking tumor reduction before performing less radical surgery and the safety of FSS for tumors above 2 cm in diameter. Currently, there is a lack of strict algorithms on radical trachelectomy approaches, and the choice is usually achieved individually, depending on the experience of the surgeon.


Venous aneurysms of the head and neck, and in particular the facial vein, are rare lesions that present as soft, compressible masses. We describe a case of an idiopathic aneurysm of the facial vein. A comprehensive literature review of this entity was conducted to better understand the disease process.A 51-year-old female presented with a one-year history of a prominent but painless right submandibular mass that was more noticeable with maneuvers such as straining. An exam showed a painless, soft, compressible, right level 1b neck mass that enlarged with Valsalva. A computed tomography scan of the neck revealed a 2.7 cm enhancing mass adjacent to the right submandibular gland. Further workup included a direct puncture venography, which demonstrated an unruptured 3 cm venous aneurysm involving the right facial vein. Surgical excision was offered to the patient, which was completed without complications. Histopathology of the mass was consistent with a facial vein aneurysm and confirmed the suspected diagnosis. The patient was seen postoperatively in follow-up and was healing well.While facial vein aneurysms are rare, it is important to recognize, work up, and treat them appropriately. A painless compressible mass that enlarges with Valsalva is suggestive of the diagnosis. Management may vary on a case-by-case basis with surgical resection being the definitive treatment of choice. Venous aneurysms are rare and represent a focal area of dilation involving all three layers of the vascular wall. These lesions may occur anywhere in the body and are most commonly found on the extremities or intra-abdominally ,2. Less Presentation and workupA 51-year-old female presented with a one-year history of a prominent right submandibular mass that was more noticeable with Valsalva maneuvers such as straining. The mass was asymptomatic and painless. She denied any episodes of bleeding or discoloration and there was no history of trauma or inflammation in the region. She had a past medical history of well-controlled hypothyroidism and denied any alcohol or tobacco use. The physical exam showed a painless, soft, compressible, right level 1b neck mass that enlarged with Valsalva, adjacent to the submandibular gland. A computed tomography (CT) scan of the neck revealed a 2.7 cm well-circumscribed enhancing mass separate from the more medially located submandibular gland (Figure Surgical approachThe patient underwent transcervical excision of the right venous aneurysm. The lesion was identified just deep to the platysma and noted to be arising from the facial vein. The facial vein, along with multiple smaller contributing vessels, was dissected and carefully isolated from surrounding structures and subsequently ligated Figure . HistopaPostoperative courseThe patient’s postoperative course was uncomplicated, and she was discharged on the same day. She was seen at her four-week follow-up appointment and was feeling well at that time, without complications. The scar was healing as expected.Venous aneurysms in the head and neck are uncommon, and involvement of the facial vein is exceedingly rare, with only a few cases described in the literature Table  2,5-10],5-102,5-While venous aneurysms in the head and neck region, particularly of the facial vein, are exceedingly rare, they are important to appropriately recognize and manage. A painless, compressible mass that enlarges with Valsalva is suggestive of the diagnosis, which can be confirmed with duplex ultrasound. Management of these lesions may vary on a case-by-case scenario based on patient preference and the potential morbidity of continued observation vs surgery. We shared a case of our patient with a right-sided facial vein aneurysm who underwent uncomplicated surgical resection.


We describe the management of a scleral thinning after uneventful pterygium surgery, it is an uncommon complication; in addition, we have reviewed similar published cases in the literature.A 48-year-old woman presented with thinning sclera in the first week after pterygium excision surgery. Conservative treatment was the first line in the management. There was no improvement for two weeks, so we decided to do a rotational flap. We put a scleral dellen diagnosis by excluding other etiologies. The condition was successfully managed, the thinning sclera healed completely. Scleral and conjunctival re-surfacing was observed.Scleral dellen is an early and rare postoperative complication after pterygium surgery. The diagnosis is confirmed after excluding other causes of scleral thinning. The exact pathophysiology of it is not determined yet, many authors described probable explanation in their published cases. We did a comprehensive review of similar cases with their management.Scleral dellen is uncommon complication after pterygium surgery, its diagnosis depends on exclusion. The management can be conservative. However, if no progression was detected do not hesitate going for surgical closure. •We describe the management of scleral thinning after uneventful pterygium surgery.•Scleral dellen is uncommon complication after pterygium surgery.•The diagnosis of Scleral dellen is confirmed after excluding other causes of scleral thinning.•The management can be conservative. However, if no progression was detected, surgical closure is the final management. Several surgical techniques are available for the treatment of pterygium; excising accompanied by adjunctive treatment with mitomycin C or conjunctival autografts is currently the most popular treatment option since it provides the most satisfactory results The condition of scleral defect after pterygium surgery has been reported in many publications as a scleral dellen, scleral melting, scleral thinning and scleral necrotizing defects. In addition, there is not a definitive pathology described for this complication neither guidelines for treatment.In this case, we present a severe acute scleral defect occurred after an uneventful pterygium surgery. In addition, we reviewed similar published cases and their management. This work has been reported in line with the SCARE criteria 2A 48-year-old Caucasian woman presented to the outpatient clinic with a history of recurrent irritation, redness and foreign body sensation in her right eye. Ophthalmologic examination revealed a primary pterygium on the nasal side of her right eye, measuring 3 mm at the limbus and 4 mm into the cornea. No other abnormalities were detected in the eye. She denied any systemic, ocular or medical histories. The pterygium was excised by a senior resident under topical and subconjunctival anesthesia . A conjunctival autograft was performed to cover the conjunctival defect using sutures without any adjunctive therapies such as intraoperative mitomycin C or cauterization, nor postoperative beta radiation.The operation ended smoothly. We gave the patient a combination therapy of levofloxacine 0.5% and dexamethasone 0.1% eye drops four times daily after surgery with antibiotic ointment.The outcome looked satisfactory the day after surgery without any complaints or complications. Three days later, however, the graft shrank and appeared grey and dry. Areas of bare sclera have appeared around the graft with congested conjunctiva. After asking her again, she denied any history for medical, ocular conditions or taking medications. An extensive therapy of topical steroids, antibiotics, and artificial tears was given.One week later, the patient came to the department complaining of mild discomfort, foreign body sensation and a black dot at the surgical site. Her corrected visual acuity was 20/25 just as before the operation, the intraocular pressure was 16 mm Hg. On slit lamp examination, the conjunctival sutures were no longer in place and a well-demarcated focal area of scleral thinning was visible measuring approximately 2 ∗ 2.5 mm surrounded by congested edematous conjunctiva. The thinned sclera was dry and the uvea was visible through the base of the lesion . There wThe patient was referred to the Internal Medicine Department in order to rule out autoimmune or any infectious diseases. Medical history, physical examination, and laboratory tests  were all in normal ranges.We made a diagnosis of scleral dellen and continued the mentioned medications with hourly lubrication. After two weeks of conservative treatment, scleral thinning did not decrease in size despite the intensive ocular lubrication in the treatment.Finally, we decided to do a surgical management with a rotation flap of adjacent conjunctiva.The medication regime contained levofloxacin 0.5% and dexamethasone 0.1% eye drops four times daily with unpreserved artificial tears 24 times a day after surgery. The outcome was good as the patient symptomatically improved and the thinning area decreased in size. Four weeks after the procedure, the thinned sclera appeared regularly thick and white in color with no more visible uvea .Fig. 2On3We are presenting a challenging case of scleral thinning after uneventful pterygium excision with autograft that covered the conjunctival defect without any adjunctive therapies.Scleral dellen is an early postoperative complication during first two weeks of bare sclera technique owing to delayed conjunctival wound closure Our first differential diagnosis to rule out was surgically induced necrotizing scleritis (SINS); SINS is a painful condition, patients typically offer history of serious, profound boring pain. In addition, the majority of cases of SINS present within few months of surgery. The managment of the thinned sclera is difficult Our patient however, was healthy at presentation. She had not any sever pain or symptoms. There are not any conditions predispose to ulceration, poor wound healing or severe tear film. Schirmer-Test was within normal limits. All laboratory studies were normal, no systemic diseases such as autoimmune processes or vasculitis were detected at presentation. Apart from the drying effect produced by the edematous conjunctiva and the loss of the graft, no other etiological factor was found.We did a comprehensive review of similar cases with their management; we found 12 published articles. All of them, are case reports or case series. The results are concluded in A conservative treatment consisting of the use of extensive artificial tears, antibiotic ointment and a patch is a useful management for the major of scleral dellen cases. However, if the case does not respond to the treatment, a surgical approach should be considered. Conjunctival flap and multilayered amniotic membrane transplantation are useful operations with minimum complications. In addition, when the case is associated with an Impending perforation, a lamellar scleral patch graft may be undertaken.More observational and case-control studies are needed in order to investigate the pathophysiology of this condition and to describe guidelines for the management.4Conservative treatment is an appropriate initial treatment for scleral dellen. In resistant cases, conjunctival flap may be a good management. More studies on the histopathology and pathophysiology should be done to identify the actual ground for this complication.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.Not commissioned, externally peer-reviewed.Case reports are exempt from ethnical approval in our institution.This article does not have funding sources.Dr. Dana Sultan.N/A.DS: Is the first author, Conceptualization, Validation, Investigation, Writing - Original draft, Writing Review & editing, Visualization. ON: The surgeon, Conceptualization, Writing - Original draft, Writing - Review & editing, Investigation. MNS: Data curation, Writing - Review & editing, Visualization. NZ and AK: Supervision, Writing - Review & editing, Project administration. All authors attest that they meet the current ICMJE criteria for Authorship.All authors have no conflict of interest to declare.


A 40-year-old man who was diagnosed with a case of small cell lung carcinoma on chemotherapy (cisplatin and carboplatin) came with complaints of swelling and pain in the left neck and shoulder region for 5 days. On inspection, redness of skin was present in the neck region, and on palpation, it showed a local rise in temperature. The patient was further advised ultrasonography which revealed complete thrombosis of the external jugular vein on the left side with vessel wall thickening and surrounding inflammatory changes. The patient was started on anticoagulants further. After 6 months follow-up ultrasound sonography (USG) was done which revealed complete resolution of thrombus. Superficial vein thrombophlebitis is an extremely rare complication seen in patients having chemotherapy. Thrombosis in the external jugular vein is rare as compared to the internal jugular vein. Common etiologies of jugular vein thrombosis include trauma, central venous catheterization, infections, and extrinsic compression by tumors.


Caustic ingestion is still a health problem of utmost importance in the West.In developing countries, this incident remains at increase and it isassociated with unfavorable factors like social, economic, and educationalhandicaps, besides a lack of prevention. Esophagocele is a rare consequenceof caustic ingestion.We aimed to describe a patient with multiple caustic ingestions who presentedan esophagocele resected by videothoracoscopy.A woman ingested caustic soda when she was only 17 years old in a suicidalattempt during a depressive crisis. Initially, she was submitted to aretrosternal esophagocoloplasty with the maintenance of her damagedesophagus. After 1 year of this first surgery, she ingested caustic sodaagain in a new suicidal attempt. Her transposed large bowel in the firstsurgery became narrow, being replaced in a second surgery by a retrosternalesophagogastroplasty. Still, at the second surgery, her damaged esophagusremained in its original position in the posterior mediastinum. However,after 5 years, she developed an esophagocele.The esophagocele was resected through videothoracoscopy in a prone position,employing four trocars. The postoperative was uneventful.Esophageal exclusion must always be recorded because esophagocele presentsunspecific symptoms. The videothoracoscopy in a prone position is anexcellent technical option to resect esophagoceles. In developing countries, thisdisease remains increasing and it is associated with unfavorable factors likesocial, economic, and educational handicaps, and a lack of prevention. Worldwide,children are the most affected, accounting for about 80% of the cases, mainly byaccidental ingestion. On the contrary, the main cause of caustic ingestion in theadult population seems to be secondary to suicidal attempt.Moreover, the impossibility of endoscopic dilation or its failure points out asurgical treatment, aiming to re-establish the alimentary tract through esophagusreplacement. This replacement can be achieved by interposition of the retrosternalstomach or by transposing the large bowel, which is actually the preferred method.Resection of a damaged esophagus is optional. The resection of the damaged esophagusincreases surgical morbidity-mortality when compared to no resection. However, withincreased risk of cancer, lack of possibility of endoscopic surveillance, and riskof infection at a rate of 50% at 5 years of the resultant esophagocele, some authorsadvise to resect the damaged esophagusThe objective of this study was to report the surgical technique employed in a17-year-old adolescent who attempted suicide twice by swallowing a moderate quantityof caustic products. Later, she presented an esophagocele.The patient was referred to our hospital after first caustic ingestion, due to asuicidal attempt, with dysphagia for her own saliva. The upper digestive endoscopyand the contrast radiography of the esophagus showed severe esophageal stenosis. Noendoscopic treatment was possible, and she was submitted to retrosternalesophagocoloplasty. The postoperative was uneventful and she was discharged afterstarted eating soft and solid foods. Concomitantly, she started psychiatrictreatment, which included follow-up in an outpatient unit.After 1 year, the patient presented a new depression crisis caused by theinterruption of her psychiatric treatment. Again, she swallowed a caustic product ina new suicidal attempt and was admitted with dysphagia which was severe for solidand soft foods and also associated with weight loss. Thus, a new digestive endoscopyand contrast radiography showed complete stenosis of the colon, initiating at theneck level.Therefore, she was submitted to her second surgery, which consisted of a large bowelresection previously transposed, associated with a new alimentary tractreconstruction employing a gastric tube and esophagogastric anastomosis at the neck,plus jejunostomy for early enteral feeding. Again, her damaged esophagus was notresected at that time, and the postoperative course was uneventful.She remained well for 5 years after this second surgery described above, with aregular follow-up in an outpatient unit, with good recovery of weight. However,after this period, she complained every day of retrosternal pain, which was worsenedby deep inspiration, pain in the left upper quadrant, weight loss, loss of appetite,and fever. The patient signed a consent form, authorizing this report.The patient was readmitted to the hospital and CT scans showed an esophagoceleassociated with an abdominal left sub-diaphragm abscess, which, probably, revealeditself with that esophagocele. This left sub-diaphragm abscess was treated byultrasound-guided percutaneous drainage and antibiotic therapy, with a resolution ofthe pain and fever. She was discharged with no symptoms.Six months later, she returned with the same symptoms described above. A new CT scanshowed an increased esophagocele .The patShe had an uneventful postoperative period without vasoactive drugs or bloodtransfusions, and an oral diet was initiated on the second postoperative day. Shewas discharged on the fifth postoperative day. At late follow-up in the outpatientunit, she presented weight recovery, with no fever or any dysphagia.. Esophageal exclusion may develop an esophagocele, when the proximal anddistal esophagus is occluded, as a consequence of the accumulation of secretion in aclosed organ. This event rarely brings symptoms, however, it can cause thoracic pain,tracheal compression, fistulization into tracheobronchial tree and neck, thoracicand abdominal abscesses, abdominal pain, cough, vomiting, fever, infection, and sepsis. Most of the esophagoceles are small, probably because in many situations thedamaged mucosa suffers atrophy.Esophagocele, or esophageal mucocele, is a rare condition with unknown frequency andis not well described in the medical literature. However, there are case reports of treatment through CT scan-guided drainage. Other case reports mention mucosal ablation with 100% alcohol. In addition, there are reports that include some patients with high surgicalrisk for thoracotomy and surgical drainage of the distal esophagus throughesophagus-jejunum anastomosis with a Roux-en-Y intestinal loop may be an option.CT scans and magnetic resonance imaging (MRI) are the main diagnostic tools, whichusually show a cystic image in the mediastinum. Most of the symptomaticesophagoceles are treated with thoracotomy followed by esophageal resection. Sometimes, resection and alimentary tract reconstructions are not feasiblein the same surgery due to increased morbidity, making esophageal exclusion anoption of treatment.Esophagocoloplasty is the choice treatment for caustic stenosis, and many authors donot recommend esophagectomy at the same surgical time.Pavankumar et al. reported a case of a 22-year-old female who ingested a chicken boneand presented an esophageal perforation, treated by esophagostomy and feedingjejunostomy. Six weeks later, the patient underwent laparoscopic-assistedretrosternal gastric bypass with cervical esophagogastric anastomosis. One yearlater, she presented an esophagocele, treated by esophagectomy by videothoracoscopyin the prone position. There were no records found in the literature on esophagoceles treated withvideothoracoscopy after caustic ingestion.Esophagectomy by videothoracoscopy is a minimally invasive technique and thetreatment of choice for many illnesses, from malignant and benign diseases, with lowmorbidity and mortality, and is a very safe method when performed by experienced surgeonsFinally, it is important to perform postoperative follow-up in patients with ahistory of ingestion of caustic products who have undergone esophagogastric bypass,evaluating the possibility of occurrence of esophagoceles.Esophagectomy by videothoracoscopy in a prone position is a feasible and safe optionto treat esophagoceles after caustic ingestions.


Falciform ligament abscess (FLA) is a rare disease, and its diagnosis can be challenging without typical image findings of an abscess. We report a patient with FLA that presented as a mass, with an indistinct border between it and the liver, in addition to disseminated foci within the liver. This made it difficult to determine whether it was FLA or a malignancy.Pseudomonas aeruginosa was cultured from the pus in the falciform ligament mass and bile in the gallbladder. Although multiple abscesses postoperatively developed in the residual portion of the liver, they could be treated through antibiotic therapy.A 69-year-old man presented with epigastric pain. Contrast-enhanced computed tomography revealed a 25-mm mass below the middle of the diaphragm. Based on an initial diagnosis of infection of the falciform ligament, we administered conservative antibiotic treatment and there was initial improvement in the patient’s clinical condition and laboratory data. However, he continued to experience mild epigastric pain. A month later, imaging studies revealed enlargement of the falciform ligament mass and the emergence of a new nodule in the liver, whereas laboratory findings showed re-elevated C-reactive protein levels. Since conservative treatment had failed, we decided to perform surgery. Considering the imaging study findings, malignant disease could not be ruled out. Based on the operative findings, we performed combined resection of the falciform ligament, left liver, and gallbladder. Histopathological examination of the resected specimens revealed extensive neutrophil infiltration and the presence of giant cells and foam cells within the lesions. These findings were indicative of abscess. FLA can spread to both adjacent and distant organs via its rich vascular and lymphatic networks. When FLA displays atypical image findings and/or an atypical clinical course, it can be difficult to distinguish it from malignant disease. In such cases, surgical treatment, with intraoperative pathological diagnosis, should be attempted. The falciform ligament is strongly connected to surrounding organs via rich vascular and lymphatic networks. Falciform ligament abscess (FLA) is a rare disease, typically caused by the transmission of bacteria from other organs via these networks. Diagnosis is relatively simple in cases with typical image findings, because an abscess usually presents on computed tomography (CT) scans or magnetic resonance imaging (MRI) as a mass with well-defined enhanced capsule wall and with internal fluid and air content. However, when an abscess has minimal fluid, it can be difficult to distinguish from a malignant tumor.Since FLA results from bacteria transmitted to the falciform ligament from surrounding organs, it could also spread bacteria to surrounding or distant organs via the same vascular or lymphatic pathways. However, instances of this have not been reported.Here, we report a patient with FLA that presented as a mass with disseminated foci in the liver and a border indistinct from the liver. These characteristics made the FLA difficult to differentiate from malignancy. This is the first report of FLA with disseminated intrahepatic foci.A 69-year-old man with no significant medical history presented to the emergency department with epigastric pain that had lasted for 5 days. On physical examination, he had a slight fever and mild tenderness around the epigastrium. Laboratory findings were unremarkable, except for mildly elevated C-reactive protein (CRP) levels of 6.9 mg/dl. Contrast-enhanced CT revealed a 25-mm enhanced mass with small low-density areas below the middle of the diaphragm Fig. . On MRI,Based on a diagnosis of falciform ligament infection, we administered conservative therapy in the form of sulbactam/ampicillin (SBT/ABPC) infusion and subsequent oral clavulanic acid/amoxicillin (CVA/AMPC). Performed at admission, the blood culture was negative. Imaging studies showed no apparent pancreatobiliary or other organ infections. The patient also had no biliary history. Additionally, the upper and lower gastrointestinal endoscopies revealed no significant findings. Therefore, the cause of FLA was unclear. The patient’s general condition and laboratory data improved, and he was discharged. However, he continued to complain of mild epigastric pain. A further CT scan was performed a month after discharge, and this revealed that the falciform ligament mass had increased in size. We also observed an obscure border between the mass and the liver and a new low-density nodule in liver segment three, with upstream bile duct dilatation Fig. . After sDuring surgery, laparotomy and intraoperative ultrasonography confirmed our imaging findings, revealing an indistinct border between the mass of the falciform ligament and the liver, and a yellowish-white nodule in liver segment three Fig. . We founPseudomonas aeruginosa was cultured from the pus in the falciform ligament mass and the bile in the gallbladder. Although multiple abscesses developed postoperatively in the remaining liver, they rapidly improved with the use of antibiotics (levofloxacin) and the patient was discharged. He did not experience subsequent recurrence of intra-abdominal abscesses.The cut surfaces of the resected specimens showed both the falciform ligament mass and the liver segment three nodule to be pale white, irregularly shaped nodular lesions. Histopathological examination revealed extensive neutrophil infiltration and the presence of giant cells and foam cells in both lesions, consistent with abscesses Fig. . PseudomFLA is a rare condition, with only about 20 adult cases reported in the literature so far, including reports of ligamentum teres abscess. Table Pseudomonas aeruginosa was detected both in the bile of the gallbladder and the abscess of the falciform ligament, bile infection likely triggered the development of the disease. Regarding the disseminated intrahepatic foci, continuous thickening of Glissonian tissue from the abscess to the disseminated foci in the liver was observed in the resected specimen, suggesting that bacteria traveled into the liver via vessels in the Glissonian tissue.The vascular and lymphatic networks that incorporate the falciform ligament connect it to the liver, diaphragm, retroperitoneum, mediastinum, abdominal wall, and chest wall. Its arterial blood flow is supplied by the left inferior phrenic artery, the middle hepatic artery, and, to a lesser extent, the left and right hepatic arteries –24. ThesAlthough FLA is rare, diagnosis is relatively easy in cases with typical image findings as an abscess usually has a well-defined enhanced capsule wall and internal fluid and air content. In this case, small cystic lesions within the falciform ligament mass suggested the possibility of an abscess. Because antimicrobial agents were initially effective, we first diagnosed the mass as an infection of the falciform ligament. However, enlargement of the mass and a new nodule in the liver on CT images after initial treatment implied a malignant tumor. Tumors of the falciform ligament are uncommon; nonetheless, a metastatic case of intrahepatic cholangiocarcinoma in the falciform ligament with similar imaging findings to our case has been reported .Pseudomonas aeruginosa was detected in the resected specimen and this is naturally resistant to the SBT/ABPC and CVA/AMPC used for effective initial treatment. Guidelines for the treatment of intra-abdominal abscesses emphasize the importance of source control [While conservative management with puncture or drainage is reported to be effective for FLA, many recommend surgical treatment. In our case, conservative treatment was only able to provide temporary relief from the disease and it soon recurred, leading to eventual surgical treatment. Conservative treatment for abscesses often requires prolonged antibiotic therapy. Relapse may occur during or after conservative treatment due to bacterial replacement or inadequate treatment. In our case,  control . The absWe have here reported a case of FLA with a mass-like appearance and disseminated intrahepatic foci. It should be recognized that FLA can spread to both near and distant organs via its rich vascular and lymphatic networks.


The gastrocnemius medial head distal musculotendinous junction injury is relatively common. Musculature contraction in an already stretched structure leads to muscle breakdown. Patients affected are often physically active middle-aged men. The typical presentation includes sudden pain, audible popping, bruising and localized tenderness. Occasionally, there is a palpable defect if the rupture is complete. Although the initial diagnosis can be made on the basis of a careful history and clinical examination, ultrasound or magnetic resonance imaging can be used to better describe the lesion. In complete ruptures, even when conservative treatment shows good results, it is common that the patient presents decreased muscle strength, difficulty returning to sports and permanent and visible gap. Considering surgical treatment in patients with complete ruptures and extensive injuries with a more than 5 cm gap may lead to better healing process, rapid rehabilitation and more efficient return to sports. The gastrocnemius medial head distal musculotendinous junction injury, also called ‘tennis leg’ and first described in 1883, is a relatively common clinical condition  related Attempting to contract an already stretched muscle can lead to tears, whether during sporting activities or common daily activities, and patients affected are often physically active middle-aged men .The typical presentation is characterized by sudden pain, an audible ‘click’, ecchymosis and localized tenderness in the area of tendinous attachment. Occasionally, there is a palpable defect if the tendon rupture is complete. Although the initial diagnosis can be clinically made, ultrasound or magnetic resonance imaging (MRI) can be used not only for confirmation but also to exclude other diseases and allow the assessment of lesion size. These factors directly influence the choice and duration of treatment; however, the literature review on large size lesions is insufficient and should be improved, so we do not really know if large lesions have the worst prognosis , 6.The surgical approach is rarely described because the basis of treatment is non-surgical . We inteCase 1 consists of a 36-year-old female, 10 years amateur volleyball player, who presented with a history of pain and audible popping in the back of the left leg during a jump landing in a volleyball match. She evolved with persistent pain and functional deficit in the leg .Case 2 patient is a practitioner of bodybuilding and competitive amateur cycling, with many years of practice; he intensified training last year. He suffered a fall of about 1.7 m over the bicycle during a journey on rough terrain, and when supporting the right lower limb on the ground, he felt pain and posterior clicking in the right calf, evolving with functional disability in the limb .Both patients denied steroids use. They were evaluated by radiographs and MRI and classified by O’Donoghue classification system as a grade III injury in both cases. Lesions were found at the medial head of the gastrocnemius muscle myotendinous transition. In Case 1, 5 cm retraction was measured and in Case 2, 7 cm. Muscle injury were classified by O’Donoghue in three grades according to size and functional loss: grade I for irrelevant tissue lesions, grade II for tissue lesions associated with strength reduction in the muscle-tendon complex and grade III for complete rupture of the muscle-tendon complex and complete functional loss , 4, 6.Due to the presence of significant gap, hematoma and poor improvement with conservative treatment, patients went for surgery. In Case 1, surgery was performed 3 weeks after the trauma, while in Case 2 it was performed after 4 weeks.A direct posterior incision measuring approximately 7 cm over the medial head of the gastrocnemius was made. Significant gap and scar tissue were observed at the proximal and distal edges of the lesion. Muscle adhesions in the fascia were released; we found abundant drainage of liquid collection, translucent with inflammatory characteristic. After delimitation of the lesion, suture was performed with high-resistance FiberWire®  and Vycril® number 0.2 threads, with muscular edges fixation and sutures. Two pairs of Krakow anchored stitches sutures, in order to grab the whole muscular mass, were tied. This prevents tears on the muscle mass and gives us a more rigid construct to suture the hole muscle structure. The key points of the described approach are highlighted in Both patients evolved with excellent results. They were conducted with temporary suropodalic immobilization on the operated limb without load for 3 weeks. In the next 3 weeks, a physiotherapeutic rehabilitation protocol was started with movement gain, flexibility and gait training. After the sixth week, strengthening and introduction to the sports gesture were started. Case 1 patient returned to sports activities 5 months after the operation and Case 2 patient returned after 4 months and 2 weeks.Routine tennis leg treatment is conducted non-surgically involving rest, cryotherapy, leg elevation, medication and a physical therapy program. Surgical treatment was reported only in association with compartment syndrome, and rarely the edema is extensive enough to cause it , 6, 7.In cases of total tears, the contracted muscle mass and the gap between the extremities can heal with fibrotic and rigid tissue, bringing an increased risk of injury recurrence, persistent pain and preventing recovery of full strength , 8, 9. CClinically, myotendinous junction injury takes longer than a purely muscular injury to heal and allow return to sports activity, and this is another important treatment issue to consider . Fast reet al. reported this same finding occurring in more than 50% of these patients.Fluid collection between the aponeuroses of the medial head of the gastrocnemius and soleus was seen in ‘tennis leg’ cases, especially at the level of the muscle belly or myotendinous junction, with pseudocystic features . In our Reviewing the literature, lesions of other muscle groups were also treated surgically with satisfactory reported results. There are no well-established values to consider the gap as large. Based on our clinical experience, we consider 5 cm as an expressive value; however, further studies are needed to validate this observation.et al. reported two cases, both presenting sports grade III O’Donoghue lesions; a 37-year-old man operated 10 days after injury and a 43-year-old woman operated 10 months after injury. Our study reported similar cases, except for the time of surgery decision. We believe that conservative treatment must be introduced initially, but also can’t be delayed too much; thus, we recommend surgery at 3–4 weeks after injury.We found only one study addressing surgical treatment. Cheng Finally, the authors recommend to consider surgery in young people actively involved in sports with persistent pain, obvious defect and calf extension dysfunction, to ensure strength for continued sports activity . LiteratThis study demonstrated that patients with gastrocnemius medial head grade III muscle injuries that did do not show improvement after a short period of conservative treatment can be successfully treated by surgical repair and postoperative physical therapy. Nevertheless, as any surgical treatment, we must be caution about potential complications and surgery indications. We recommend future studies to better evaluate this new treatment possibility.The authors declare no conflict of interest in carrying out this paper.


A 71‐year‐old male presented with a 15‐hour history of migratory right lower quadrant (RLQ) abdominal pain. He had no nausea, vomiting, diarrhoea, dysuria or recent illnesses. His medical history was significant for a laparoscopic‐assisted radical prostatectomy (2016) and laparoscopic right inguinal & femoral hernia repair (2011). A colonoscopy 2 years prior was unremarkable.Examination revealed a soft abdomen, no masses but tenderness to light palpation in the RLQ. Vital signs were normal. Full blood count, urea, electrolytes & creatinine, liver function tests and lipase were normal, while C‐reactive protein was elevated at 11 mg/L.Computed tomography (CT) of the abdomen and pelvis with portal venous contrast reported a right‐sided, ventrolateral or Spigelian hernia containing inflamed appendix with tip located between external oblique aponeurosis and internal oblique muscles Fig. . We perfThe patient underwent laparoscopic appendicectomy and hernia repair. Intra‐operative findings showed a hernial gate 5 mm wide, consistent with a Spigelian hernia and incarcerated appendicitis within Fig. . The appAppendicitis is common, with a 7%–8% lifetime risk,Light (2013) reported Spigelian hernia diagnosis with ultrasound had sensitivity of 90% and positive predictive value of 100%, while CT was 100% & 100%, respectively.linea Spigeli) in 1645. Klinkosch (1764) named the eponymous hernia resulting from its defect. These can be acquired or congenital  hernial gate with a sharp fascial edge.The literature reports open surgery in 11/18 (61%) cases and laparoscopic intra‐abdominal approaches in 5/18 (28%). In 4/18 (28%), surgeons used mesh to repair the hernia at the primary operation. Only 3/18 (17%) reported studies described finding a normal appendix.This case demonstrates the anatomy, workup and management of appendicitis within a Spigelian hernia and underlines the value of preoperative imaging and laparoscopic repair.The corresponding author is the recipient of the Cynthia Banham Burn Injury Research Fellowship  and received the Australian Government Research Training Program Fees Offset Scholarship for a higher degree .This case has not been reported, presented or published before.Guy H. M. Stanley: Data curation; formal analysis; investigation; project administration; writing – original draft; writing – review and editing. Tristan Gilliland: Data curation; formal analysis; investigation; project administration; writing – original draft; writing – review and editing. Matthew W. Trinder: Conceptualization; methodology; supervision; validation; writing – review and editing. Yu Xin Liew: Writing – review and editing. Enoch Wong: Methodology; supervision; validation; writing – review and editing. Jennifer Ryan: Supervision; validation; writing – review and editing.


A 54-year-old man was seen in the clinic with the chief complaint of epigastric pain radiating to the left groin region and a predominant postprandial abdominal discomfort. Upon examination, a painless round mass with reduced mobility was felt in the left flank during deep palpation of the abdomen. His past medical history was irrelevant. Ultrasound and IV contrast-enhanced CT scan confirmed the presence of a large tumor and an exploratory laparotomy for removal of the tumor was performed. The microscopic examination of the specimen confirmed the primary diagnosis of retroperitoneal tumor (RPT) and identified it as an extragonadal germ cell tumor with a vestigial origin, which is a rare type affecting the kidney and adrenal gland. Primitive RPTs are histologically classified as mesenchymal and neuroectodermal or vestigial. These histological types are rarely found in surgical practice and are challenging to diagnose and treat due to the peculiarities of the site of origin where they develop. RPTs are extremely rare and approximately 80% are malignant and detected lately during the disease's course, commonly discovered in advanced stages of local or systemic evolution. Currently, surgical intervention remains the only effective method of treating these tumors. Retroperitoneal tumors (RPTs) are a heterogeneous group of neoplasms originating in the retroperitoneal space (RPS) and do not refer to the retroperitoneal organs or the abdominal cavity. Malignant metastases from distant organs are also excluded from this group. Structurally, RPT can be solid and/or cystic. By histological origin, solid tumors can be divided into four groups: mesenchymal, neuronal, vestigial, and lymphoproliferative -3. AccorImaging investigations (CT and MRI) and biopsy play a crucial role in providing information necessary for differential diagnosis by determining the tumor characteristics, namely, the site, size, shape, its relationship to adjacent anatomical structures, their invasion, as well as the presence of metastases. CT scan can identify the tumor and its relationship with adjacent structures. It can also detect the presence of degeneration inside the tumor as well as calcifications, which are indirect signs indicating a malignant type and aggressiveness of the tumor process. Nuclear magnetic resonance might reveal the heterogeneity of the formation, as well as alternating cystic-degenerated areas with solid areas -8. Pre-oA 54-year-old man, with no past surgical history, was referred to the doctor for epigastric pain radiating to the left groin region and a predominant postprandial abdominal discomfort. There was no associated history of weight loss, fever, or urinary complaints. The clinical examination focused on the abdomen revealed a distended abdomen and moderate pain in the left lumbar region where a hard round mass with reduced mobility extending superiorly into the left hypochondrium and inferiorly into the pelvis was felt. Signs of peritoneal irritation were negative. The liver and spleen were not palpable. Laboratory investigations including cancer antigen 125 (CA -125), carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), and beta-human chorionic gonadotropin (HCG) levels were within the normal range. Investigations performed were IV contrast-enhanced CT  with all margins clear (R0-resection). The post-procedure hospital stay consisted of six days without any complications. Following a 3.5-month postoperative period, the patient showed no clinical signs of recurrence or distant progress. A routine imaging (MRI) examination was carried out over six months after surgery.The RPS is a virtual anatomical space. It is bounded anteriorly by the parietal peritoneum, posteriorly by the intraperitoneal fascia, upward by the diaphragm, and laterally by the fold of the peritoneum from the lateral abdominal wall to the posterior abdominal wall and extending downward to promontory and linea terminalis or pelvic brim. The RPS content comprises adipose tissue, layered by fascia, which includes the retroperitoneal organs, blood vessels, and peripheral nerves. The clinical signs of tumors that invade this space are nonspecific and often secondary, depending on the tumor topography and relationship with the adjacent anatomical structures, found at the time of diagnosis. Smaller tumors (less than 5 cm) are usually “clinically silent” and are discovered accidentally the majority of the time ,12. As tClinical manifestations are not specific to this histological type of tumor. Most RPTs are of mesodermal origin, the most common being liposarcoma, leiomyosarcoma, and undifferentiated pleomorphic sarcoma. Although germ cell tumors (GCTs) are often present in the testes or ovaries, these types of extragonadal tumors are rare. These tumors arise from the remnants of primordial germ cells that accidentally remain within the aforementioned spaces during their physiological migration in the urogenital ridge, a process that occurs between the second and the eighth week of embryonic development. Tumors originating from extragonadal germ cells are often detected near the midline, especially between the T6 and S2 vertebrae; whereas the RPS is the second most common site of their development after the mediastinum. The imagistic studies show that tumors developed from extragonadal germ cells have characteristics similar to a gonadal tumor.GCTs can occur at any age and can be of the adult (95%) or juvenile (5%) type, with subtypes distinguished by clinical and histological features . The cliThe extragonadal GCTs are aggressive neoplasms that may occur almost anywhere; however, the most common sites are the mediastinum, retroperitoneum, and pineal gland. High-precision imaging investigations, such as CT and nuclear MRI, are still the main imaging methods for diagnosing RPT and planning surgical treatment. The rarity of these tumors and the complexity of their treatment require multidisciplinary management in specialized centers to improve oncologic and clinical outcomes.


Metastases from renal cell carcinoma (RCC) are rarely located in the small bowel and usually present either with iron deficiency anaemia due to occult bleeding or obstructive symptoms. A 65-year-old man with not known malignancy was admitted to our hospital with symptoms of intermittent bowel obstruction. The abdominal computed tomography (CT) scan depicted a large tumour of the right kidney and obstruction of the small intestine at the level of the proximal jejunum. A jejuno-jejunal intussusception was found on laparotomy, due to endoluminal lesions that proved to be metastatic from RCC. Intussusception of the small bowel due to metastatic RCC is a very rare combination and only a few such cases have been reported so far in the literature. Renal cell carcinoma (RCC) is the most common neoplasm of the kidney and the seventh most common neoplasm in the developed world. It is associated with more than 140 000 deaths per year. The majority of diagnoses are made in men in their seventh decade of age. The neoplasm is categorized in various subtypes and it may metastasize to almost every organ with the lungs, bones, liver and brain being the most common. Metastases from RCC are rarely located in the small bowel and usually present either with iron deficiency anemia due to occult bleeding or obstructive symptoms. Intussusception of the small bowel due to metastatic RCC is a very rare combination and only a few such cases have been reported in the medical literature so far . Small bWe present here a patient with metastatic renal carcinoma to the small bowel, seen recently to our institution, with obstructive symptoms due to intussusception.A 65-year-old man with not known malignancy, was admitted to our hospital with symptoms of intermittent bowel obstruction. He had no previous history of abdominal surgery and physical examination revealed abdominal distention, metallic bowel sounds, pallor, and signs of mild dehydration. Furthermore, a fixed subcutaneous lesion was palpated in the right subcostal region. Laboratory tests revealed iron deficiency anaemia. A plain abdominal radiograph in the upright position showed dilated small bowel loops in the upper abdomen. Upper GI endoscopy showed esophagitis and a small hiatal hernia whereas colonoscopy was unremarkable. The abdominal CT scan depicted a large tumour of the right kidney and obstruction of the small intestine at the level of the proximal jejunum . The perThe patient’s postoperative course was unremarkable, and he was discharged from hospital in a good condition. Histological examination of the jejunal specimen confirmed multiple metastatic lesions from RCC. The subcutaneous lesion of the torso was similarly metastatic. Subsequently the patient was referred to medical oncologists for further management.Small bowel intussusception in adults is rare, rendering its diagnosis challenging due to non-specific symptoms. However, it can be the first presentation of primary or metastatic neoplasms. Especially patients with a positive cancer history, presenting with unexplained small bowel obstruction symptoms, should raise high suspicion for metastatic disease. Small bowel metastatic tumours are most commonly originated from melanoma, head and neck, breast, and oesophageal cancers.Due to the non-specific and often obscure symptoms that accompany malignant neoplasms of the small bowel, either primary or metastatic, as well as the difficulty in diagnostic examination of the small bowel due to the low diagnostic accuracy of conventional paraclinical tests  are the main reasons for delaying and making challenging the diagnosis of neoplasms of this part of the digestive tract.On the other hand, more sophisticated examinations that could aid diagnosis are not always available . A high index of clinical suspicion combined with proper imaging can aid early diagnosis, preventing serious complications such as perforation and peritonitis. The diagnosis is often made on the operating table. Renal carcinoma rarely metastasizes into the small intestine and the patient presents with a similar clinical picture. In patients with a history of primary malignancy with unexplained abdominal symptoms, screening for bowel metastasis is mandatory. Careful and detailed evaluation of clinical and imaging findings combined with obtaining a good and detailed history contribute to the punctual detection of the cause that led to the problem, and its prompt treatment.Unexplained intestinal symptoms, such as small bowel ileus and iron deficiency anaemia, although not so rare should raise suspicion for a variety of pathological entities. Neoplastic metastases should be high on our list especially in patients with a positive cancer history. Diagnosis is not always feasible with imaging studies and an exploratory operation is often mandatory.