Hydatid cysts of the female reproductive system represent a rare entity. We report a case of a primary hydatid cyst of the right ovary of a postmenopausal woman that was diagnosed incidentally.A 72-year old overweight woman with history of three vaginal deliveries was referred due to uterine prolapse. During clinical examination of the patient, preoperative pelvic ultrasound revealed an ovarian cyst with benign characteristics. After oncology review, a laparoscopically assisted vaginal hysterectomy with bilateral salpingo-oophorectomy was conducted; the histopathology of the cyst revealed a hydatid cyst. Postoperative abdominal computed tomography identified no other sites of infection, indicating the ovary as the primary site of infection. During follow-up no recurrence occurred.Hydatid cysts usually have a low progression and tend to be asymptomatic. Medical treatment may be successful in small asymptomatic cysts, however a close follow-up is needed after antihelminthic treatment. Surgical management with removal of the intact cyst is the preferred method for large cysts.We report a rare case of ovarian hydatid cyst that was effectively removed intact during a laparoscopically assisted vaginal hysterectomy with no recurrence during follow-up. So fa2A 72-year-old woman was referred to the outpatient gynecologic department due to suspected uterine prolapse. She had a history of three vaginal deliveries, did not smoke and reported menopause at the age of 52. She was treated with valsartan for chronic hypertension, while she reported no history of jaundice or surgical operations. At the age of 62 she was diagnosed with an abnormal Pap test  with negative HPV DNA test. However, during follow-up, no subsequent cervical pathology was detected.2 and all vital signs were normal; the temperature was 36.2 °C, the heart rate was 68 beats/min, the blood pressure was 120/75 mmHg, the respiration rate was 18 breaths/min and O2 saturation was 100%. Serum liver and renal tests, as well as chest X-Ray findings were also normal. As part of a standard preoperative protocol, transvaginal sonography (4–9 MHz transducer) was performed. This identified a cystic multilocular tumor (max diameter 9 cm), with solid components  and presence of acoustic shadow under the right adnexa, while no abnormalities were detected in the left adnexa or the uterus. Serum CEA and Ca-125 values were normal. Using the International Ovarian Tumor Analysis (IOTA) ADNEX model, we calculated a low risk of malignancy 1.4% [On the current physical examination, uterine prolapse stage III (POP-Q) was confirmed. The body mass index of the patient was 28 kg/mThe histopathology specimen revealed a hydatid cyst of the ovary. Additionally, a postoperative abdominal Computed Tomography (CT) revealed no other sites of infection, including the liver; thus, the ovary was considered the primary site of infection. A referral to the outpatient department of Infectious Diseases was offered to the patient. During follow-up, to date, there was no recurrence of the disease.3Echinococcosis is endemic in several countries of the world, including East Europe, South America and Mediterranean area . EchinocAs already mentioned, liver is the most common primary location for this disease . HoweverHydatid cysts typically have a slow progression and tend to be asymptomatic; sometimes jaundice may be the main symptom due to intrabiliary rupture . Other sRegarding diagnosis, hydatid cysts of the ovaries often mimic ovarian tumors, leading that way to unnecessary diagnostic procedures . UltrasoAs for the management, asymptomatic cysts may be treated with antihelminthic drugs; albendazole is typically used in uncomplicated hydatid disease, but close monitoring is mandatory during treatment because of the possible side effects ,16. In c4This was a rare case of a primary ovarian hydatid cyst that was diagnosed incidentally following a referral due to uterine prolapse. This case highlights the need for higher awareness of rare types of ovarian masses. The healthcare provider should always keep in mind that, especially in cases of endemic hydatid disease, echinococcosis should always be included in the differential diagnosis of ovarian cysts, leading that way to earlier and more accurate diagnosis and associated management of the disease.The authors have no conflict of interest to declare.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This article does not contain any personal information that can lead to the identification of the patient.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.Katsamagkas Taxiarchis: Paper design, data collection, paper writing.Tsakiridis Ioannis: Paper design, data collection, paper writing.Evaggelinos Dimitrios: Paper design, paper writing.Skafida Paraskevi: Paper review, Picture preparation.Dagklis Themistoklis: Picture preparation, paper review.Kalogiannidis Ioannis: Paper design, data collection, paper review.N/A.Ioannis Tsakiridis, Ioannis Kalogiannidis.Not commissioned, externally peer-reviewed.


The patient was a 60‐year‐old woman with rheumatoid arthritis referred for dyspnea. Transthoracic echocardiography (TTE) revealed a mass occupying the left atrium. 3D transesophageal echocardiography  affirms that this manuscript is an honest, accurate, and transparent account of the clinical image being reported; that no important aspects of the case have been omitted.


GCTTS is the second most popular soft tissue tumor at the hand next to ganglion cyst, and also named tenosynovial giant cell tumor or pigmented villonodular tenosynovitis. It is divided into localized form and diffuse form. We introduce a report of a rare case of GCTTS in a female where lesions were identiied within the left ring finger and also conducted a literature review.We describe a 32-year-old female patient with GCTTS a single digit since six months. Radiographic and histopathological examination is necessary to help determine whether to take further treatment. Surgical excision was performed, including complete removal of the tumor and reconstruction of the pulley with autologous tendon. Histopathology suggested that these masses were consistent with GCTTS without malignancy. There was no clinical and radiologic evidence of recurrence six months after surgery.GCTTS is a benign fibrous tissue tumor originating from the tenosynosheath, bursae and joint synovium. This tumor is more common in adults aged 30–50, and is slanted toward females. The major risk of GCTTS is recurrence and joint damage, which requires surgical resection. The integrity of the pulley plays an important role in the function of the hand. In this case, the ipsilateral metacarpal tendon was taken during the operation to reconstruct the pulley to reduce the possibility of loss of hand function.This case represents a rare case of GCTTS at the hand within a single digit. Due to its high recurrence rate, the tumor should be completely removed to reduce the possibility of recurrence. Radiographic and histopathological examination must be performed on the tumor, which is determined to be benign and does not require further treatment. The function of the hand should be reconstructed to minimize the loss if necessary. •We describe a 32-year-old female patient with GCTTS a single digit since six months.•Preoperative examinations including clinical examination and imaging examination were improved.•The scope and size of the tumor were fully evaluated to determine the surgical method.•We completely excised the masses and the involved tendon sheath.•The part of the ipsilateral palmaris longus tendon was used to reconstruct the A2 pulley.•Postoperative pathology was performed to determine the nature of the tumor.•The tumor should be completely removed to reduce the possibility of recurrence. AccorHere, we introduce a report of a rare case of GCTTS in a female where lesions were identiied within the left ring finger and also conducted a literature review. This report was approved by the hospital ethics committee and conducted with the informed consent of patient and her families. The work has been reported in line with the SCARE criteria .2A 32-year-old female, right hand dominant, visited to our clinic with a six-month history of left ring finger discomfort and obvious growing masses. Based on physical examination, the nodules were 7 × 0.7 × 0.5 cm in size at the volar aspect of the left ring finger and the fourth metacarpal. Physical examination showed mild pain and swelling; These masses were irregular in shape and unclear from the surrounding tissue; however, no paresthesia was noted, and normal circulation of the capillaries were present. The motion of the proximal interphalangeal and metacarpophalangeal joint were moderately restricted, and the motion of the distal interphalangeal joint is normal. The smooth glide and grip strength of left hand were worse than right hand. The patient has no history of smoking and alcohol abuse, and no family member has any history of related diseases.X-ray examination showed the mass shadow without bone erosion. Magnetic resonance imaging (MRI) showed the size and extent of these masses. These masses ranged from the middle part of the fourth metacarpal bone to the proximal middle phalanx of left ring finger. Preoperative tumor indicators were normal.According to the patient's requirements and symptoms, surgical treatment was attempted by two orthopaedic attending physicians, both of whom have more than 3 years of working experience. Surgical treatment was attempted. We performed a Z-shaped incision on the surface of these masses. The masses at the volar aspect of the left ring finger and the fourth metacarpal were clearly revealed. These masses closely surrounded the flexor tendons. The tendon sheath and bony were slightly corroded by the masses. We completely excised the masses and the involved tendon sheath. The part of the ipsilateral palmaris longus tendon was used to reconstruct the A2 pulley. The wound healed completely without infection after the operation. One week after surgery, she complied with doctor's advice to start rehabilitation exercise to reduce adhesion of tendon tissues. Postoperative rehabilitation exercise included passive activity three days after surgery and active activity one week after surgery see .Histopathologic examination showed that the tumor was lobulated and surrounded by dense and transparent collagen. The intratumoral cells were composed of a mixture of histiocytoid monocytes, osteoblastic multinucleate giant cells, xanthoma cells, chronic inflammatory cells, ferruginous phagocytes and collagenous matrix . HistopaPostoperative follow-up was conducted every three months, the patient expressed her gratitude that there was no deformity or numbness that might occur in preoperative communication. The patient made a full recovery without significant swelling and restricted movement. The flexion and extension of the metacarpophalangeal joint and proximal interphalangeal joint of the ring finger were normal without bowstring deformity six months after the operation. The smooth glide and grip strength of left side were similar to right side. Meanwhile, there was no clinical and radiologic evidence of recurrence.3GCTTS is a benign fibrous tissue tumor originating from the tenosynosheath, bursae and joint synovium . This tuThe major risk of GCTTS is recurrence and joint damage, which requires surgical resection . ChoughrManske and Tang JB et al. suggested hand function would be partially lost because of the removal of A1 and A2 pulley ,13. Ther4Our case represents a rare case of GCTTS at the hand within a single digit. Moreover, because of its high recurrence rate, the tumor should be completely removed to reduce the possibility of recurrence. In addition, radiographic and histopathological examination must be performed on the tumor, which is determined to be benign and does not require further treatment. Finally, the function of the hand should be reconstructed to minimize the loss if necessary.This report was conducted in compliance with ethical standards. Informed written consent has been obtained and all identifying information is omitted.None.Zhengming Lv-Operation of case, conception of study, drafting of manuscript Jie Liu-Modification of manuscript, approval of the final version for submission.This is a case report study.lianghuimin889757@163.com).Huimin Liang (Not commissioned, external peer review.Informed written consent has been obtained and all identifying information is omitted.No conflicts of interests.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


Hemangiomas are common hepatic lesions and are mostly asymptomatic. Operative removal should only be performed when the lesions are symptomatic, and removal of the hemangioma is deemed to be more beneficial than the risk of the operation itself.The multiple hemangiomas of our patient were discovered nine years before first symptoms. The patient presented with pulmonary artery embolism due to a compression of the vena cava inferior by a hemangioma in segment I. No other cause of thromboembolic events could be diagnosed. We performed surgical enucleation of the hemangioma, which resulted in the normalization of blood flow in the inferior vena cava. As the inducing factor for clot development was removed, no permanent thrombosis prophylaxis was implicated.Pulmonary embolisms owing to compression of the inferior vena cave are rare.Until now to our knowledge, pulmonary embolisms have never been described as an indication for hepatic hemangioma enucleation. About 52A 50-year-old male presented after having suffered a pulmonary artery embolism four month earlier. A magnetic resonance tomography (MRI) showed multiple HH. Those were first discovered incidentally nine years prior and were now growing in size. The patient had not experienced local symptoms related to the HH like pain or nausea. The largest HH measured 83 × 57 mm A+B and w3Hemangiomas are benign hamartomatous tumors, with a prevalence of 1–20%, that rarely show symptoms . Growth Compression of the IVC is described in two case reports and resulted in lower limb edema as described by Akbulut et al.  and in pIn conclusion, in selected cases of IVC compression owing to benign liver tumors leading to pulmonary embolism tumor enucleation/resection seems to be an effective and safe therapy. Thus, beside severe local complications, symptomatic IVC compression represents a seldom but possible indication for surgical therapy in HH patients.Nothing to declare.Nothing to declare.No ethical approval was required for this case report.Patient gave consent for publishing.Sarah Winterland wrote the manuscript.Tim Reese wrote the manuscript.Gorgios Makridis critically reviewed the manuscript.Karl J. Oldhafer critically reviewed the manuscript.N/A.Tim Reese.Karl J. Oldhafer.Not commissioned, externally peer-reviewed.


The tumor was thoracoscopically confirmed to be a subpleural pulmonary tumor of the left lower lobe, and wedge resection was performed. Histological examination confirmed the diagnosis of pulmonary hematoma. On reviewing the callus formation of the ribs, which was suggestive of rib fractures, the pulmonary hematoma was determined to be traumatic in origin. The postoperative course was uneventful. We reviewed a rare case of pathologically proven traumatic solitary pulmonary hematoma. The rarity of this case is enhanced because the hematoma initially appeared to be a posterior mediastinal tumor.Solitary pulmonary hematoma is a rare consequence of blunt chest trauma. Moreover, there has been no reported case of solitary pulmonary hematoma radiographically diagnosed as a posterior mediastinal tumor. We present the case of a 63-year-old man who was referred for an oval-shaped opacity at the left paraspinal area on a chest X-ray. Chest computed tomography showed a well-circumscribed posterior mediastinal tumor on the left paraspinal lesion with extrapleural sign and callus formation on the left ribs posteriorly (7 Pulmonary hematoma refers to the presence of blood within the alveolar and interstitial spaces and is most often caused by blunt thoracic trauma. It has also been reported as a pulmonary pseudocyst and is most commonly found in children and young adults , 2. BlunWe report a case of traumatic solitary pulmonary hematoma (SPH) for two reasons; firstly, our pulmonary hematoma was radiographically indistinguishable from a posterior mediastinal tumor, and secondly, pathologically proven traumatic SPH has rarely been reported in the literature.The patient was a 63-year-old man with a history of a minor fall and subsequent traumatic subdural hematoma 3 months prior. He had no history of anticoagulant use and had no significant family history. He had quit smoking 23 years before. The patient was referred to us for the investigation of an abnormal shadow detected by chest X-ray during an annual health screening. Chest computed tomography (CT) revealed a paraspinal 20 mm diameter oval mass abutting the lower thoracic spine. The tumor showed extrapleural sign and was well-circumscribed without intraspinal extension. The capsule of the mass was slightly enhanced with intravenous contrast Figures . Close tNonpenetrating chest trauma often causes pulmonary contusion and intrapulmonary hemorrhage. Pulmonary hematoma, which is caused by laceration of the visceral pleura during lung injuries following blunt chest trauma, is a much less frequent sequela than pulmonary contusion and intrapulmonary hemorrhage . Cases oRadiographical diagnosis in the present case was challenging. Firstly, the sharply marginated spherical mass adjacent to the paravertebral space on the CT scan with the extrapleural sign  stronglyTreatment usually involves conservative therapy, as hematomas are self-resolving . AccordiSurgical resection is not commonly performed owing to the self-resolving nature of the cyst . TherefoSPH is an uncommon complication of blunt chest trauma. This is the first report of pathologically proven SPH which was radiographically indistinguishable from a posterior mediastinal tumor.


Epilopic appendagitis (EA) is an uncommon condition of abdominal pain caused by the local inflammation of the fat-filled peritoneal outpouchings due to torsion or thrombosis of its vessels leads to ischemia and gangrenous necrosis of the aappendages, as it can cause peritoneal irritation, acute ischemia, and fat necrosis.We present a case of epilopic appendagitis mimicking appendicitis of a 10 years old male, presented to the emergency department with severe right quadrant pain pointedly at the right lumbar area. Associated with constipation and nausea for once. Computed tomography (CT) scan with contrast was performed showing an ovoid fat structure with thin enhancing rim and surrounding inflammatory stranding as well as prominent lymph nodes at hepatic flexure, free fluid and no evidence of appendicitis. The patient was discharged with pain control medications.Epiploic Appendages are mobile, pedunculated peritoneal out pouches. Considering its mobility and narrow pedicle appendages are disposed to torsion leading to appendagitis causing local inflammation, peritoneal irritation, acute ischemia, and fat necrosis. The patient’s main complaint would be a subacute lower abdominal pain, left-sided in 60–80% of cases.Early recognition of this condition is crucial to avoid an operation when unnecessary leading to prolonged hospital stays. The management is conservative with analgesic. White blood cell count and CRP are generally normal, though maybe mildly raised, infrequently it could be associated with fever, nausea, and vomiting . It’s a In this report, we present a case with abdominal pain who was diagnosed with EA. And was successfully treated with conservative management.This report has been written in accordance with SCARE criteria guidelines for case reports .2In July 2019, A 10 years old Saudi male was brought to the emergency department by his parents complaining of abdominal pain.The pain started 5 days before the presentation, it was generalized at first, then it became only localized to the right quadrant area, pointedly at the right lumbar area. The pain was severe with intermittent with an on and off in character, with no relieving factors and it increases with motion, not radiated to anywhere else, and this was his first episode of similar pain. It was associated with constipation and the patient also reported being nauseated once, with no vomiting, fever, night sweats, or loss of appetite.2). All his vital signs were stable.Our patient has been diagnosed with asthma since he was 4 years old, controlled on Ventolin as needed, it has been a month since his last asthmatic attack. He has no previous admissions to any hospitals, and no previous surgical history as well. On clinical examination, the patient was in pain,  scan with contrast was offered to rule out clinical suspicion of acute appendicitis or other pathology , Fig. 3.3Epiploic Appendages are mobile, pedunculated peritoneal out pouches developing from the serosal surface of the colon, the two most common sites for this to develop is the cecum and sigmoid. Regarding size, it’s 0.5–5 cm long with a thickness of 1–2 cm comprising of adipose tissue and peritoneal vessels. Its blood supply is from two arterioles from the vasa recta and a single venule . ConsideEA can arise at any age, pediatric cases are very rare with no gender preponderance unlike in adults it is most likely in the 4th and 5th decades with men gender preponderance . It is mThe typical presentation is with acute or subacute lower abdominal pain, left-sided in 60–80% of cases. And on examination, there is localized tenderness with or without guarding and rebound tenderness. Due to the indistinct presentation of the complaints, patients are often misdiagnosed with other acute inflammatory diseases such as acute appendicitis, diverticulitis, or cholecystitis. Mostly patients are vitally stable with normal laboratory results but a mild leucocytosis and minor elevation of C-Reactive Protein in some cases as reported [2 whose symptoms included abdominal pain, nausea, constipation and mild tenderness of the lumbar area on examination was found to have EA.In the presenting case, a ten-year-old boy with a body mass index of 25 kg/mThe diagnosis was achieved in the past through surgery, but currently, imaging studies showed high diagnostic yield. Normally epiploic appendages is not shown in imaging studies unless inflamed. CT is the diagnostic method of choice because of the distinctive appearance of EA as it appears as pericolonic oval-shaped mass with fat and soft tissue hyperattenuating rim corresponding to the inflammation and thick visceral peritoneal lining with periappendageal fat stranding. A hyperdense central dot or linear high density ‘central dot sign’ is some cases seen demonstrating a thrombosed vessel or hemorrhagic necrosis . SimilarEA on ultrasonography manifests as a non-compressible hyperechogenic mass near the colon wall, with hypoechoic rim indicating the inflammation around the peritoneum with an absence of blood flow on Doppler US scan ,16. MRI EA is a self-limiting, benign disease that mainly managed conservatively with Nonsteroidal anti-inflammatory drug (NSAID) treatment. Nevertheless, EA can be followed by a variety of complications such as adhesions, obstruction, Intussusception and local abscess formation, as it also has the possibility to recur in some cases. Thus, failure of medical management is an indication for surgical intervention besides complicated EA like in obstruction and abscess formation ,9,16,19.In the current case, the patient was diagnosed by a CT with contrast and was managed effectively with conservative management and discharged from the hospital without complications.4These symptoms are not specific and could mimic appendicitis as in the presentation of this patient. CT with contrast was done to verify the diagnosis however the benign condition of appendagitis was confirmed via the finding of pericolonic ovoid mass with rim attenuation and pericolonic fat stranding. When venous thrombosis is the case a central hyperdense dot sign is also considered specific. Early recognition of this condition is crucial to avoid an unnecessary antibiotic, operation and prolonged hospital stays. The management is conservative with NSAIDs. Follow up CT is unnecessary, but if done could show a decline in the pouch size, calcifications could also be seen in old infarcts.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.There are no sources of funding.Approval has been given by King Fahad Armed Forces Hospital Research and Ethics Committee, Jeddah, Saudi Arabia has approved this study. .Written informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. This report does not contain any personal information that could lead to the identification of the patient.Ohoud Baajlan: First and corresponding author, writing – Original Draft, Review & Editing and data collection.Hotoun Bokhari: Contributed Study concept, data collection, interpretation, writing – Original Draft.Kahlid AlGhamdi: Contributed to the study concept, and Writing – Original Draft and methodology.Mazin Zidane: Supervised the writing of the manuscript and approved the final manuscript.1.Name of the registry: King Fahd Armed Forces Hospital – Jeddah.2.Research and Ethics Committee.3.Unique identifying number or registration ID: REC 3264.Hyperlink to your specific registration (must be publicly accessible and will be checked):Dr. Mazen Zidan, MDPediatric Surgery,King Fahd Armed Forces Hospital,Saudi Arabia, Jeddah.Not commissioned, externally peer-reviewed.


Aplasia cutis congenita (ACC) is a rare heterogeneous congenital disorder characterized by focal or widespread absence of the skin.Its estimated incidence is 1–3 in 10,000 live births and about 70% to 90% of cases present as isolated scalp lesions [A woman in her early twenties with a history of alopecia since birth presented with 2–3 months of waxing and waning, dull, throbbing, and point tenderness in one of the patches of alopecia. The alopecic patch had been present on the right parietal-occipital scalp since birth and has been stable in size and appearance for years. Three other round patches of alopecia had also been present since birth and remained asymptomatic. On clinical examination of the scalp, an atrophic white patch of alopecia was noted . Ill-defOn dermoscopic examination, the alopecic patch showed a translucent epidermis with multiple branched blood vessels and hair bulbs at the edge of the patch .Based on the clinical and dermoscopic findings, the diagnosis of ACC was favored. A non-contrast head CT showed no evidence of osseous, vascular, neural, or soft tissue defects. The patient was counseled to avoid trauma to the lesion and was instructed to follow up with her primary care physician for management of scalp tenderness and pain, likely representing headache or migraine, rather than a symptom of the lesion.Recent published reports demonstrate the emerging use of dermoscopy and trichoscopy as a valuable tool for diagnosing ACC –5. DermoDermoscopy is useful in distinguishing ACC from other similar appearing disorders in its differential such as alopecia, tinea capitis, and trichotillomania. ACC can be differentiated from other types of congenital or acquired alopecia, such as triangular temporal alopecia, which shows presence of vellus hairs only in affected sites; alopecia areata, which shows black dots, yellow dots, and exclamation hairs; tinea capitis, which shows coiled or comma shaped hairs; and trichotillomania, which shows broken hairs and flame hairs . MembranCurrently, there is no consensus on the management of ACC. Conservative therapy is generally suggested for small lesions, whereas the risks and benefits of surgical intervention are often weighed for treatment of larger lesions in consultation with pediatric plastic surgeons.In conclusion, dermoscopy/trichoscopy is a valuable diagnostic tool for ACC and can help distinguish ACC from other types of congenital or acquired alopecias. Dermatologists should familiarize themselves with the dermoscopic findings of ACC—a translucent epidermis, a visible vascular network, lack of appendages, and hair bulbs arranged radially along or sometimes within the margins of alopecia.


Anisakiasis is a parasitic infection caused by Anisakis worms found in raw fish. Most cases of anisakiasis occur in the stomach and rarely occur in the intestine. It is extremely rare for live larvae to break through the intestine into the mesentery and cause severe intestinal ischemia. Anisakiasis can be treated conservatively, because the larvae will die in approximately 1 week, but, sometimes, a serious condition can arise, as in this case. We report the first case of extraluminal anisakiasis in which a live Anisakis worm caused severe intestinal ischemia.The patient was a 26-year-old woman who ate squid a week prior. She had abdominal pain and was admitted to our emergency department. On physical examination, abdominal guarding and rebound tenderness were present in her lower abdomen. Contrast-enhanced computed tomography showed ascites, the whirl sign, localized submucosal edema of the intestinal wall, and a dilated small bowel segment with edema. We suspected the strangulated small bowel obstruction based on the CT-scan findings. To rule out the strangulated small bowel obstruction, laparoscopic exploration was performed. Bloody ascites in the pouch of Douglas and severe inflammation in 20 cm of the ileum were observed. An Anisakis larva had perforated the intestinal wall and was found alive in the mesentery. The ileum had developed a high degree of ischemia, so the affected section was resected. Histopathological examination revealed that the Anisakis worm body was in the inflamed mesentery and caused a high degree of ischemia in the intestinal tract. The patient was discharged 9 days after surgery.A living Anisakis larva punctured the mesentery of the small intestine, resulting in severe intestinal ischemia. As seen in this case, intestinal anisakiasis may cause serious symptoms, and a low threshold for performing diagnostic laparoscopy for the early diagnosis of bowel ischemia secondary to anisakiasis can be useful in determining the definite diagnosis and indications for resection. Gastrointestinal anisakiasis has become common worldwide with the spread of raw fish consumption –3. ApproThe patient was a 26-year-old woman with a medical history of only asthma in childhood. She ate a sushi roll with squid a week ago and then had abdominal pain and was admitted to our emergency department. On physical examination, no allergic reaction, such as hives or bronchospasm, was observed, and her lower abdomen was flat and hard with tenderness and guarding. Laboratory examinations showed an elevated white blood cell count of 17,160/μl . Laboratory examinations showed increases in IgE-RIST levels . There were no other abnormal findings. Contrast-enhanced computed tomography (CT) showed ascites, the whirl sign, localized submucosal edema of the intestinal wall, and a dilated small bowel segment with edema (Fig. We suspected the strangulated small bowel obstruction based on the CT-scan findings.The presence of acute abdominal guarding and the CT-scan findings indicated that strangulated small bowel obstruction could not be ruled out completely, and a laparoscopic examination was performed. A 12 mm port was placed in the navel, and two 5 mm ports were placed in the left and right flanks. Bloody ascites in the pouch of Douglas and severe inflammation and bloody ascites were observed in 20 cm of the ileum. Neither the oral side nor the anus side of the inflamed intestinal tract was narrowed, and the intestinal tract suddenly changed from a normal appearance to an inflammatory appearance. No cords that caused strangulation were observed. The Anisakis worm body was found to have punctured through to the outside of the intestine, and the worm was found alive and moving in the mesentery. The umbilical wound was extended to 2 cm, and the ileum was placed outside the body cavity. Strong inflammation of the intestinal tract was observed. A segmental resection of 20 cm of the inflamed bowel, located 40 cm from the ileum end, was performed. The small intestine was reconstructed with a functional end-to-end anastomosis (Fig. The resected specimen was associated with a high degree of ischemia along the entire thickness, and the living Anisakis worm body was confirmed in the mesentery. Histological examination revealed the presence of parasites in the mesentery, phagocytosis of neutrophils in the surrounding area, and granuloma formation. The mucous membrane of the intestinal tract was extensively degraded, and the muscular layer showed severe bleeding. Eosinophilic infiltration was not remarkable, and the phagocytosis of neutrophils was often observed Fig. .Fig. 3ExThe patient was discharged 9 days after surgery.In Japan, there is a culture of eating raw fish, which can lead to gastrointestinal anisakiasis. Yasunaga et al. reported that the annual incidence of bowel anisakiasis in Japan is estimated to be approximately 3.0 per 1 million people per year, and the associated ileus, bleeding, and intussusception rates are 50.7%, 8.0%, and 2%, respectively. Among all patients with anisakiasis, 7% undergo surgical treatment –11. It hStudies have reported that the time from the consumption of raw fish to the development of abdominal pain is 12–24 h for gastric anisakiasis and 5–7 days for intestinal anisakiasis , 17–19. In the patients with anisakiasis, the parasites can be retained in the intestinal lumen and remain alive for up to 1 week at most, so conservative treatment is possible . HoweverIn this case, the patient suffered from severe intestinal ischemia, and timely observation of the abdomen with surgery was important, as well as clinical findings such as abdominal guarding. Moreover, laparoscopic exploration is minimally invasive and imposes a small burden on the patient. This approach is also very useful as it requires minimal additional incisions when intestinal resection is required . HoweverThis is a very rare case in which a living Anisakis perforated the mesentery, causing severe intestinal ischemia with bloody ascites. Based on the pathological findings, the intestinal tract may have become highly ischemic due to the direct inflammation caused by the Anisakis perforating the intestinal wall into the mesentery, the collapse of the mesenteric blood vessels, vasoconstriction due to allergic reaction, and ischemia from the granuloma formation process. The pathological results indicated that intestinal necrosis was starting and that resection was appropriate. In this case, the clinical findings of strong abdominal symptoms and severe local circulatory injury and laparoscopic findings of bloody ascites were the indications for resection to treat this patient with intestinal anisakiasis.We experienced a case of small bowel anisakiasis in which a living worm perforated the intestine, inflamed the mesentery, and caused ischemic damage. Intestinal anisakiasis can be considered a serious condition, and close observation by surgeons may be necessary. Laparoscopic exploration is useful in diagnosing intestinal anisakiasis and guiding the decision for bowel resection.


Primary pure angiosarcoma of the testis is an exceptionally rare testicular malignancy, which is poorly understood. We present the fifth and youngest case in the current medical literature. Additionally, all cases of angiosarcoma of the testicle, both occurring with associated germ cell tumour and without, were compared in an extended tabular format.A 56-year old man presented with unilateral scrotal pain, swelling and erythema. Ultrasonography revealed two testicular lesions with a high suspicion of malignancy but serum tumour markers were negative. A radical orchidectomy was performed with clear surgical margins. Diagnosis of primary pure angiosarcoma of the testis was confirmed on subsequent histopathology.Primary pure angiosarcoma is a rare testicular neoplasm. We present the fifth case in the literature. Clinical and radiological features are non-specific. The diagnosis is purely histological, with the pathologist choosing immunohistochemistry based on abnormal morphology. Local invasiveness is variable but metastatic sites are typical for extra-gonadal angiosarcomas. Primary pure testicular angiosarcoma diagnosis confers a relatively better prognosis compared to angiosarcoma arising in the context of a testicular germ cell tumour. While extra-gonadal angiosarcomas are associated with high rates of local recurrence following resection, in all cases of testicular angiosarcoma there were no local recurrences following radical orchidectomy. Surgical resection remains the most effective treatment for both subtypes of testicular angiosarcoma. Angiosarcomas are an uncommon group of malignancies that arise from vascular endothelial cells and generally carry a poor prognosis. Reported five-year survival rate is 35% in non-metastatic disease . IncidenGerm cell tumours (GCT) are the most common testicular neoplasm, which most frequently comprises teratoma or seminoma , 9. GCTsFor the purposes of this paper, the following subtypes of angiosarcoma are henceforth referred to as: extra-testicular soft tissue angiosarcomas , and two gonadal subtypes: primary pure angiosarcoma of the testis (PPAS), and angiosarcoma as a component of a testicular germ cell tumour (AS-GCT). In the latter, the angiosarcoma component might arise either within the testicular primary or within a germ cell tumour metastasis.PPAS and AS-GCT are extremely rare, thus little is known about these conditions and further work is required. Here, we describe the fifth and youngest case of PPAS. Following, we summarise all previous cases of PPAS –19 and AWe report our case of a 56-year-old man of Bulgarian origin working in the UK, who initially presented to primary care with a four-day history of right scrotal swelling, redness and pain, with a palpable abnormal testicular mass on examination. The patient had no past medical or family history of note. He was a 30-pack year smoker, with no occupational exposure, nor any history of previous chemo- or radio-therapy. He was treated with oral antibiotics for presumptive clinical diagnosis of epididymo-orchitis and an urgent ultrasound scan was arranged in secondary care. All blood tests were normal, including a full blood count and differential, urea and electrolytes, β-HCG, lactate dehydrogenase (LDH), and alpha-fetoprotein (AFP).Ultrasonography demonstrated two discrete, heterogenous, hypoechoic lesions within the parenchyma of the right testis, with some cystic changes. The larger lesion measured 2 cm in diameter. There was no evidence of extension beyond the testicular tunica albuginea. Angiosarcomas typically appear highly vascular on ultrasonography, however in this case was there was no evidence of internal vascularity Fig. a. BilateIn the context of partially treated epididymo-orchitis, our differential diagnoses at that time included intra-testicular abscess and primary testicular neoplasm, potentially a teratoma. The case was discussed at local multi-disciplinary team (MDT) meeting and a right radical orchidectomy as a definitive therapeutic procedure was performed.Pathological examination revealed the right testis to measure 50 × 40 × 40 mm , and the spermatic cord measured 45 × 20 × 25 mm. This gives an estimated testicular volume of 41.6 ml, where a normal range is 12–30 ml . On grosMicroscopically, both lesions displayed similar appearances Fig. b–e. EachImmunohistochemical analysis was performed. The lesions were diffusely and strongly positive for vascular markers, CD31 and CD34. The markers looking for potential background germ cell tumour  were negative. The following antibodies were also negative: EMA, S100, CAM5.2, MNF116, BerEp4 and calretinin.In light of these findings, the final histopathological diagnosis was given as high-grade angiosarcoma ie PPAS. The patient had a re-staging CT scan three months post operatively due to lower back pain, which demonstrated no evidence of recurrence or metastatic disease. Subsequent follow up continued with active surveillance at a tertiary centre. The patient remained well at review six months after initial presentation.We have reported the fifth case of primary pure angiosarcoma (PPAS) of the testis. The four existing cases of PPAS, plus the index case, are summarised in Tables n = 5), whereas AS-GCT affects younger men . The aetiology of all four previous cases of PPAS, plus the index case presented, remains unknown. Previous radiation therapy and chemotherapy are known causative factors in the pathogenesis of extra-gonadal angiosarcomas [PPAS tends to occur in elderly patients  are  of PPAS , 22, 23. of PPAS . Diagnos of PPAS . AS-GCT, of PPAS . Epithel of PPAS , 22, 23. of PPAS , 22, 23.Initial misdiagnosis as embryonal carcinoma with teratoma occurred upon macroscopic and microscopic evaluation of two surgical AS-GCT specimens , 23. Sin. [. [. [. [, there was invasion into the epididymis. We found no apparent explanation for the discrepancy in extent of local invasion between cases of PPAS.Local invasiveness was variable between cases of PPAS Table . In the .  one tumo. [.  and Mase. [. [.  there wa[. [. [. , there wThe contralateral testis was not affected by metastatic disease in any of the cases of PPAS or AS-GCT. Metastatic sites of the PPAS and AS-GCT cases were similar to those of extra-gonadal angiosarcoma Tables  and 4 [4Although extra-gonadal soft tissue angiosarcomas are associated with high rates of local recurrence , none ofAll cases of PPAS were treated using radical orchidectomy only Table . In contOverall, two 40%) of the five PPAS cases suffered metastatic disease and died shortly thereafter, whereas three (60%) were alive without metastasis at follow-up, including the index case Table . In cont0% of theWhile follow-up was limited for most cases, survival for gonadal PPAS appeared superior to primary angiosarcoma that arises in extra-gonadal sites , 4, 15. In conclusion, PPAS is a rare testicular neoplasm. We present the fifth case in the literature. Clinical and radiological features are non-specific. The diagnosis is purely histological, with the pathologist choosing immunohistochemistry based on abnormal tumour morphology. Local invasiveness is variable but metastatic sites are typical for extra-gonadal angiosarcomas. PPAS confers a relatively better prognosis as compared to AS-GCT. While extra-gonadal angiosarcomas are associated with high rates of local recurrence following resection, in all cases of PPAS and AS-GCT there were no local recurrences following radical orchidectomy. Chemotherapy is associated with poor outcomes, thus surgical resection remains the most effective treatment for both subtypes of testicular angiosarcoma.


During the recent outbreak of COVID-19, various atypical extrapulmonary manifestations are being seen, including neurological ones. Reported cases mainly include encephalopathy, myelitis, and cranial nerve involvement. This case describes uncommon neuroradiological finding in the context of COVID-19.We report an atypical case of COVID-19 presenting with stroke-like episode, with MRI brain showing isolated bilateral posterior internal capsule involvement. This has rarely been reported in literature.As the numbers of COVID-19 cases are increasing, such atypical presentations should be kept in mind. COVID-19 pandemic continues to spread across the world with critical challenges for the public health and medical communities globally. Its manifestations are predominantly respiratory, with multiorgan dysfunction in severe cases. Neurological involvement is not common, but data is growing –4. This A 58-year-old male, known hypertensive and diabetic, presented with sudden onset of slurring of speech for 1 day. He also had history of fever since 2 days, prior to these complaints. On examination, he had dysarthria, anarthria, and had difficulty in meaningful writing. However, he was conscious, alert, with no sensory or other motor weakness. Cranial nerve functions were intact. There were no meningeal signs or bladder and bowel dysfunction. Clinically, stroke was suspected, for which he was referred to the radiodiagnosis department for MRI brain. MRI showed bilateral symmetrical diffusion restriction on DWI Fig.  and wereNeurological involvement in COVID-19 was initially suggested by multiple case reports showing encephalitis/acute necrotizing encephalopathy in MRI of affected patients –4.A recent multicenter study discussed neuroimaging findings in 37 patients of COVID-19 with neurological symptoms and abnormal MRI brain  . The mosVarious mechanisms have been described by which the central nervous system is affected. The human coronavirus (HCoV) has neuroinvasive capacities and may be neurovirulent by two main mechanisms: viral replication into glial or neuronal cells of the brain or autoimmune reaction with a misdirected host immune response , 9.Kihira et al. in their case series of 5 patients also suggests strong association between hypoxia and leukoencephalopathy .Symmetric confluent leukoencephalopathy favors a component of post-hypoxic leukoencephalopathy, and more focal white matter lesions  may suggest post viral autoimmune demyelination .Demyelinating lesions following COVID-19 have rarely been reported. Zoghi et al. reported a case showing demyelination of bilateral posterior internal capsules extending to ventral pons and also with splenial involvement along with longitudinally extensive transverse myelitis of cervical and thoracic cord .We report isolated symmetrical demyelination of bilateral posterior internal capsules, which showed restricted diffusion on DWI sequence, appearing hyperintense on T2/FLAIR sequences and hypointense on T1 sequence. There was sparing of the brain stem and spinal cord. The absence of grey matter involvement, and no hemorrhage or cavitation, suggests demyelination, rather than necrotizing encephalomyelitis. Although our patient had stroke-like presentation, no specific vascular territory was involved. Bilateral internal capsule involvement associated with COVID-19 infection and acute presentation suggested it to be COVID-19-associated demyelination. To the best of our knowledge, this is the first such reported case.Imaging differentials to be considered are metabolic leukoencephalopathy, amyotrophic lateral sclerosis, and neuromyelitis optica syndromes. These can be ruled out on the basis of history and imaging findings.COVID-19 associated with demyelination, though mostly presents like acute disseminated encephalomyelitis, in rare cases can present like acute isolated symmetrical internal capsule demyelination. As the number of patients with COVID-19 increases worldwide, clinicians and radiologists should be aware of these findings and have high index of suspicion for COVID-19 in patients presenting with stroke-like episodes.


Frantz's tumor of the pancreas is a rare phenomenon, and it accounts for 1–3% of all neoplasms of the pancreas. Its percentage is much higher in younger persons, especially in younger women, as compared to the rest of the population.The present study describes a 32-year-old female patient in whom a preoperative imaging diagnosis confirmed a mass in the junction of the pancreas' body and tail. Based on the anamnesis, the preoperative diagnosis, and the patient's general status, the decision was made to performed laparoscopic enucleation of the pancreatic tumor. The operation and postoperative recovery passed without complications. Definitive histopathological and immunohistochemical findings confirmed a solid pseudopapillary neoplasm of the pancreas.Depending on the localization and the size of the tumor, surgical options range from typical and atypical resections of the pancreas to minimally invasive surgical procedures, such as local excision and enucleation. Laparoscopic procedures have a comparative advantage in cases of enucleation and resection of the pancreas. The low frequency of recidivation and a favorable prognosis, even after repeated surgery, are additional reasons for favoring the laparoscopic approach over the classical surgical approach.A minimally invasive surgical approach should be applied whenever the dimensions and the localization of the tumor permit it, bearing in mind all the benefits and advantages that this surgical technique offers. •Solid pseudopapillary neoplasm of the pancreas, is known as Frantz's tumor.•Around 1,000 cases of Frantz's tumor have been described.•32-year-old patient underwent laparoscopic enucleation of an 18 mm pancreatic tumor.•Laparoscopic enucleation is a feasible option for the treatment of these masses. It mainly occurs in younger individuals, predominantly women . Frantz'Ultrasonography (USG) of the abdomen is the initial diagnostic method; nevertheless, computerized tomography (CT) and magnetic resonance imaging (MRI) of the abdomen are much more precise and superior methods. Frequently, CT and MRI can indicate the presence of a mass in the pancreas, which has the characteristics of cystic degeneration, bleeding within the cyst, and the presence of a capsule . DiffereThe only curative treatment modality is surgical treatment. Within this modality, the available options range from resection procedures on the pancreas, depending on the tumor's localization, to a minimally invasive surgical procedure on the pancreas in the form of the enucleation of these neoplasms .The present study aims to present a rare disease of the pancreas, which was treated safely and efficiently by applying laparoscopic enucleation with all the benefits this approach offers when used appropriately. A review of the literature is also performed. The work has been reported in line with the SCARE guidelines .29. No other alterations were encountered. An abdominal ultrasound was done, without any abnormal findings, so an MRI was ordered, detecting a focal area with a distortion in the parenchyma, diagnosing an 18 mm pancreatic mass in the junction of the corpus and tail of the pancreas. There were no signs of infiltration of the surrounding vascular structures and no connection to the duct of Wirsung  . A drainPostoperative recovery went uneventful. The abdominal drain was removed on the third postoperative day. On the fourth postoperative day, the patient was discharged from the hospital with normal laboratory findings. A month after surgery, ultrasound imaging of the patient's abdomen was performed, and without abnormalities. At this time, laboratory analyses were also performed, and the results were within the normal reference ranges. Six months after the operation, a follow-up MRI of the abdomen was conducted without any abnormal findings. The patient is currently on her 12 month follow-up without complications nor recurrence.Definitive histopathological and immunohistochemical findings confirmed a solid pseudopapillary neoplasm of the pancreas. The tumor did not show cytological or histological elements of malignancy .Fig. 3Hi3The solid pseudopapillary neoplasm of the pancreas was first mentioned in the literature in 1933 . HoweverThese tumors most commonly remain asymptomatic or cause non-specific complaints, regardless of their size. In addition to the compressive effect on the surrounding structures and the occurrence of a palpable mass in the abdomen once they reach a specific size, occasional acute or chronic pain, loss of appetite, vomiting, and a loss in body mass, may also occur .In the patient described in the present study, symptoms were present around two months, in non-specific pain below the left costal arch. The pain was of lower intensity, more discomfort in that part of the abdomen, and occasional intensification in the pain scale.Appropriate diagnosis plays an essential role in deciding on further treatment. The initial diagnostic methods applied are US and CT of the abdomen. A heterogeneous lesion can be seen in the latter, which often demonstrate a peripheral enhancement of contrast, characteristic of the fibrous pseudocapsule. MRI of the abdomen is a more sensitive method than CT . Some auFrantz's tumor has a low malignant potential. There are rarely metastases, and they are most commonly localized in the liver. Even when there are metastases, the overall 5-year survival is around 97% .Surgery is the only and primary curative form of treatment. Depending on the localization and the size of the tumor, surgical options range from typical and atypical resections of the pancreas to minimally invasive surgical procedures, such as local excision and enucleation . LaparosDue to the favorable localization of the tumor, its size, and bearing in mind all the advantages of a minimally invasive surgical approach, we chose a laparoscopic enucleation of the tumor, which went uneventfully.4With its mainly non-specific symptomatology, Frantz's tumor represents a diagnostic challenge and is usually detected as a coincidental finding during other examination procedures. As it mostly occurs in the younger population, especially in younger women between 18 and 35 years old, one must consider the best therapeutic approach to treat this tumor. Laparoscopic enucleation is a feasible option for the treatment of these masses.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.All procedures performed in this study were reviewed by Ethics Committee and complied with the principles laid down in the Declaration of Helsinki.This research group did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Dr. Mauricio Gonzalez-Urquijo.Conceptualization, D.E.; V.M; M.G.U; Writing-review and editing, B.T, M.V; N.G; D.J Literature review, M.B.; V.M; M.G.U; B.T Writing draft, M.V.; M.G.U, D.E.; Supervision, M.G.U.Not commissioned, externally peer-reviewed.Ethics Committee of the Clinical Center of Tecnologico de Monterrey.Laparoscopic Enucleation of Frantz's Tumor of the Pancreas: Case Report and Literature Review to be conducted.DECISION: We approve the academic clinical work No. 01134TM.Date: 26/01/2021.Name of the registry: Laparoscopic Enucleation of Frantz's Tumor of the Pancreas.Unique Identifying number or registration ID: NCT04728750.https://clinicaltrials.gov/show/NCT04728750.Hyperlink to your specific registration (must be publicly accessible and will be checked): None.


Stump appendicitis is a rare etiology of acute lower right quadrant abdominal pain often forgotten in the emergency room (ER). The Mac Burney scar or a previous laparoscopic appendectomy always rule out the eventuality of appendicitis and mislead management. Advanced imaging tools are more than compulsory to help correct the diagnosis. Computed tomography (CT) scan is the option of choice that may be replaced if unavailable by simple ultrasound examination. The treatment is mainly surgical. We report the case of a stump appendicitis occurring 12 years after laparoscopic appendectomy in an 18-year-old girl. The diagnosis was based on consistent clinical signs and conclusive radiological data. A successful completion appendectomy was performed with good outcome. Appendectomy is the most common surgical procedure in emergency abdominal surgery. Stump appendicitis is a rare complication after appendectomy. Its clinical presentation is comparable to that of acute appendicitis. Although unusual, it should be included in the differential diagnosis of right lower quadrant pain in patients who have already had an appendectomy. Recognition of this entity is crucial because a delayed diagnosis can cause serious complications. We report a case of stump appendicitis in an 18-year-old girl who underwent laparoscopic appendectomy at the age of six years.9/L and a C-reactive protein rate of 80mg/L. An abdominal ultrasound showed a hypoechoic thickened tubular structure of more than 8mm diameter in the right iliac fossa. An abdominal CT scan showed pericoecal inflammatory change with an enhancing wall tubular structure extending from the internal side of the caecum suspect of appendiceal remnant, associated with a mild amount of free fluid , arising from the cecum, with peri appendiceal inflammatory reaction. A hyperechoic small formation may also indicate the presence of a foecolith ,5. Compuet al. conducted on 3130 patients who underwent appendectomy between 2008 and 2017, three patients were successfully managed via open Mac Burney laparotomy. Laparoscopy was performed for two patients primarily for diagnostic purpose and conversion was necessary for one of them [The treatment of choice for appendicitis on stumps is completion appendectomy either by the conventional laparotomy or by laparoscopy. An ileo-coecal resection may be necessary in case of extensive inflammation, peritonitis and/or perforation ,7. There of them . In orde of them .The non-specific clinical presentation and especially the history of an appendectomy can make the diagnosis of stump appendicitis a challenge for the unfamiliarized practitioner and lead to a therapeutic delay with serious consequences. Although rare, this diagnosis must therefore be kept in mind in every case of any pain in the right iliac fossa. Radiology plays a key role in eliminating other differential diagnoses and dispelling any diagnostic doubts. The treatment is above all surgical.


Degos and Civatte first described clear cell acanthoma (CCA) in 1962 and later in a review article found that, in most instances, the lesion was a solitary red-brown dome-shaped papule that involved the distal lower extremity. The first morphologic variant of CCA was reported as a “giant form of the acanthoma of Degos” which measured 45 × 40 mm, about twice the size of the largest CCA documented earlier. Since then, many variants of CCA have been described, including polypoid, pigmented and atypical. Herein, we describe a new variant of CCA and add another example of the polypoid variant to the literature. The new variant exhibits cellular features of trichilemmoma but architecturally differs from it. We also attempt to broaden the list of CCA variants summarized by Tempark and Shwayder by adding ours and a few more examples of CCA. The new variants of CCA include verrucous, linear, subungual and trichilemmal. Degos and Civatte first described clear cell acanthoma (CCA) in 1962 ,4,5.During their review , Degos aThe exact etiology of clear cell acanthoma is unknown as it is unclear whether clear cell acanthoma is a neoplastic process or an inflammatory dermatosis . AlthougA 74-year-old female presented with a 3 mm pink papule on the right side of the neck with a clinical impression of basal cell carcinoma. The patient was being treated for anxiety and depression and hypercholesterolemia. There was no history of Cowden syndrome. A 4 × 3 mm shave specimen was processed and revealed circumscribed acanthosis of the epidermis. Keratinocytes showed typical pale cytoplasm and large perinuclear vacuoles reminiscent of trichilemmal keratinocytes . Large pA 69-year-old female presented with a polypoid lesion on the right of the neck with a clinical impression of irritated intradermal nevus. There was no other relevant history except that she was on Lipitor. A 9 × 6 mm shave specimen was processed and revealed a lesion with polypoid architecture, showing prominent acanthosis with keratinocytes containing pale cytoplasm . No cleaThe typical presentation of clear cell acanthoma is a red to brown dome-shaped papule on the leg of an elderly individual.  It is usSeveral variations in the clinical and histological appearance of CCA have been reported. Most recently, Tempark and Shwayder  have attWe recently came across two variants of CCA in our practice. One with novel trichilemmal differentiation and the other with polypoid architecture. These encounters prompted a review of the literature for variants of CCA. We found that the polypoid variant has already been described, but there was no mention of a trichilemmal variant. We add our case and a few more variants of CCA from the literature to expand the list of Tempark and Shwayder. The giant variety was the first deviation from the conventional form of CCA, reported in 1966 by Duperrat et al. , which mWeitzner  describeThere is only one report of the verrucous form of CCA in the Spanish literature . This leSeveral cases of polypoid, polypous or pedunculated CCA have been reported in various locations, including the head and neck, nipple, scrotum and lower extremity ,29,30,31Clear cell acanthoma is a benign neoplasm or a reactive condition depending on the etiologic postulation. However, both benign neoplastic and reactive conditions have the biologic potential to progress to dysplasia or cancer. Grunwald et al.  first reShirai et al.  reportedThe above-described cases appear to be incidental and do not warrant labeling CCA a premalignant condition.The pigmented variant was first reported in the Spanish literature by Sanchez and Iglesias in 1975 , while LIt appears that, for CCA to be pigmented, melanocytic hyperplasia, with associated melanin-laden dendrites, is needed. Melanin transfer to keratinocytes is impeded possibly due to the latter being distended with glycogen, causing pressure blockage and resulting in the accumulation of melanin in melanocytic dendrites; however, the mechanism of melanin transfer from melanocytes to keratinocytes is more complex and the exact cause of impeded transfer in CCA is not known.In contrast to healthy skin or pigmented seborrheic keratoses, pigmentation of the surface in pigmented CCA is not imparted by keratinocyte melanization but follows the pattern of melanocytic lesions.As discussed, CCA can be solitary or multiple, however, in some instances, the number of lesions ranges from a few lesions to a few hundred lesions. In such cases, the term “eruptive” has been applied by the authors. Several cases of the eruptive variant have been reported ,48,49,50Delacretaz et al. , in the This rare variant was noted in a 4-year-old black male on the left flank as a hypopigmented linear plaque composed of small coalescing papules . The plaCheng et al.  reportedThe lesion described in our first case report demonstrates features of CCA including psoriasiform acanthosis, pale keratinocytes, PAS positivity, a diastase-labile staining pattern and sharp demarcation from the adjacent uninvolved epidermis. However, it differs from CCA in having no neutrophil exocytosis. Furthermore, in addition to pale cytoplasm, large clear perinuclear vacuoles were noted, reminiscent of outer sheath keratinocytes and keratinocytes of trichilemmoma. Peripheral palisading of basal keratinocytes was also identified.One may argue that this case is merely a trichilemmoma which was also incidentally first described in 1962. Keratinocytes in trichilemmoma similarly contain cytoplasmic glycogen, and hence the demarcation between lesional and normal epidermis is also noted. The clinical and histological findings in our case, however, are not those of an exo-endophytic folliculocentric lesion located on the face. This lesion is a horizontally oriented papule on the neck, unlike trichilemmoma, which is vertically oriented. Thick eosinophilic basement membrane typical of trichilemmoma is also not seen in our case. Sharp demarcation accentuated by PAS staining in our case is tinctorial, similar to that seen in CCA. The demarcation in trichilemmoma is both tinctorial and architectural in the form of epithelial collarettes. We considered calling this lesion a “trichilemmal acanthoma”, however, due to the findings mentioned above, we prefer to document this case as a trichilemmal variant of CCA.In the discussion of CCA versus trichilemmoma, an argument regarding the nomenclature of CCA is brought to light which is also reflected in the literature, which is whether to call these lesions “pale cell” or “clear cell” acanthoma. Keratinocyte cytoplasm in trichilemmoma is typically clear, while it is pale in keratinocytes of CCA. Perhaps the more appropriate term for CCA is pale cell acanthoma; however, this is not the objective of this paper. Another interesting fact is that CCA and GA, like trichilemmomas, are also reported to be associated with Cowden syndrome. Since all three of these lesions show cytoplasmic glycogen accumulation, there may be a disturbance of glycogen metabolisms in keratinocytes in patients with Cowden syndrome.Based on immunohistochemical findings, Hashimoto et al.  have sugDermoscopic examination in our case was not performed. Dermoscopy in CCA reveals a “string of pearls” appearance, dotted vessels arranged linearly in circular pattern  Figure . This apIn this paper, we have described a novel variant of CCA and added one more example of the rare polypoid variant. The novel trichilemmal variant may pose a diagnostic quandary to histopathologists since it shows a silhouette compatible with CCA but exhibits cytologic features suggestive of trichilemmoma. Negative CD34 staining will readily distinguish the two conditions.We also expand the list of variants of CCA so that the clinicians are aware of its broader spectrum of clinical presentations. As more variants of these cases are reported, the list of variants could be expanded. Furthermore, the research could be targeted towards the underlying etiology of CCA, as well as early diagnosis in relation to the various clinical presentations. CCA may be suspected in patients presenting with verrucous, cystic, pigmented and subungual lesions and in lesions that follow Blaschko’s lines. Histopathologists must also be aware of the expanding subtypes of CCA. It would be helpful to keep CCA in the differential during the microscopic examination of verrucous, pigmented, polypoid or cystic squamoproliferative lesions.Furthermore, since trichilemmoma, CCA and GA are all reported to be associated with Cowden syndrome and show cytoplasmic glycogen accumulation in keratinocytes, a possibility of disordered glycogen metabolism in keratinocytes in patients with Cowden syndrome is conceivable. Further research to substantiate this claim is, however, warranted.


Thymoma is a very rare pediatric tumor, accounting for less than 1% of all childhood mediastinal tumors with scant literature, and only 23 pediatric cases were identified by a pediatric tumor surveillance registry between 1973 and 2008. In contrast to adult thymomas, pediatric thymomas have an aggressive tendency, though the majority is discovered as incidental findings. Patient presentations to the emergency department (ED) are often subtle and non-specific such as dyspnea, cough, and chest pain, requiring a broad differential on the part of the emergency clinician. Because of this presentation, diagnosis often occurs later in the disease process when compared with adults. Chest radiograph may demonstrate an enlarged thymic shadow or cardiomegaly, necessitating further cardiac workup, commonly routed through cardiology. Computed tomography and biopsy are required for definitive diagnosis, requiring a multidisciplinary approach to management. We present a case of a 16-year-old female complaining of progressive dyspnea and chest pain over the course of one to two months with radiographic cardiomegaly. She was found to have a Masaoka stage III World Health Organization (WHO) type B3 thymic endothelial neoplasm and underwent surgical resection. As an exceptionally rare pediatric diagnosis, thymoma of the anterior mediastinum presents a challenging diagnosis in children, with only 23 pediatric cases identified by a pediatric tumor surveillance registry between 1973 and 2008 . Though A previously healthy 16-year-old female presented to the emergency department (ED) for one day of chest discomfort after playing soccer. She described her upper, compressional in nature localized to upper and central chest, associated with orthopnea and dyspnea. On initial presentation, vital signs were within normal limits. Physical exam was notable for non-reproducible chest pain, and laboratory evaluations including complete blood count, comprehensive metabolic panel, troponin, and brain natriuretic peptide were all within normal limits. Electrocardiogram (ECG) demonstrated normal sinus rhythm at 87 beats per minute. Chest x-ray demonstrated cardiomegaly without focal consolidation, effusion, or pneumothorax  chest with contrast was obtained for further evaluation of the mass and revealed a large mass inseparable from the right heart border pericardium, displacing the heart to the left with associated compression of the superior right atrium and the superior vena cava (SVC) Figures , 4.Needle biopsy revealed a thymoma, Masaoka stage III WHO type B3 (TEN) with atypical presentation. Cardiothoracic surgery successfully excised the tumor, and she was discharged on hospital day eight without complication.Thymoma in the pediatric population can present in a variety of ways, many of which are non-specific, overlapping with cardiopulmonary pathologies. Presenting symptoms have a wide range from asymptomatic and incidental finding to compressive symptoms of local anatomical structures, including SVC syndrome, respiratory distress, chest pain, cough, orthopnea, and dyspnea -4,6. PatParaneoplastic syndromes or autoimmune disease, most commonly myasthenia gravis, though often associated with adult mediastinal masses and thymomas, are not seen in the pediatric population ,8. In coDue to disease rarity, discovery of pediatric thymoma is often an incidental finding on chest radiograph or CT . A contrThe mainstay of treatment is complete surgical resection. In the ED, treatment should be focused on resuscitation and airway management as mass effect may cause airway compromise prompting advanced airway management. Long-term management is extrapolated from the adult population due to low pediatric prevalence ,8,10-11.Thymoma is very uncommon in the pediatric population. Its vague and overlapping presentations with other life threats should prompt emergency physicians to keep a high index of suspicion for this disease. These tumors may present with compressive symptoms of surrounding structures or incidentally on imaging and should be fully imaged with a contrasted chest CT. Discovery should prompt a multidisciplinary follow-up to include cardiothoracic surgery, oncology, and cardiology as surgery and adjunctive chemotherapy and radiation are the mainstays of treatment. While rare, this case highlights the uncommon nature of pediatric thymoma in a potentially life-threatening ED presentation.


Aneurysmal bone cysts (ABC) are rare, benign primary bone tumors. Although benign, they can be locally aggressive resulting in erosion of bone and surrounding tissues over time. In later stages, depending on the clinical urgency, immunotherapy or surgical resection remain treatment options. This report illustrates a case of a 32-year-old female who presented with chronic worsening low back pain without neurological deficits. Radiological imaging revealed a large destructive mass arising from the thoracic spine invading into the central canal, causing critical central stenosis and cord compression. Histopathology revealed ABC. This case highlights the importance of including ABCs and other ‘benign’/locally aggressive lesions in the differential of patients with insidious musculoskeletal complaints. This case also demonstrates that one can be neurologically asymptomatic despite having critical central canal stenosis and cord compression if the causative lesion is slow growing. Understanding this allows us to arrange for most appropriate management. A 32-year-old female who is 7 months post-partum presented with left-sided lower back pain that began during the second trimester of her pregnancy. The pain was originally attributed to her pregnancy but persisted post-partum. She described the pain as worse when supine with occasional radiation to the left gluteal area. She is otherwise healthy with no neurological deficits. The review of systems was negative and the patient did not report any systemic symptoms. On physical examination, the patient had no pain on palpation of the spine and normal symmetric strength and sensation as well as intact reflexes with normal gait patterns.A plain radiograph of the hip demonstrated bony irregularity along the left border of T12 vertebral body and to a lesser extent the T11 level .CT of the lumbar spine was performed and revealed a large 10 cm irregular, destructive expansile soft tissue mass with its epicentre arising from the T11 and T12 vertebral body and left pedicle with body destruction of the left-sided posterior elements . The masMRI of the spine revealed the lesion to contain multiple fluid-fluid levels . It has The patient underwent ultrasound-guided biopsy, which was preferred over CT guidance for several reasons. Ultrasound guidance would reduce radiation exposure to the patient and could be performed more quickly and readily, thus reducing the time to diagnosis. While there is a theoretical risk of under sampling, the track of entry and target of biopsy was planned with sarcoma orthopedic surgeon to ensure optimal success.The biopsy was performed via posterior approach, under sterile conditions and with local anesthesia. Biopsy specimens were obtained using an 11-gauge access and 13-gauge biopsy needle together with the powered needle driver. Three core samples were obtained and the specimens were sent to the pathology department for analysis.An MRI of lumbar spine revealed a large expansile mass arising from T12 vertebral body. (a) Axial T2 sequence of a normal central canal . (b) Axial T2 sequence demonstrates with internal heterogeneity with multiple fluid–fluid levels, invading into the central canal causing significant central canal stenosis, displacing the cord with complete effacement of the surrounding CSF but no cord edema. The borders of the lesion are however well circumscribed with scalloping of the adjacent bony structures, suggesting a chronic locally aggressive pathology. (c) Axial T1FS sequence demonstrates central areas of hematoma within some of the fluid–fluid components. (d) Axial T1FS post-contrast sequence demonstrates soft tissue heterogenous enhancement. Coronal T1FS post-contrast demonstrating the size of lesion and is well circumscribed.The differential diagnosis for the CT-demonstrated destructive lesion would include but not be exclusive to primary and secondary malignancies  dependant on the age group. However, the clinical presentation of chronicity together with the imaging findings suggests a slow-growing and locally aggressive lesion such as a giant cell tumour, aneurysmal bone cyst, osteoblastomas or chrondroblastomas.The differential diagnosis for the MR findings of a fluid–fluid level include but is not exclusive for an aneurysmal bone cysts (ABC) (either primary or secondary to a giant cell tumor) or more aggressive lesions such as telangiectatic osteosarcoma or hypervascular metastases such as renal cell or lung. ABCs and telangiectatic osteosarcomas share many imaging features but have very different prognoses. They are often difficult to distinguish in large and locally aggressive cases such as this and histopathological correlation is required to obtain a final diagnosis.The patient underwent an ultrasound-guided biopsy. Histological examination revealed a primary aneurysmal bone cyst .1 Plan for re-evaluation in a few months to assess the need for surgery to stabilize the spine. The patient was started on Denosumab monthly subcutaneous injections. She was also started on calcium and vitamin D supplements.In view of the imaging findings of severe central canal stenosis, orthopedic spinal team and oncology team were consulted urgently. The patient’s case was discussed at an interdisciplinary tumor board meeting which recommended that the patient be started on denosumab. Denosumab is a human monoclonal antibody that binds to the human RANK ligand (RANKL) on the surface of osteoclasts and their precursors, inhibiting osteoclast formation, function and survival, leading to decreased bone loss and destruction.A repeat MRI 4 and 9 months later showed interval shrinkage of the entire lesion with significant improvement of the pressure mass effect on the central canal, with only mild central canal stenosis . The pat2 They represent approximately 1.4% of primary bone tumors. Among primary bone tumors, 3–30% of ABC cases involve the vertebral column, particularly the posterior elements.2,3 Prevalence of ABC varies within the vertebral column, with the cervical spine being involved in 30–40% of cases, the thoracic spine in 25–50% and the lumbar spine being most common in 40–45% of cases.3ABC are rare, benign primary bone tumors that can be fast-growing and locally destructive.4 They occur predominantly in the pediatric population but can occur in adults, often in the first two decades of life and with a female predilection.2Other areas affected include the mandible, clavicle, feet, and fingers.2 It can result in large lesions affecting the spine leading to significant morbidity. While there are discussions of ABCs in the literature, many of them involve ABCs of the mandible and literature about ABC of the thoracic spine are limited.5They are expansile entities that can cause significant osteolytic destruction of bone and surrounding tissue.6,7 However, we present a case of a female with non-specific back pain and no other significant neurological symptoms. She had no evidence of pathological fracture or progressive paraplegia which would raise the usual red flags for an underlying aggressive process. It is therefore important to consider this rare entity among the list of differential diagnoses for nonspecific, chronic back pain, especially among younger patients.Patients with an ABC often present with pain in the affected area along with neurological deficits. Paresthesia, paresis and abnormal gait are common neurological manifestations when the spine is involved.It is important to proceed with imaging modalities to make the proper diagnosis as ABCs have characteristic features. Its erosive process can be represented as destruction of the facet joints along the vertebral column. A plain film of the spine or the area of interest can be enough to raise clinical suspicion which leads to either a CT and MRI which will be able to characterize the lesion with its large, expansile characteristic along with fluid-filled levels. If such a mass is detected on imaging, the next appropriate step would be image-guided biopsy of the target and confirm with histopathology.8 It is a non-specific symptom that can often continue for a long period of time before further workup is done. This case outlines the importance of being aware of the potential insidious and non-specific presentation ABC can have and to be cognizant of the radiographic characteristics that suggest a destructive process.The diagnosis of ABC can often be missed if the clinician involved does not include it in the differential diagnosis. Low back pain is an extremely common complaint and a leading cause of visits to emergency departments, walk-in clinics, and family physician visits.4 However, among patients who undergo curettage or surgical resection, recurrence rates are high and vary from 10 to 59%.9 These lesions tend to recur more often in pediatric patients .9,10 Treatment with radiotherapy yields lower recurrence rates but has been associated with radiation-induced morbidity and is therefore less common.4 Percutaneous doxycycline has also been documented to have favorable response for the treatment of ABCs.11 A recent study has demonstrated favorable clinical and imaging regression of disease with a single injection of doxycycline and could be considered as a novel therapy for management of ABCs.11There are various treatments for ABC including both surgical and non-surgical options. Different approaches include curettage, excision, selective arterial embolization or radiotherapy. The decision to treat and which options are most feasible depend on patient preferences, the location of the mass and its size.12 Denosumab has traditionally been used to treat giant cell tumor of bones, with which ABCs share some pathological features, and are now being used to manage ABCs in an off-label manner.1 In particular, the use of denosumab for spine or pelvic ABCs is especially important as surgical outcomes in those areas may lead to serious morbidity.12 While not yet approved by the Food and Drug Administration, several case series have been published and the existing literature suggests that Denosumab therapy is an effective therapy for ABC. The literature supports that Denosumab leads to favorable clinical and radiological response, which has also been demonstrated in the case of the patient in this case report.1In recent years, Denosumab has been used to successfully treat ABCs with the aim to reduce tumor size.ABCs only represent a small percentage of primary bone tumors but together with slow growing and benign or locally aggressive lesions, are important differentials to consider when presented with chronic non-specific pain. We present a case of thoracic spine ABC causing critical central canal stenosis but with no clinical neurological findings. This case also appropriately highlights the importance of an accompanying clinical history and examination as this would define a different treatment plan.Back pain is a very common presenting complaint but can be the first and only clinical sign to indicate severe underlying pathologies.Subtle and vague longstanding ‘musculoskeletal pain’ can be explained by chronically slow growing benign but locally aggressive tumors such as an ABC.Importance of multimodality imaging in obtaining and narrowing a diagnosis. CT aided in assessing bone destruction. MRI characterized the internal structure of the lesion and extent of local involvement. Fluid–fluid levels point towards a vascular lesion such as an ABC, giant cell tumor and also seen in aggressive lesions such as telangiectatic osteosarcoma. Ultrasound-guided biopsy obtained the diagnosis.Critical central canal stenosis noted on imaging may be present in neurological asymptomatic patients. This highlights the importance of marrying clinical findings with radiological findings. This is critical in deciding the appropriate treatment plan for the patient.


Ovarian rhabdomyosarcoma is extremly rare and the diagnosis might be a real dilemma clinically and histologically. We report here the case of a 19-year-old patient, who presented a progressive increase of the abdominal volume associated with dyspnea and general conditions deterioration. The pelvic MRI showed bilateral ovarian masses associated with peritoneal carcinomatosis. CA125 was elevated (273u/ml) while other markers including bHCG, inhibine, AFP were normal. Simultaneously, the patient developed a cutaneous lesion in the thenar's lodge of the right hand rapidly increasing volume, painful and necrotic. The MRI of the right hand showed a large necrotic tissue mass of the right thenarian lodge without bone involvement which may correspond to a secondary localization. Cutaneous biopsy was performed and revealed a skin localization of undifferentiated malignant tumour and IHC analysis were compatible with alveolar rhabdomyosarcoma. After these findings, an exploratory laparotomy was performed and revealed the presence of two bilateral ovarian masses with ascites of great abundance and large dissemination of carcinomatosis nodules. Several biopsies were performed and the histological analysis with IHC have confirmed the diagnosis of ovarian rhabdomyosarcoma . The patient received chemotherapy based on: vincristine, adriamycin and cyclophosphamide with peritoneal and thenar progression after 6 cycles. Patient refused hand amputation and was proposed for radiotherapy. A second line chemotherapy with etoposide and ifosfamide was established.


Capillary hemangiomas are hamartomatous congenital vascular malformations that are particularly uncommon in the spinal epidural space, and those with intrathoracic extensions are extremely rare. Although considered benign, capillary hemangiomas can cause rare hemorrhagic complications and risk of spinal cord compression or extension into the neural foramen. Therefore, surgery should be considered even in the absence of neurological symptoms. The literature reports three patients either underwent a partial resection or a complete tumor removal was achieved by accessing the lesion through a posterolateral approach and removing the costotransverse joint.The patient underwent a same-day, two-staged gross total resection of the tumor via combined posterior right-sided T7-T8 complete facetectomy and extradural mass resection with T7 nerve transection, followed by a posterolateral fusion of the T7-T8 vertebra. Stage 2 consisted of a video-assisted intrathoracic approach for the removal of the remaining tumor.The two-stage surgical procedure described in our case report allows for complete removal of intrathoracic and intraspinal portions of the mass with less morbidity. Hemangiomas are one of the most common benign spinal tumors and are usually located in thoracic or lumbar vertebrae, rarely extending into the spinal canal or neural foramina ,2. HemanCapillary hemangiomas are hamartomatous congenital vascular malformations consisting of a cluster of capillaries lined by flattened endothelium with feeding and draining vessels. Although considered benign, capillary hemangiomas can cause rare hemorrhagic complications and risk of spinal cord compression or extension into the neural foramen; surgery should, therefore, be considered even in the absence of neurological symptoms -7.There have been a handful of primarily spinal ECH cases reported in the literature, but cases with intrathoracic extensions are even less common ,8,9. FurA 29-year-old female patient was admitted to the hospital for septic shock with a urinary tract infection, pyelonephritis, and nephrolithiasis. During the hospital admission, the patient underwent an extensive workup, including a CT scan without contrast that showed a right-sided paraspinal mass at the T7 level Figure . MRI of the thoracic spine with and without contrast demonstrated a 6.2 x 3.1 x 2.1 cm well-circumscribed solid and avidly enhancing right paraspinal T2-hyperintense lesion at the T7 level with extension into the right neural foramen, and into the dorsal and ventral epidural spaces but with no intradural extension. Additional small hemangiomas were seen in the right lateral aspect of the T9 vertebral body, C7, T7, and L1 vertebrae , the patient elected to proceed with surgical resection. She underwent a same-day, two-staged surgery. Stage 1 included a posterior right-sided T7-T8 complete facetectomy, extradural mass resection with T7 nerve transection, and a posterolateral fusion of the T7-T8 vertebra. Under the general anesthesia, the patient was first positioned prone onto the Jackson table and a mid-thoracic incision was taken down through the dorsolumbar fascia, followed by a subperiosteal dissection out to the transverse processes of T7 and T8. Two pedicle screws were placed on the left at T7 and T8. A right-sided complete T7-T8 facetectomy was completed, the exiting nerve root was completely skeletonized, and the dorsal root ganglion (DRG) identified. There was a vascular tumor circumferentially within the foramina, which was curetted and resected. The nerve root proximal to the DRG was coagulated and cut with microscissors in case any tumor was located within the nerve root itself. The remainder of the tumor was cleaned out from this area and the epidural space. The wound was then closed in a standard manner in multiple layers.Stage 2 was then completed by a general surgeon. The patient was placed into a left lateral decubitus position with slight rotation anteriorly and the chest was entered through the sixth intercostal space through the serratus muscle immediately at the lateral aspect of the inframammary fold. A 15-mm port was placed, and a 30-degree endoscope in the pleural space was introduced. After the lung was deflated, additional 5-mm ports were placed posterior of the eighth intercostal space below the tip of the scapula, at the seventh intercostal space posterior the axillary line, and an additional between the two. The lung was retracted cephalad and the inferior pulmonary ligament was incised and dissected up to the inferior pulmonary vein, providing sufficient visualization of the tumor, which was immediately at the level of the inferior pulmonary vein posteriorly . The nucleoli were regular and ovoid, without significant nuclear atypia or mitotic activity (B). Immunohistochemically, CD34 antibody staining was performed and shown to be strongly positive (C). Additionally, an immunostain for smooth muscle actin was performed and was shown to be focally positive, but not diffusely or strongly staining (D). The histopathological information further supported the diagnosis of capillary hemangioma.Clinical symptoms of ECH depend on the size and location of the mass and usually manifest with radicular symptoms and compressive myelopathy. Contrarily to cavernous hemangiomas, there were no ECH cases reported involving hemorrhages. Although our patient was asymptomatic, it was decided to treat this hemangioma surgically due to her young age and plans to become pregnant. Akhaddar et al. reported on a 19-year-old female patient who developed back pain and progressive gait disturbance in the third trimester of gestation and complete paraplegia in the immediate postpartum period . They hyThe list of ECH reported cases is presented in Table There have been only four ECH with intrathoracic extension reported, including the present case. Kang et al. reported a dumbbell-shaped T2-T4 hemangioma with epidural and intrathoracic extensions . LaminecThis case report adds to the literature by describing an asymptomatic patient with ECH and intrathoracic extension. The two-stage surgical procedure described in our case report allows for video-assisted complete removal of intrathoracic and intraspinal portions of the mass with less morbidity. Previously reported similar cases either described a partial resection or a complete tumor removal by accessing the lesion through a posterolateral approach and removing the costotransverse joint.


Case Presentation. A 41-year-old male presented with a coincidental renal mass at the inferiomedial aspect of the right kidney. He underwent laparoscopic partial nephrectomy. On the third postoperative day, he developed fever. CT scan showed minimal urine leak from the tumor site and a JJ stent was inserted. Due to severe bladder symptoms, the stent was removed and a perirenal drain was inserted and removed in few days. He did well initially but in two weeks, he started to develop urinary tract infections. Repeat CT scan showed ongoing urinary leak from the site of the previous surgery. Retrograde pyelography demonstrated a complete UPJ stenosis with an ureterocalyceal fistula. Trial for reanastomosis failed due to severe adhesions and small intrarenal pelvis. An ureterocalyceal anastomosis has to be performed to another calyx.  Postoperative urinary leak is a well-documented complication following partial nephrectomy. It usually presents as persistent discharge from the retroperitoneal drain, nephrocutaneous fistula, urinary collection, systemic manifestations, or abdominal symptoms. Herein, we report for the first time on a case of urinary leak postlaparoscopic partial nephrectomy which did not heal and led to the formation of ureterocalyceal fistula.  We report for the first time on an ureterocalyceal fistula following laparoscopic partial nephrectomy. This complication might be prevented by a careful dissection of the area close to the ureter or by an insertion of a JJ stent for an adequate time if a ureteric injury is suspected. Nephron-sparing surgery has become the standard of care for clinical stage T1a and selected clinical stage T1b renal tumors . This isPostoperative urinary leak following partial nephrectomy is a well-documented complication with an incidence ranging from 18% in some series to less than 2% in the most recent ones –6. It usHerein, we report for the first time on a case of urinary leak postlaparoscopic partial nephrectomy which led to the formation of a ureterocalyceal fistula.Surgicel using polyglactin as well. Histopathology demonstrated a 2.9 × 3.8 × 3.4 cm Fuhrman grade II clear cell carcinoma which was confined to the capsule (T1a N0 M0).A 41-year-old male presented with a coincidental right renal mass. He gave a history suggestive of chronic prostatitis and had mild urinary frequency and occasional mild urgency. He also had a history of previous open appendectomy. Preoperative CT scan showed a heterogeneously enhancing mass at the inferior pole of the right kidney suggestive of neoplastic lesion (PADUA score 8)  for whicPostoperatively, he did well and the drain was removed after 48 hours as it was bringing only 45 cc of serosanguinous fluid as suggested by potassium and creatinine levels, which were similar to the serum values. One day later, he developed high-grade fever, and CT scan showed minimal urine leak from the site of the partial nephrectomy . He refuThree days postdischarge, he presented with severe bladder spasms and insisted on catheter removal which was reinserted 24 hours later. He then developed fever with minimal abdominal pain for which he was admitted on the 9th postdischarge day. CT scan showed extravasation of urine at the site of the previous surgery with fluid collection (3.8 × 1.8 cm) associated with few gas bubble and mild right pleural reaction. He was offered a nephrostomy tube but he totally refused again, so he was convinced to have a perirenal drain, which was inserted in the presence of the JJ stent and urethral catheter. Subsequently, he continued to have severe bladder spasms despite the antimuscarinic agents. Indeed, he tried several times to pull the catheter which got blocked and all the urine from both kidneys was coming out from the perirenal drain. In view of this and the agony that he had, we decided to remove the JJ stent and urethral catheter and leave only the perirenal drain.Subsequently, almost half of urine output was coming out from the perirenal drain. Another CT scan showed the pigtail drain tube to be adjacent to the site of partial nephrectomy and no contrast was going down the ureter. So, the drain was pulled out 2 cm under CT guidance. CT scan then showed free drainage of urine along the ureter. The drain was left in place for two days during which it did not drain any urine. The patient felt well with no fever, so the drain was removed three days later. During all this time, the kidney did not show any significant dilation on either ultrasound or CT scan.Postdischarge, he did well initially, but in few days, he started to develop urinary tract infections that were occasionally associated with low-grade fever but no abdominal pain. Ultrasound again did not show any abnormality. One month later, he was readmitted with high-grade fever. CT scan showed an ongoing leak which was, this time, more medial with minimal dilation of the collecting system. A trial to insert a JJ stent failed and retrograde pyelography showed normal ureter up to approximately 3 cm below the ureteropelvic junction which had a blind end and there was a fistula between the upper ureter and lower calyceal system  Figures . Using aPostoperative urinary leak following partial nephrectomy is a well-documented complication , 8. The In the current case, it is difficult to ascertain the cause of the stenosis of the upper ureter but it appears that a combination of urinary leak at the site of partial nephrectomy and a possible ureteric injury had resulted in the formation of the ureterocalyceal fistula. The most likely cause for the expected ureteric injury was an inadvertent diathermy injury to the vascular supply of the ureter or even a direct but unnoticed ureteric injury as the tumor was relatively close to the ureter. The fact that no direct injury was obvious during laparoscopic dissection and the fact that the retrograde pyelography and the insertion of JJ stent were totally uneventful when performed almost a week after surgery indicate that the injury was a mild one which took some time to cause a break in the ureteric wall and fistula formation. One of the factors that could have caused or at least contributed to the ureteric injury is the infections and collections, which formed postoperatively in the adjacent area. Other remote possibility was the inadvertent injury by the percutaneous needle during drainage of the perirenal collection which was located at the lower pole and upper ureter.In this case, no glue was used during the procedure. In this regard, there was a report of urine leak associated with fibrin glue which led to almost complete occlusion and stricture formation of the upper ureter which was associated with enfolding of the ureter by fibrin glue causing marked stiffness and adhesions .The early removal of the JJ stent due to severe bladder spasms and intolerance despite the use of anticholinergics must have also contributed to the formation of the fistula. If the stent was kept in for longer time, this probably would have ended in ureteric stricture but prevented this complication.In conclusion, herein we report on the first case of a ureterocalyceal fistula following laparoscopic partial nephrectomy of an inferiomedial renal tumor. Careful dissection of the tissues in the medical aspect adjacent to the ureter and leaving a JJ stent for an adequate period in case of suspicion of ureteric injury might prevent such complication.