Spontaneous primary tumor regression, or burned-out tumors, refers to the presence of a metastatic tumor with the histological regression of the primary lesion. The burned-out phenomenon has been reported in various malignancies, with testicular germ cell tumors (GCTs) accounting for a significant share of these cases. However, burned-out testicular tumors are a rare clinical phenomenon and are generally difficult to diagnose, as there is no evidence of primary testicular cancer. Here, we describe the case of a 42-year-old male who presented to our hospital complaining of right abdomen and groin pain for several months. On physical exam, the patient had normal genital and rectal exams. An abdominal-pelvic computed tomography (CT) scan of his abdomen and pelvis revealed a large retroperitoneal mass with radiographic characteristics of a sarcoma. Given his groin pain, the patient had a testicular ultrasound, which revealed scar tissue in the right testicle. His testicular tumor markers showed elevated β-human chorionic gonadotropin (β-hCG) and lactate dehydrogenase (LDH) but normal α-fetoprotein (AFP). He underwent right radical inguinal orchiectomy, with pathologic examination of the testicle revealing a burned-out testicular tumor. The patient was then treated with four cycles of bleomycin, etoposide, and cisplatin (BEP). His post-treatment tumor markers were normalized; however, his abdomen-pelvic CT scan showed a persistent mass. The patient underwent retroperitoneal lymph node dissection (RPLND) with the removal of 12 lymph nodes. However, pathologic evaluation of the lymph nodes revealed no evidence of neoplastic cells. The patient has remained disease-free after five years of follow-up.This report highlights the potential of burned-out testicular tumors in young and middle-aged men presenting with a retroperitoneal mass. Furthermore, it underscores the importance of obtaining testicular ultrasound in these patients to rule out regressed testicular tumors. Testicular cancer is a rare malignancy, accounting for only 1% of all malignant tumors in men . About 9Here, we present the case of a 42-year-old male with a large retroperitoneal mass that was initially suspected to be a primary retroperitoneal sarcoma but later revealed to be metastasis from a burned-out testicular tumor.A 42-year-old male with no significant medical history presented to our hospital complaining of progressively worsening dull pain in his right lower abdomen, groin, and thigh for the past six months. His physical exam revealed diffuse lower abdominal and right groin tenderness, with mild right groin and thigh swelling. His rectal and genital exams were normal. Color doppler ultrasound of his right lower extremity showed normal blood flow with no evidence of thrombosis. The patient’s CT scan of the abdomen and pelvis showed a large right retroperitoneal mass causing lateral displacement of the kidney Figure . The iniSubsequently, the patient had a CT scan of the chest and the mediastinum, showing no metastatic disease. A biopsy of the retroperitoneal mass revealed testicular germ cell neoplasia. Post-orchiectomy tumor markers showed a mild decrease in β-hCG and LDH, although both remained significantly high compared to the normal range. The patient received four cycles of chemotherapy with bleomycin 30 mg, etoposide 200 mg, and cisplatin 50 mg (BEP) without any treatment-related complications. After completing the entire course of BEP, the patient’s testicular tumor markers, including β-hCG and LDH, were within normal limits. His abdomen and pelvis CT scans, however, showed a persistently enhancing retroperitoneal mass Figure . The patBurned-out testicular GCTs are extra-gonadal metastatic GCTs with no evidence of neoplastic cells in the testes . The firBurned-out testicular tumors are generally difficult to diagnose, as there is no evidence of primary testicular cancer. This often leads to the misdiagnosis of the metastatic lesions as the primary tumor . This waDifferentiation between burned-out testicular tumors and primary extra-gonadal GCTs is crucial, as it can change the patient’s treatment plan and prognostic outcome. Primary testicular cancers are more sensitive to chemoradiation and typically have a significantly better outcome, with a more than 90% five-year survival rate ,11. MeanBurned-out testicular tumors are a rare clinical phenomenon and are often difficult to diagnose. Here, we report the rare case of a patient with a burned-out testicular tumor who presented with a large retroperitoneal mass. The initial radiographic findings of the mass were highly suggestive of primary retroperitoneal sarcoma versus a significantly lower likelihood of metastatic RCC. However, because of his initial complaint of right groin pain, we obtained an ultrasound of his testicles, which revealed two hypoechoic foci, which were found to be burned-out testicular tumors after right orchiectomy. The patient was then successfully treated with four cycles of BEP, remaining disease-free after five years of follow-up. This report highlights the importance of considering burned-out testicular tumors in patients presenting with a retroperitoneal mass, despite the absence of testicular mass. Given the potential for testicular tumors to undergo spontaneous regression after metastasis, it is prudent for clinicians to obtain a testicular ultrasound in young and middle-aged men presenting with a retroperitoneal mass.


Pigmented skin lesions of the penis include melanocytic and non‐melanocytic lesions.in situ squamous cell carcinoma, clinically appearing as a slow‐growing, well‐defined, hyperpigmented plaque and its location on the genital area is uncommon in white populations.Reed nevus is a deep pigmented melanocytic lesion, commonly located on the lower extremities of young adults and the penile location of this lesion is rarely reportedReflectance confocal microscopy (RCM) is a non‐invasive diagnostic technique that improves the diagnostic accuracy of equivocal pigmented and non‐pigmented skin lesions. Only few case reports described RCM features of pigmented genital lesions.Herein, we report two common pigmented lesions with an unusual penile localisation in which RCM has been useful for diagnosis and management.A 16‐year‐old boy presented with a 4 mm brown/black, irregularly shaped macule on the glans penis, that appeared 3 months earlier and changed over time Fig. . DermatoA 45‐year‐old man presented with a 1 cm asymptomatic pink/brown macule on the penis shaft that had appeared one year earlier Fig. . DermatoThe diagnosis of clinically atypical pigmented lesions on the genitalia can be challenging since differential diagnosis with melanoma might be difficult.RCM has been recently shown to play a role in the non‐invasive diagnosis of vulvar nevi,Genital disorders are generally a source of anxiety and a biopsy in this sensitive area is not preferred for the related pain and risk of scarring thus a fast and non‐invasive diagnosis is highly desirable. In addition, RCM reduces the risk of infection as well as costs, resources and time.In conclusion, RCM is an additional tool that can be used in clinical practice to aid clinical diagnosis of pigmented lesions, especially if located in sensitive areas such as genitalia where unnecessary surgery is preferably avoided.


Paragangliomas are rare neuroendocrine tumors mostly diagnosed in young adults. Their association with pregnancy is even rarer, and their impact is even more serious in the absence of adequate management, which may vitally involve maternal and fetal prognosis. In this report, we present a rare case of a left lateral aortic paraganglioma in a pregnant woman in her third trimester during her 31 weeks of gestation, who consulted for a hypertensive peak; the methoxylated derivatives were positive. An abdominal MRI showed a left lateral aortic mass, suggesting a paraganglioma. After a multidisciplinary discussion, the patient underwent laparoscopic surgical resection of the mass after preoperative medical preparation. Pathological examination confirmed the diagnosis of paraganglioma. The overall stay was six days without any short-term complications, including anything related to fetal viability, with a vaginal delivery at 37 weeks of amenorrhea. The patient was followed up for six months with no complications. We highlight the importance of preoperative medical preparation followed by surgical resection in the framework of a multidisciplinary consultation for an improved maternal-fetal prognosis. Paragangliomas are rare neuroendocrine tumors that develop from chromaffin cells; in most cases, they involve embryonic neural ridges secreting catecholamines . They arA 35-year-old female patient, primiparous, and pregnant with an estimated 31 weeks of amenorrhea, consulted our emergency department for a hypertensive peak during pregnancy follow-up associated with palpitations, tinnitus, sweating, and intense headaches. Her medical history was remarkable for high blood pressure for three years under alpha-methyldopa, without any familial history of hypertension. On physical examination, she had an elevated blood pressure of 180/100 mmHg, a normal pulse of 82 beats per minute, a respiratory rate of 26 breaths per minute, and an oxygen saturation of 94% on room air with a capillary blood glucose level of 1.06 g/L. Pulmonary auscultation was unremarkable; the abdominal examination showed a fundal height reaching 28 cm, without any tenderness or palpable mass.As part of the etiological evaluation, routine labs including blood test, liver function, creatinine, and 24-hour proteinuria were within normal ranges; preeclampsia was ruled out. Given the presence of Menard's triad  and to obtain the etiological diagnosis, we considered pheochromocytoma or paraganglioma. Urine metanephrines testing was performed, which revealed an elevated normetanephrine level of 4.78 μmol/day  and metanephrines level of 5.93 μmol/day . Since the patient was pregnant, an abdominal MRI was performed, which showed a left-lateralized abdominal juxta-aortic formation, well-limited in heterogeneous T1 iso-intensity with punctiform areas in spontaneous T1 hyperintensity, and heterogeneous T2 hyperintensity, measuring 36 x 33 mm, suggesting a paraganglioma  and the fetus  . The cliThe diagnosis of certainty is pathological, with an appearance of a huge rounded tumor, encapsulated with a firm, elastic, and highly vascularized consistency. Immunohistochemistry staining confirms the diagnosis. There is no pathological criterion to distinguish between benign and malignant tumors .The treatment of paragangliomas must be decided within a multidisciplinary setting. Complete surgical resection without microscopic residue remains the only curative treatment with a survival rate exceeding 75% at five years . On the The condition is associated with a poor prognosis, with a fetal mortality rate of 55% and maternal mortality of 25%. Early diagnosis during pregnancy and good therapeutic management can reduce fetal mortality to 15% and maternal mortality to 4% .Retroperitoneal paraganglioma during pregnancy is a rare entity. The diagnosis is usually reached based on the presence of atypical gravid hypertension, accompanied by suggestive clinical signs, or resistance to treatment. It can be confirmed by simple and reliable biological tests. Imaging tests can help with the diagnosis and surgical planning of paraganglioma. Its management represents a real challenge. The maternal and fetal morbidity rate is significant and requires multidisciplinary management at various points of the disease course. The prognosis is poor, especially in cases of late diagnosis. However, thanks to management optimization, the mortality rate has dropped significantly of late. Hence, we recommend that every case of severe hypertension at a young age be taken seriously and explored thoroughly.


Acute appendicitis is a surgical emergency. However, the presence of vermiform appendix in a hernial sac is rare. It is even rarer to find inflamed appendix in an hernial sac. The most common site is right groin hernia . There is low incidence of an incisional hernia following renal transplantation, as compared to patients with laparotomy. Appendicitis in hernial sac masquerades clinical presentation of an incarcerated hernia. Computed tomography plays a pivotal role in early diagnosis, demonstrating a dilated appendix with wall thickening and peri-appendiceal fat stranding. Patients are managed with appendectomy. The management of appendiceal hernias without inflammation remains controversial, with few reported cases managed with hernia sac repair or appendectomy. In this report were described a case of appendicitis in an incisional hernia following renal transplantation which was managed with appendectomy. Acute appendicitis defined as inflammation of the appendix, have an annual incidence of 1 per 1000 person Appendicitis occurring in the incisional hernia is extremely rare In this report, we describe a case of appendicitis in the incisional hernia following renal transplantation.A 58-year-old male with clinical history of autosomal dominant polycystic kidney disease who previously underwent left total nephrectomy (in 2003) and renal transplantation  presents to the emergency department with acute onset right abdominal pain that gradually worsened over the span of 5 days. On arrival, the patient was afebrile and vital signs were stable. Physical examination revealed tenderness to deep palpation in the right lower quadrant and right flank.9/L, Hemoglobin 16.9 g/dL, Hematocrit 49.7%, Platelet 454 109/L, Red Blood Cell Count 6.22 million/mm3, International Normalized Ratio (INR) 1.2, serum sodium 134 mEq/L, serum potassium 3.7 mEq/L, serum chloride 104 mEq/L, serum creatinine 1.04 mg/dL, blood urea nitrogen 15 mg/dL, and serum Lactate 0.9 mmol/L. Urine analysis was clean, reported as negative for glucose, bilirubin, ketones, blood, leukocytes, and protein, occasional bacteria, pH of 6.0 and specific gravity of 1.008. Urine Culture was reported no growth for 5 days.Initial laboratory workup was as follow: White Blood Cell Count 16.1 × 10CT abdomen and pelvis with intravenous contrast was performed. A wide-neck right lower quadrant incisional hernia was noted, with stranding and inflammation within the hernial sac  and 2. AOf note, other specific differential diagnosis to be considered in patients with renal transplantation include: perioperative acute tubular necrosis, renal allograft compartment syndrome, renal allograft torsion, acute or chronic renal transplant rejection, renal artery stenosis, renal vein thrombosis, arteriovenous fistula, perinephric fluid collection from infection or hematoma, renal artery pseudoaneurysm, urinary obstruction, graft pyelonephritis, opportunistic or community-acquired infection and donor-related malignancy Subsequently, exploratory laparotomy was performed which revealed a perforated appendicitis within the incisional hernial sac, confirming the diagnosis. Pathology reported as acute transmural appendicitis with perforation and ischemic changes. Viable proximal and distal mucosal margins and uninvolved by inflammatory process. Following surgery, the patient made an uneventful recovery.Abdominal hernias may be congenital or acquired and are further classified based on the location, with inguinal hernia being the most common type The presence of the appendix in the hernial sac is rare and in literature it is reported as low as 0.51% (out of 1950 patients with appendicitis) and has male predominance Appendicitis, inflammation of the vermiform appendix is a very common condition and major cause of abdominal surgery in young patients. It typically presents with periumbilical pain, right iliac fossa pain, fever and nausea-vomiting. The pathophysiology mechanism for appendicitis includes obstruction of the appendiceal lumen resulting in venous congestion, ischemia and/or necrosis and fluid accumulation Appendicitis within the hernia sac have a variable presentation and do not follow typical manifestations of acute appendicitis. Reported cases in the literature demonstrates similar clinical presentation to incarcerated hernia The management of non-inflamed appendix in the hernia sac remains controversial. A few reports have advocated surgical removal of any appendix encountered within an incisional hernia, even in absence of clinical and radiologic evidence of acute appendicitis Although appendicitis in the incisional hernia is a rare phenomenon, clinicians and radiologists should consider this diagnosis to prevent complications from delayed surgical treatment. CT might be helpful in early diagnosis.Authors received waiver of informed consent for this case report, since no identifiable information (PHI) was shared.


Though a rare event, gallbladder perforation (GBP) can occur in children and adolescents in the absence of pre-existing cholelithiasis. Moreover, type 1 perforation is seldom found in this cohort. Vague clinical presentation and inconclusive routine investigations can often result in delayed diagnosis. Computed tomography (CT) and intraoperative diagnosis should be utilized to timely diagnose and prevent fatal outcomes. Here, we present a rare case of type 1 GBP in an otherwise healthy 15-year-old boy with no known underlying etiology. Our purpose is to emphasize that although rare, a high clinical suspicion of GBP should be kept in mind even when dealing with acute abdomen in a pediatric population for preventing associated mortality. With an overall incidence of 2% to 11%, gallbladder perforation (GBP) is extremely rare in adults with potentially life-threatening outcomes. One of the most common causes of GPB is acute calculous cholecystitis [Literature suggests that children/adolescents are even less susceptible to developing cholecystitis, let alone GBP ,4. The fHere, we present a rare case of type 1 GBP in an otherwise healthy 15-year-old boy with no known underlying etiology diagnosed only after exploratory laparotomy. The occurrence of a perforation in an adolescent male together with non-specific symptoms and inconclusive CT findings makes our case highly unique.A 15-year-old male school-going adolescent with no known comorbidities was brought to the emergency department with a complaint of acute abdominal pain for one day. The pain was sudden and severe in onset, initially localized to the epigastrium, which after a few hours became generalized. The patient had not passed stool and flatus for one day and had a loss of appetite. There was no associated vomiting and fever. The patient recalled a milder episode of epigastric pain three months ago that resolved on its own. The patient had no history of tuberculosis contact and any febrile illness. Moreover, systemic review and past medical and family history were unremarkable.On clinical examination, an anxious-looking young boy of average height and build, conscious, and oriented was lying on the bed. Vital signs recorded were heart rate of 95 beats/minute, respiratory rate of 30 breaths/minute, blood pressure of 120/80 mmHg, and he was afebrile. He had a distended abdomen with generalized tenderness more towards the epigastric and umbilical region with marked guarding in the upper part of the abdomen. Gut sounds were absent. On digital rectal examination, the rectum appeared empty and collapsed. The rest of the systemic examinations were unremarkable.A provisional diagnosis of acute abdomen with peritonitis was made, with suspicion of a perforated appendix or a hollow viscus perforation. Resuscitation included administration of intravenous (IV) fluids followed by urinary catheterization and placement of a nasogastric tube to decompress the abdominal distension. Laboratory investigations are demonstrated in Table Subsequently, an exploratory laparotomy with a vertical midline incision was planned. Intraoperative inspection revealed 500 ml of bilious fluid in the peritoneal cavity. The fluid was collected for culture and sensitivity testing. The bowel was run after washing the cavity with warm normal saline. We also found a small pinpoint perforation of less than 5 mm in the gallbladder wall adjacent to the liver Figure ; howeverThe patient had an uneventful recovery postoperatively and was discharged on the fifth postoperative day. Fluid for culture and sensitivity report showed no bacterial growth. The specimen for the histopathology report showed chronic cholecystitis without any evidence of dysplasia or malignancy.GBP as the complication of acalculous cholecystitis is an infrequent finding, with only a few cases reported among children. Perforations due to enteric fever, systemic stress, i.e. burns, and cardiovascular surgery, and those occurring spontaneously are less common ,4. MalesChronic cholecystitis is rare in the younger population and presents a different course than in adults. A five-year review of children undergoing laparoscopic cholecystectomy revealed that 87.1% of the population had chronic cholecystitis, though only half of the patients had a chronic symptomatic history . RelatedInflammation leading to ischemia and subsequent necrosis is the predominant mechanism behind spontaneous GBP. The fundus is the most susceptible to ischemia since it is the most distal portion of the gallbladder to receive blood. This makes the fundus the most commonly involved site in type 1 GBP . AccordiGBP is a diagnostic and therapeutic challenge due to its non-specific presentation and smaller perforation size. Often USG and AXR misdiagnose GBP as cholelithiasis and pancreatitis, respectively ,6,7. ClaRapid measures to investigate and manage are warranted as GBP is associated with high mortality rates 12-42%) [-42% 2,1. ClinicaTo this date, cholecystectomy remains the standard mode of treatment. However, its superiority in terms of safety and efficacy over other therapeutic options, such as percutaneous drainage, is not yet established . RecommeIn adolescents/pediatric age groups, a high clinical suspicion of gallbladder perforation is warranted when dealing with acute abdomen, especially when adjunct investigations are not conclusive. Prompt diagnosis and management are crucial in decreasing mortality rates. Radiological investigations may assist in making a presumptive diagnosis, but the definitive diagnosis in most cases is based on intraoperative examination. Adequate follow-up and exploring of the possible causative factors/coexisting etiologies is necessary.


Focal nodular hyperplasia (FNH) is a benign rare liver neoplasm in children and includes only 2% of all pediatric liver tumors. Here we reported the case of a 14-year-old girl with vague flank pain who was managed conservatively.Our case is a 14-year-old child , with a 5 cm diameter lesion in the right lobe of the liver in CT scan, and histologic findings compatible with FNH. A solid mass lobulated contour, intense enhancement with a hypodense central area, possibly indicative of central scar, was seen. Despite her mild flank pain we did not insist on surgical resection and managed her conservatively. Her pain resolved 2 weeks later and an imaging follow-up with ultrasound 6 months later showed no increase in size or numbers.FNH is an uncommon mass lesion in children. Our patient had mild symptomatic severity, and several guidelines recommend surgical treatment in this condition, but our team performed conservative and medical treatment for her and got the desired result. Therefore, the combination of these factors raises the importance of introducing the case. According to FNH’s nature, stability, complications, and evaluation of pain are essential to avoid unnecessary surgeries. Hepatic tumors may be either malignant or benign, Focal nodular hyperplasia (FNH) is a nonmalignant hepatic tumor which is rarely seen in childhood and compromises up to 2% of all pediatric liver tumors and predominantly found in females with the age spectrum between 20 to 50 . Most ofA 14 –year-old teenager with no past medical history referred to the gastroenterology clinic with a complaint of chronic vague right flank pain 2 months ago, the severity of pain was mild with frequent pain-free intervals. There were no significant changes in the severity of pain during these periods, she also describes that she had a low level of pain and could ignore it most of the time.The physical exams were unremarkable and only positional right flank pain in lateral bending was noted. The lab tests were sent and CBC count, liver enzymes, alkaline phosphatase, and alpha-fetoprotein level all were within normal limits. The ultrasonography of the liver revealed an ill-defined 5 cm diameter hyperechoic homogeneous mass lesion in the right lobe. The CT scan demonstrates also 5 cm diameter mass with intense enhancement in the arterial phase in the right lobe in segments VII, VIII .The microscopic evaluation from core needle biopsy of the liver reported the liver tissue with distorted architecture, fibrotic bands, prominent blood vessels, the proliferation of bile ductules, and no evidence of viral effects or cellular atypia. All the histologic findings were compatible with focal nodular hyperplasia .According to the nature of FNH mass and definite diagnosis through biopsy, despite her mild flank pain we did not insist on surgical resection and managed her conservatively. Her pain resolved 2 weeks later and imaging follow-up with ultrasound 6 months later showed no increase in size or numbers.FNH is a benign liver neoplasm, and it is described by hepatocyte hyperplasia and a central stellate scar, its pathogenesis is not well understood and maybe a vascular injury or environmental factors are indicative. Overall, the FNH is the second common benign tumor that is driven from the liver cell and is especially common in young women between the ages of 20 to 5, with a male/female ratio of 1:12 , 4. FNH Abdominal pain is the most common presentation which has been described in symptomatic patients and usually the lesions are more than 4 cm by compressing adjacent organs or distention of Glisson’s capsule may cause abdominal pain but it is important to consider the severity of pain and quality of life, as we discuss in our case the pain was transient and surgery should be reserved for significantly symptomatic FNH masses and low threshold in pain evaluation could lead to unnecessary surgery .Despite hepatic adenoma, complications such as tumor rupture, necrosis, and hemorrhage are also rare in FNH so conservative management in this lesion has favorable outcomes. Laboratory findings often do not demonstrate clinical significance, and tumor markers, such as AFP, are usually within normal limits and only 1/2 of cases have mildly elevated levels of gamma-glutamyl transpeptidase and in our reported case, all the mentioned laboratory results were within normal limits .The majority of reports consider measurement of AFP and glutamine synthetase immunostaining for assessing other differential diagnoses such as hepatoblastoma in suspected patients. Imaging, ultrasound, and MRI have 82.6% sensitivity and 97.4% specificity for the FNH diagnosis and if the diagnosis remains uncertain, a liver biopsy is helpful (US characteristics reported in our case were unable to distinguish the FNH from an adenoma or malignant lesions,optimal evaluation helical multi-phase CT scan with contrast during the hepatic arterial and portal venous phases was performed. A 5 cm hyperdense lesion during the hepatic arterial phase and hyperdense central scar during the delayed portal venous phase was reported . The manRecent follow-up studies demonstrated that in 2/3 of the cases, the mass size remains stable while 1/4-1/3 of them reduced in size even complete remission is noted and only in few cases increasing in size and numbers was reported . In lineSurgical resection should be considered if there is an evidence of progressive growth, indefinite diagnosis or hepatitis B virus carriage, or in large lesions, the exact size and cut off in children is not recommended and it seems that it depends on the age, body weight, and height, however in patients with persistent symptoms, it is wise to consider surgery , 13.Embolization and vascular occlusion are also considered in symptomatic but un-resectable lesions . Since FEthics:In this study, no additional costs and procedures were imposed on the patient. Due to not mentioning the patient's details, our case report received the ethics code R.TUMS.SINAHOSPITAL.REC.1399.046 from the Ethics Committee of Tehran University of Medical Sciences.


A 64-year-old female was admitted to our clinic with a 9-cm-sized adrenal mass. The patient's main symptom was hirsutism, which included thinning scalp hair and excessive hair growth over her torso and arms. Upon investigation, elevated values of testosterone, androsterone D4, and DHEA-S were found. Contrast-enhanced abdominal CT and MRI scans revealed a heterogenous large mass (diameter 9 × 8.5 cm) with focal calcifications, necrotic areas, and a clear distinction from the adjacent structures. The patient underwent a right adrenalectomy. The histological examination of the tumor revealed a borderline adrenocortical oncocytoma. The patient had an uncomplicated postoperative course and was discharged on postoperative day 8. Similar cases reported in the literature are also being reviewed in this case report. Oncocytomas or oncocytic neoplasms are tumors composed exclusively or predominantly of cells called oncocytes or oncocytic cells . OncocytAdrenal oncocytomas are an extremely rare entity, and since their first description by Kakimoto et al. in 1986, a total of ~185 cases have been reported worldwide , 5. TheyThe aim of our paper is to report a case of a virilizing androgen-secreting adrenal oncocytoma and provide a summary of the very limited literature regarding the clinical and pathological features of similar cases.A 64-year-old Caucasian female was referred to our clinic by her private doctor for a mass in the region of her right adrenal gland, ~9 cm in size. The mass was found, accidentally, during an ultrasonography for known gallstones. The patient did not complain about abdominal pain or discomfort. On clinical examination, a mass was palpated in the right renal region. Hirsutism, with thinning scalp hair and excessive hair growth over her torso and arms, was noted. However, our patient did not report any other symptoms such as weight loss, headaches, diaphoresis, palpitations, or any change in her skin, urination, and bowel habits.Her past medical history included arterial hypertension, treated with nebivolol, amlodipine, and valsartan, and two surgical operations .The patient underwent full laboratory testing, useful for the differential diagnosis of the mass, which showed elevated values of testosterone , androsterone D4 , and DHEA-S . The values of cortisol, aldosterone, dopamine, epinephrine, norepinephrine, and creatinine were within normal ranges.A contrast-enhanced abdominal CT scan showed a quite large heterogenous mass (diameter 9 × 8.5 cm) with focal calcifications . The lesAn abdominal MRI scan was performed, and it showed the right adrenal gland lesion, with a mean signal intensity in the T1W images, and a mean signal (with a few high-intensity elements) in the T2W images . It alsoTaking into consideration the tumor size, the secretion of androgens, and the possibility of malignancy, an open surgical approach was decided. The patient underwent a trans-abdominal right lateral adrenalectomy. No drugs were administered preoperatively, as no clinical or biochemical findings of cortisol or catecholamine hypersecretion were found.The histological examination of the tumor revealed a borderline adrenocortical oncocytoma. Macroscopically, the tumor was a descriptive, almost circular lesion, surrounded by a fibrous capsule. Its size was 9.4 × 8.5 × 7.3 cm, and it weighted 213 g. In its cross sections, it had a white-yellow complexion, had a coarse nodular shape, and it was elastic. In places it had a soft and focal chalky texture. Microscopically, the tumor emerged from large cells arranged in nests or beams, with dense eosinophilic cytoplasm and small round deep-colored nuclei, without increased nuclear atypia or mitotic activity. Finally, immunohistochemical tests revealed that the tumor cells were positive for vimentin, CD56, Melan A, S-100, and synaptophysin .The patient had an uncomplicated postoperative course and was discharged on the 8th postoperative day. As the tumor was not malignant, she received no further treatment. The timeline of the patient's course is presented in Adrenal oncocytomas are a rare form of adrenal tumors, and the functional ones are a small minority of these. More specifically, functional oncocytomas responsible for the masculinization of female patients due to the increased androgen secretion occur even less frequently. We identified 19 such cases from literature, of which we were able to retrieve 17 and collect clinical, biochemical, and histological data  8–22, 2–26.These tumors appear in females, as was our patient, and can occur in a large age range 3.5–58). Their clinical signs are vocal changes, muscle hypertrophy, breast atrophy, and clitoral hypertrophy, or simply hirsutism with thinning scalp hair and excessive hair growth. In three out of the 19 cases, features of Cushing's disease were present . Their c. ElevateTumor size ranged from 2.2 to 28.5 cm and tumor weight ranged from 8 to 5,720 g. In terms of their localization, they were all unilateral, found in the anatomical position of the right  or left  adrenal gland, with the exception of two cases , where these tumors were identified in an ectopic retroperitoneal position , 20. MacMicroscopically, they were composed of large eosinophilic and granular cytoplasmic cells with a central pycnotic nucleus, with a solid, trabecular, tubular, or papillary growth pattern. Finally, regarding the immunohistochemistry of the oncocytomas, they appear to be positive for vimentin, Melan-A, synaptophysin, and inhibin-α and negative for chromogranin. Regarding the percentage of malignancy among masculinizing oncocytomas reported in the current literature, it is similar to that of oncocytomas in general (~20%). However, there are specific criteria for the characterization of adrenal oncocytomas  as defined in 2004 by Bisceglia et al. . The majAs the final diagnosis of these adrenal masses is based primarily on histological examination and immunohistochemistry, their management should be surgical removal . Size anRegarding the surgical approach that should be performed (open or laparoscopic), this also depends on their size and function . TraditiThe rarity of these tumors and the lack of wide clinical data do not allow the establishment of guidelines for the postoperative treatment and follow-up of oncocytomas. However, the data so far show that benign adrenal tumors have an excellent prognosis, with only one case reported in the literature as recurrent . The samTo conclude, masculinizing adrenal oncocytomas are extremely rare tumors, characterized by androgen hypersecretion and clinical characteristics resulting from androgen hypersecretion. Surgical resection remains the recommended treatment and the only one that will lead, with the help of an experienced pathologist, to a safe diagnosis of the disease, and its categorization as benign, borderline, or malignant.The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).The patient was informed that her name and initials will not be published and that efforts will be made to conceal her identity, while images or other clinical information relating to her case may be presented in a medical publication and as a result the material may be seen by the general public.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.EK, SB, and PC conceived the paper's objective and performed data collection and extraction. EK, SB, OI, and KG-D performed the operations and were responsible for the postoperative course of the patient. All aforementioned authors along with MP and VF wrote the initial draft. IM and SA offered significant help in revising the present manuscript in order to reach its definitive form. All authors made substantial contribution and reviewed the document carefully prior to submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A congenital cheek fistula is a rare malformation in the buccal area. Here, we report the case of a congenital cheek fistula in a 50-year-old woman who visited our clinic with complaints of swelling and pain in her left cheek. Physical examination revealed a small hole in the left corner of the mouth present since birth. She had no other congenital malformations in the maxillofacial region such as an accessory ear and cleft lip. Manual compression of the cheek mass induced serous discharge from the hole. Magnetic resonance imaging (MRI) showed a cystic lesion in the left cheek and a fistula within the orbicularis oris muscle that opened into the small hole. After immediate incision and drainage of the cyst, both the cyst and fistula were surgically resected. The cystic lesion was completely delineated from the boundary of the parotid gland. The orbicularis oris muscle was partially incised to remove the fistula and the surrounding scar tissue. Histopathological examination of the resected specimen revealed a cavity consisting of epithelium inside the fistula. The postoperative course was insignificant. No recurrence of the cyst was observed six months postoperatively. The operative and pathological findings demonstrated that the ectoderm-derived epithelial tissue was enclosed by the mesoderm-derived muscle tissue. The mixture of different germ layer-derived tissues suggested that the fistula was a type of congenital transverse facial cleft induced by malfusion of the mandibular and maxillary prominences during embryonic development. The differential diagnoses of the congenital cheek fistula included orocutaneous fistulas and salivary fistulas. MRI was useful in delineating the border between the lesion and the surrounding tissue. A congenital cheek fistula is a rare condition that presents as a hole in the buccal area. Because congenital cheek fistula is classified as Tessier number 7, it is assumed to be caused by incomplete malfusion of the maxillary and mandibular prominences during early development ,2. PatieA 50-year-old woman was referred to our hospital for a left cheek lump associated with severe pain Figure . Her medPhysical examination revealed that she had a small hole in the left cheek close to the angle of the mouth. She had a fistula since birth and sometimes experienced serous secretion that was not enhanced on eating. Manual compression of the cheek lump prompted serous secretion from the hole Figure .Magnetic resonance imaging (MRI) revealed a cystic lesion in the left cheek with a high-signal area on diffusion-weighted imaging Figure . The cysStaphylococcus aureus and Prevotella bivia. The connection between the perioral hole and the oral cavity was not evident. The wound was washed with normal saline and povidone-iodine ointment was applied daily.An immediate skin incision of the lump yielded a white purulent discharge that was compatible with the MRI findings indicating that the perioral hole communicated subcutaneously with the cyst Figure . CultureAfter the resolution of the inflammation, resection of the cystic lesion was performed under general anesthesia Figure . CrystalThe patient’s postoperative course was uneventful. No cyst recurrence or infection occurred during the postoperative six months Figure . MoreoveThe facial cleft is a congenital morphological abnormality of the bone and soft tissue of the maxillofacial area. Cleft lip and palate are the most common types of facial cleft, with other atypical facial clefts being less common. The transverse facial cleft is characterized by a cleft that extends from the angle of the mouth to the ear, thus corresponding to Tessier classification number 7 . There aThe existing literature regarding the congenital cheek fistula is limited; however, a periauricular fistula is one of the most common congenital malformations in the craniofacial area. Nakano et al. reported three neonatal cases of cheek fistulas classified as Tessier number 7  and suggOne of the differential diagnoses of congenital cheek fistula includes orocutaneous fistula, which represents a communication between the oral cavity and the outer skin surface. Patients with an orocutaneous fistula and cleft lip are classified as having Van der Woude syndrome ,5. In ouAnother possible differential diagnosis is a congenital salivary fistula of the parotid gland. The parotid gland opens into the oral cavity through the Stensen duct; however, various factors, such as trauma or surgery, cause aberration of the duct opening into the skin, resulting in a parotid cutaneous fistula . CongeniFluoroscopy with a contrast agent is a reliable diagnostic imaging technique for fistulas . ComputeMRI has been reported to be an alternative scanning tool for fistulas because of its low invasiveness and high-resolution images . GadodiaWe report a rare case of a congenital cheek fistula with inflammation. The operative findings demonstrated that the fistula extended through the orbicularis oris muscle, suggesting that the fistula was a type of transverse facial cleft caused by malfusion of the maxillary and mandibular prominences. MRI clearly showed the boundary between the cystic lesion and the surrounding tissue as well as the course of the fistula.


Susac syndrome (SS) is a rare microangiopathy that involves arterioles of the brain, retina, and cochlea. Diagnosis is extremely difficult because of the rarity of the disease and because the signs and symptoms often occur at different times. Multidisciplinary approaches and multimodal images are mandatory for diagnosis and prompt therapy. In this report, we describe a case of SS and the application of multimodal retinal imaging to evaluate the ophthalmologic changes and to confirm diagnosis. Early diagnosis and therapy based on the associations of steroids and immunosuppressants are necessary to limit the sequelae of the disease. Susac syndrome (SS) is a rare autoimmune syndrome characterized by microvascular alterations involving the precapillary arterioles of the brain, retina, cochlea, and semicircular canals . This diIn this paper, we considered the application of the multimodal retinal imaging approach to describe a case of SS.A 33-year-old man was admitted to the emergency unit for headaches, a referred visual field loss, dizziness, and weakness of the limbs. The patient had a history of malignant external otitis , hearingAlthough the clinical trio including focal neurological deficits, hearing defeat, and retinal arterial occlusions is considered pathognomonic, the whole clinical manifestation occurs in only 13% of patients at onset ,3. The mIn conclusion, MRI and FA are the main diagnostic instruments and may lead clinical ophthalmologists to the correct diagnosis of SS; however, new diagnostic instruments such as OCTA and wide-field color retinal photography may provide an advantage in early diagnosis and follow-up of SS, offering an effective alternative to standard FA; in evaluating microvascular changes in all capillary plexuses; and in monitoring retinal vessel density alterations during prompt therapy without dye injection.


Among them, leiomyomas are common. Surgical enucleation is indicated in cases, which have symptoms or large tumors. The enucleation through video assisted thoracoscopic surgery has been developed as a preferred approach for the majority of lesions in recent years. However, the complete thoracoscopic enucleation for an esophagus leiomyoma at the level of the azygos vein without cutting the vein and nor using artificial pneumothorax by COThis case report was a 64-year-old female who presented dysphagia and chest pain. Chest computed tomography and esophageal endoscopy displayed an esophageal mass. We used complete thoracoscopic enucleation to treat this condition. The tumor was at the level of the azygos vein. Therefore, it was difficult to remove the tumor without cutting the azygos vein without utilizing the artificial pneumothorax. However, we enucleated it completely with no complications.The complete thoracoscopic enucleation of the esophageal leiomyoma at the level of the azygos vein without cutting the vein without using the artificial pneumothorax should be applied. A methylene blue swallowing study is an alternative method to a barrium swallowing study while the chest tube is still placed in the pleural space. This case report describes a patient with an esophageal leiomyoma at the level of the azygos vein undergoing complete thoracoscopic enucleation successfully at our department of surgery. This case has been reported in line with the SCARE Criteria for case reports Benign tumors of the esophagus are rare. Among them, leiomyomas are common. Studies have reported an incidence of benign esophageal tumors ranging from 0.005% to 7.9% in autopsy cases. The true incidence of esophageal leiomyoma is uncertain because many leiomyomas are asymptomatic and are often incidental findings 2A 64-year-old female was admitted to our hospital due to dysphagia and chest pain persisting for 2 months. The medical history of the patient and her family was not significant. She presented herself at our thoracic department. Results of physical examination were normal. Gastroscopy revealed an esophageal submucosal protrusion with a smooth surface. This mass was about 25 cm from the superior incisor . We didnThe chest computed tomography showed a round high-density shadow on the right edge of the esophagus at the level of the azygos vein , 3.Figs.0 frontal incline (semi prone position). The screen was in front of the patient. The surgeon and the assistant surgeon were at the back of the patient. Three trocarts were used. The first trocart of 1 cm in diameter was in the sixth intercostal space at the anterior axillary line for the camera. The second trocart of 1 cm in diameter was in the seventh intercostal space at the posterior axillary line for instruments and devices. The third trocart of 0.5 cm in diameter was in the fourth intercostal space at the middle axillary line for instruments (After preoperative preparation, the complete thoracoscopic enucleation was performed under double-lumen endotracheal intubation of anesthesia. The patient was placed in left lateral decubitus position about 45truments .Fig. 4Th2 insufflation. The thoracoscopic visualisation demonstrated an esophageal intramural tumor at the level of the Azygos vein (We didn't use artificial pneumothorax by COgos vein .Fig. 5LoThe mediastinal pleura was incised longitudinally above the tumor. The esophageal segment containing the tumor was exposed. The muscle of the esophagus was cut to expose the tumor that has a white, grey color and smooth surface. The tumor was sutured with a vicryl 2.0 to facilitate pulling up the tumor. The tumor was isolated and enucleated completely out of the mucosa. We performed the enucleation of the tumor without cutting the Azygos vein , 7.Figs.endo-bag and removed out of the thoracic cavity through the incision at the eighth intercostal space at the posterior axillary line. We washed the thoracic cavity by crystal solution. After checking the bleeding at the sites of trocars, a chest tube 28F in size was placed into the pleural space through the incision for the camera. All incisions were sutured by silk. The procedure lasted for 2 h. There were no perioperative complications. The blood loss was minimal.Then we injected 50 ml of air into the esophageal lumen but no bubble of air at the bed of the tumor was recognized. The muscular layer of the esophagus was closed by interrupted sutures of vicryl 3.0. The mediastinal pleura was also sutured . The tumAfter the operation, the patient was transferred to the surgery intensive care unit. 6 h later, she was transferred to our thoracic surgery department. On the first postoperative day, the patient swallowed 10 ml of methylene blue solution. There wasn't any leakage of the methylene blue in the chest drainage. On the same day, the chest x-ray was normal. Therefore, the chest tube was removed. The patient ate soft food on the third postoperative day and normal diet from the fourth postoperative day. She discharged from the hospital on the fifth postoperative day. The pathological result is leiomyoma . The immDuring the follow up three months later, the patient didn't have the dysphagia and the vague chest pain. The barium swallowing x-ray was normal .The patiThis case was operated by Dr. Trong Vu Than who is the chief of the thoracic surgery department of Da Nang hospital in Vietnam. He is a senior thoracic surgeon who has a vast amount of experience in video assisted thoracic surgery.Written informed consent was obtained from the patient for publication of this case report and any accompanying images.3Esophageal leiomyoma is more popular than other esophageal benign tumors. It is most commonly located in the middle and lower segments of the esophagus On the postoperative day 1, the patient swallowed 10 ml of blue methylene solution to rule out again the leakage of the esophagus. The chest tube was removed on the postoperative day 2. We think the blue methylene swallowing study is necessary instead of doing the barium swallowing study when the chest tube is still in place because of reducing the risk of x-ray exposure to the patient.4This is a case report of a esophageal leiomyoma extending 3 cm in the longest axis. Therefore, we couldn't confirm the feasibility of the complete thoracoscopic enucleation for tumors more than 3 cm at the level of the azygos vein.5The complete thoracoscopic enucleation of an esophageal leiomyoma at the level of the azygos vein is safe and effective without dividing the azygos vein without using the artificial pneumothorax.The blue methylene solution swallowing study is an option to rule out the leakage of the esophagus when the chest drainage is still placed in the pleural cavity.The authors have no conflicts of interest to declare.


Glomangiomas are rare and benign hamartomas that commonly occur in the upper extremities. It is not typical for benign glomangiomas to be larger than one centimeter in size, and they usually present as a faint, blue-red subungual papule associated with a triad of symptoms of paroxysmal pain, pain with cold exposure, and tenderness to touch.We herein report a case of a 72-year-old man with multiple comorbidities presented to our clinic as a case of right-hand middle finger swelling for the past five years. Initially, it was not painful. However, the pain became more noticeable when he lowers his hand, and it was relieved when he kept it elevated. There were no skin changes around it with minimal tenderness over the swelling. Hand MRI demonstrated a well-defined small lobulated nodule at the radial aspect of the middle finger, at the level of the middle phalanx with no invasion to an adjacent structure. Surgical excision was done and the patient was diagnosed by histopathology to have glomangioma.Glomangiomas, also known as glomus tumors, are rare and benign hamartomas that commonly occur in the upper extremities. The hand is the most common site for glomus tumors, particularly the subungual area, the lateral aspect of the digits, and the palms. Female patients are the most common to present with subungual glomangioma. Multiple papers reported different presentations, and due to the rarity of the conditions and overlapping in clinical and imaging characteristics with other conditions, it was challenging to diagnose.Such atypical cases must be approached with high clinical suspicion and proper imaging and investigations so as to not delay diagnosis and management.  Glomangiomas are rare and benign hamartomas that commonly occur in the upper extremities . GlomangA 72-year-old man with multiple comorbidities presented to our clinic as a case of right-hand middle finger swelling for the past five years. It started to bother him in the last five months. Initially, it was not painful. However, the pain became more noticeable when he lowers his hand, and it was relieved when he kept it elevated. On examination, there was a soft swelling on the dorsal aspect of the radial side of the right middle finger middle phalanx about 3 cm x 2 cm in size. There were no skin changes around it with minimal tenderness over the swelling. He has a full range of motion with intact sensation Figure .Hand X-ray did not show any abnormalities. Hand MRI demonstrated a well-defined small lobulated nodule at the radial aspect of the middle finger, at the level of the middle phalanx. This nodule is measuring about 1.2 cm x 0.7 cm in anteroposterior (AP) and transverse diameter, respectively, with no invasion to adjacent structure (Figure The patient was then booked for an excisional biopsy of the swelling. It was a well-loculated mass with a feeding vessel without any attachments to the surrounding structures Figure . PatholoGlomus tumors refer to hyperplasia of the glomus body. A glomus body is an apparatus of the skin and a type of arteriovenous anastomosis that controls the body temperature. Glomangioma found in the subungual area mostly occurs in female patients  and it a Histologically, they consist of glomus bodies, smooth muscles, and blood vessels. Glomus tumors can be identified as three types depending on the composition of the tumor: glomangiomas mainly consist of blood vessels; solid glomus tumors are mainly composed of glomus cells, and glomangiomas mainly consist of smooth muscles. While glomus tumors are essentially benign, glomus tumors in rare cases are accompanied by sarcomas to form glomangiosarcoma . A variety of common and uncommon soft tissue tumors often have overlapping imaging characteristics, the appropriate diagnosis of which can be a source of confusion for both clinicians and radiologists . On MRI, The symptoms and clinical presentation of paroxysmal pain, tenderness, and aggravation of the symptoms by coldness are significant in establishing a diagnosis. A study done by Lee et al. retrospectively reviewed 15 patients with subungual glomus tumors of the hand. All of them were presented with a chief complaint of pain in a subcutaneous nodule in the hand. In all of the presentations, the pain was caused by pressure, but in one case, the pain occurred as cold intolerance. Three cases featured nail deformities. Seven showed bluish discoloration in the nails. All of the patients had a solitary glomus tumor in one digit . Bordianu and Zamfirescu published a report of a patient with a glomus tumor on the dorsolateral side of the distal phalanx of the left thumb associated with intermittent episodes of severe pain and cold intolerance . Another In comparison to previous studies, our patient presented with a benign three-centimeter glomangioma of the hand for five years that only recently became painful when lowering the hand. The patient did not mention cold intolerance. And there were no skin changes, with minimal tenderness over the swelling. Giving an initially unclear clinical picture and recent changes of the symptoms, it raised the suspicion of malignant changes. The use of imaging was needed. Hand X-ray did not show any abnormalities. Hand MRI only demonstrated a well-defined small lobulated nodule at the site of the mass. Surgical excision was done and the patient was diagnosed by histopathology with having glomangioma.Despite the well-documented clinical features of glomus tumor and that glomus tumors and glomangiomas are a well-known cause of chronic pain in the digits, atypical clinical presentations of glomangioma that are not associated with paroxysmal pain, tenderness, and cold intolerance could obscure the clinical picture thus potentially delaying diagnosis and treatment. As physicians, we should keep an open mind and have high suspicion when we face such cases with atypical presentations that indicate further investigation and prompt intervention.


Hidradenitis suppurativa (HS) is a debilitating disorder characterized by chronic inflammation in intertriginous areas. Malignant transformation to squamous cell carcinoma (SCC) is rare and is mostly diagnosed in the perianal area in men. The clinical behavior of SCC in HS can be aggressive, with local invasion and distant metastases.Case descriptions.We describe two cases of vulvar SCC in HS. The first demonstrates a 75 year old woman with a severe undertreated HS for over 30 years, who presented with a widespread vulvar cancer with lymphangitis carcinomatosa and inguinal and pelvic lymphadenopathy within several weeks after first suspicion of a malignancy. She died shortly after diagnosis. The second case describes a 61 year old woman diagnosed with HS 7 years ago, who presented with a rapidly progressive vulvar cancer with suspicion for ingrowth in the anal sphincter, vagina and levator ani muscle with inguinal and pelvic lymphadenopathy. She received radical chemoradiation with a complete response on imaging, but had a local recurrence within 2 months after finishing treatment. A posterior exenteration was performed but 5 months after surgery she had a second recurrence in the vulvar scar and pelvic floor muscles with possible bone metastases. She received palliative chemotherapy.Vulvar SCC in an area of HS is a rare condition which is difficult to diagnose. It can have an aggressive course with rapid progression and a high frequency of metastases at presentation. Early surgical excision of HS to diagnose occult malignant transformation, appropriate imaging to establish the extent of the disease and an aggressive treatment plan without any delays are recommended. The prePathogenesis involves immune dysregulation leading to increased secretion of antimicrobial peptides and inflammatory cytokines. Follicular hyperkeratosis and plugging leads to occlusion and dilatation of the pilosebaceous unit, with subsequent rupture and discharge of follicular content. This results in inflammatory reactions with an influx of neutrophils, lymphocytes and histiocytes leading to abscess formation and architectural tissue changes .Although HS is more common in women than in men, malignant transformation to squamous cell carcinoma (SCC) affects mainly men, mostly in the perianal or perineal area . The cliWe describe two cases of vulvar SCC in HS to increase awareness of this potential serious complication in patients with HS.2A 75 year old woman was referred to the dermatology department because of a severe undertreated HS Hurley stage III. Since her forties she had multiple surgical deroofings. She smoked 5 cigarettes a day.She reported a continuous pain in her groins and labia with recurrent infection and bleeding. Physical examination showed multiple sinus tracts with suppurating nodules and abscess formation in her groins, vulvar and pubic region and perianally. On her left upper leg a lenticular erythematous livid exophytic papule located on a sinus tract was seen. A skin biopsy showed epidermal hyperplasia and an extensive chronic active inflammatory infiltrate without any signs of dysplasia or malignancy. She was prescribed clindamycin 300 mg twice daily with rifampicin 300 mg twice daily after which the inflammation regressed and the pain disappeared. As the inflammation and pain recurred after attempts to stop the antibiotics this treatment protocol was continued with satisfaction.A few months later the patient mentioned that she had noticed a new lesion in her left groin. During physical examination extensive scarring, sinus tract formation, papules and comedones were observed as well as a 2 cm long fissure in her left groin without any signs of active infection. Differential diagnosis was a ruptured sinus tract in severe HS. Because of this observed progression despite treatment she was referred to a plastic surgeon for radical excision.In the waiting time for the radical excision, the patient was reassessed by the dermatologist 2 months after the previous visit. The clinical presentation of the lesion in the left groin had changed with deroofing of the lesion and a yellowish debris. Differential diagnosis was granulation tissue or SCC. A biopsy revealed at least high grade dysplasia, but invasion could not be excluded. The surgical excision by the plastic surgeon was therefore expedited.Three weeks after last inspection a radical excision of the HS in both groins was performed by the plastic surgeon. The patient was discharged a day later but required frequent returns to clinic because of compromised wound healing. Histology showed a SCC grade 3 in the left groin with depth of invasion of 11 mm without perineural or lymph vascular invasion. Excisional margin was positive for carcinoma. The histology of the right groin showed fistula and reactive changes but no dysplasia or carcinoma. A computed tomography (CT) scan of the chest and abdomen was performed with multiple enlarged inguinal lymph nodes and a 12 mm pelvic lymph node. Differential diagnosis was lymph node metastases or reactive lymphadenopathy postoperatively in a patient with active HS.A re-excision was scheduled 6 weeks after the primary surgery. However, progression of the lesion in the left groin was visible with extensive vulvar changes suspicious for a widespread malignancy with lymphangitis carcinomatosa. The primary lesion was re-excised and vulvar mapping was performed . PatholoFurther treatment focused on best supportive care. Two weeks after discharge euthanasia was performed as per patient request because of refractory pain.3A 61 year old woman was diagnosed with HS around the age of 54. She had multiple surgical incisions and drainages because of her HS and was treated for a perianal abscess in the past. She smoked 5 cigarettes a day.She complained of daily serosangulent and purulent fluid loss for which she used multiple gauzes and sanitary towels a day. This caused a lot of pain and fatigue and influenced her daily life. She used clindamycin 300 mg twice daily, without rifampicin because of side effects. Because this treatment was unsatisfactory in controlling her HS, screening for the start of adalimumab was initiated.In the meantime she visited the dermatologist because of a painful vulvar lesion with purulent discharge and bleeding from this lesion. She had trouble sitting because of severe pain and had a weight loss of 6 kg in a few weeks. Physical examination showed an ulcer of 4–5 cm, and a palpable lymph node in the left groin of 2 cm. Vulvar biopsy showed a SCC grade 2 with lymph vascular invasion. Immunohistochemistry showed wildtype p53 and diffuse strong positive p16 expression. The PCR was positive for high risk HPV 16. Ultrasound guided biopsy of the inguinal lymph node did not confirm metastasis.The patient was referred to a gynecologist. A joint consultation together with the radiotherapist was scheduled no later than 3 weeks following the last inspection. Physical examination showed an extensive ulcerating tumor of 7 by 4 cm and about 5–6 cm in depth, on the perineum, left and ventrally of the anus, with a second more solid lesion of 3 by 4 cm dorsally of the anus . Pelvic She was treated with chemoradiotherapy 30 fractions of 1.65 Gy with a boost of 2.15 Gy on the vulvar tumor and suspicious lymph nodes, with weekly cisplatin 40 mg/m2. Because of side effects only 2 of the 5 scheduled cisplatin courses were administered. Post-treatment physical examination showed a complete response.However, less than 2 months after treatment the pain recurred and a lesion of 2 by 3 cm was visualized in the same location as the primary tumor . Biopsy A posterior exenteration was performed including complete resection of the HS, the distal vagina, the anus and the rectosigmoid with a permanent colostomy. The wound was closed by a plastic surgeon using reconstruction with a Vertical Rectus Abdominis Muscle (VRAM) flap, a gluteal thigh flap, and a VAC pump. Pathology results revealed a SCC of 3.1 cm with a depth of invasion of 6.8 mm with free margins.Physical and mental recovery was challenging. Five month after surgery, there was progressive vulvar pain with serosanguinolent fluid discharge. Inspection revealed residual HS with two small sinus tracts with induration and edema, but no visible or palpable signs of SCC recurrence. Nonetheless, MRI showed tumor recurrence in the vulvar scar and pelvic floor muscles with possible bone metastases. She received 6 cycles of palliative chemotherapy (carboplatin and paclitaxel) after which she had stable disease on imaging, but 3 months after completing the last cycle imaging showed progressive disease with a 6 cm tumor in the pelvic floor muscles with invasion of the pubic bone.4These two cases show that vulvar SCC in an area of HS is difficult to diagnose and can have an aggressive course with rapid progression.The various external features of HS make it difficult to identify SCC in HS. In a case series with 13 patients with SCC in HS, the clinical aspects of the suspect areas varied from a 3 cm ulcerating and granulating lesion to a 15–20 cm wide tumoral mass . SuperfiEven though it is rare, there are several previously published case reports on women with SCC in an area of HS. Some of them describe patients with only stage 1 vulvar cancer with good outcome after surgery alone without adjuvant treatment , howeverThe association between HS and SCC is a topic of debate . ChronicTP53 mutations often in a background of lichen sclerosus, another is initiated by a high-risk HPV infection. With p53 and p16 immunohistochemistry the TP53 mutational status respectively the HPV status can be determined to classify vulvar cancer into three molecular subtypes. In a retrospective cohort study with 415 women with vulvar cancer 18% of tumors were HPV positive, 66% of tumors were HPV negative with a p53 mutation and 15% of tumors were HPV negative with a p53 wildtype (Intrinsically different subtypes of vulvar cancer have been identified . The moswildtype . The womIn conclusion, SCC and especially vulvar SCC in HS is a rare condition which is difficult to diagnose, with a high frequency of metastases at presentation and an aggressive course with rapid progression. We recommend early surgical excision of HS to diagnose occult malignant transformation, appropriate imaging prior to treatment to locate lymph node or distant metastases, and an aggressive treatment plan without any delays.T.F.M. Vergeldt: Conceptualization, Writing – original draft. R.J.B. Driessen: Writing – review & editing. J. Bulten: Writing – review & editing. T.H.J. Nijhuis: Writing – review & editing. J.A. de Hullu: Writing – review & editing.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Rieke Driessen reports grants and personal fees from Galderma, Novartis, Abbvie, Janssen and Leo Pharma, outside the submitted work. Fees were paid directly to the institution. The other authors have nothing to disclose.


He has since started using a wheelchair. Upon examination, he denied symptoms of increased intracranial pressure or prior head trauma. Further examination revealed nystagmus; scanning speech; and intentional tremor, hypertonia, and hyperreflexia of the right upper and lower limbs. Brain magnetic resonance imaging revealed multiple hypointense lesions in the subcortical and deep white matter involving the bilateral parietal, frontal, and occipital lobes; pons; cerebellar peduncle; and cerebellum (A 30-year-old man with a history of acquired immunodeficiency syndrome (AIDS) (CD4=13 cells/mmrebellum . Imaging,Widespread lesions due to oligodendrocyte infection by the JC virus characterize PML, which is rare and usually associated with AIDS, hematologic malignancies, or immunosuppressive treatments. The availability of antiretroviral therapy has significantly reduced the incidence of PML and its associated mortality. PML typically presents insidiously with focal neurological deficits that vary depending on the location of the lesions


The success of endodontic therapy is attributed to complete arbitration of the bound entities concealed within the complexity and absolute disinfection of the root canal system, thus, deeming it mandatory to effectively negotiate and overcome the challenges posed by obstruction, either iatrogenic or anatomic. To achieve this, considerable depth of knowledge and expertise with reference to variations in root canal morphology and clinical mishap management is substantially as important as developing fine observation skills in conjunction with an appropriate armamentarium and a keen sense of determination, thereby enhancing one's clinical acumen by several folds. In the present case, following rubber dam isolation, the temporary restoration was removed, and the remaining carious dentin was excavated. Endodontic access cavity was refined and explored with a DG-16 probe, following which three separate canal orifices were identified in the pulp chamber floor . On further observation under a surgical operating microscope and continuous exploration with the DG-16 probe, a fourth canal was found in the mesial aspect of the tooth . With instrumentation, it was confirmed that a fractured object was indeed present at the apical third of the mesiolingual root of tooth 38. Bypassing of the fractured fragment was initiated with a size 10 SS K-file coupled with copious irrigation with 3% sodium hypochlorite. In the present case report, four distinct canals comprising 3 mesial and 1 distal canal were recognized, and the fractured instrument in one of the canals was bypassed successfully. The root canal in all its glory is a relentless enigma unfolding itself during the endodontic treatment procedure. It is therefore pertinent to remember that a complete understanding of the bound entity is indeed an essentiality in order to achieve the most prolific of all outcomes . A succeThe general prerequisites to be considered prior to the management of a complex anomaly often involve earlier discussed criteria as well as a definite focus on the pulp chamber floor, proper judgement, and use of sufficient armamentarium keeping in mind the biological anthropology of a tooth and its varied anatomy . Apart fA 31-year-old Indian male patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of spontaneous pain in the lower left back tooth region for the past 4 days. Medical history was noncontributory. The patient revealed a history of intermittent pain for 3 weeks which continued to increase in severity, aggravated while chewing food at the affected site, and relieved with medication. The patient gave a detailed history on the subjective symptoms and disclosed that the tooth had been treated 8 months back. On clinical examination, it was noticed that the patient had undergone extraction of teeth 36 and 37, and restoration was present in 38. Soft tissue examination revealed neither oedema nor tenderness to palpation. The tooth elicited moderate to severe tenderness on the application of finger pressure. Multiple parallax radiographs were taken to assess the condition of the tooth and its surrounding structures. The preoperative radiograph revealed radiopacity in the pulpal chamber and at the apical third of one of the roots . While tThe tooth was anaesthetised with 1.8 ml 2% lignocaine containing 1 : 200,000 epinephrine . Following rubber dam isolation, the temporary restoration was removed, and the remaining carious dentin was excavated. The endodontic access cavity was refined and explored with a DG-16 probe , following which three separate canal orifices were identified in the pulp chamber floor . On further observation under a surgical operating microscope  and continuous exploration with the DG-16 probe, a fourth canal was found in the mesial aspect of the tooth . Once all four canals were scouted, the access was modified into a trapezoidal cavity using an Endo Z bur  to obtain straight-line access of all four canals. Nickel-titanium (NiTi) ProTaper Gold SX orifice shapers (Dentsply Maillefer) were used for coronal enlargement followed by patency establishment using a size 10 stainless steel (SS) K-file (Dentsply Maillefer). With instrumentation, it was confirmed that a fractured object was indeed present at the apical third of the mesiolingual root of tooth 38. Bypassing of the fractured fragment was initiated with a size 10 SS K-file coupled with copious irrigation with 3% sodium hypochlorite. The size 10 K-file was implemented mesially along the inner curvature of the target site to bypass the fragment lodged within the curvature. Following each attempt, the file was removed, inspected, cleaned, and engaged again with a gentle push-pull and/or watch winding motion. On inspection, if a file was distorted, it was immediately replaced with a new size 10 K-file and instrumented repeatedly as described above till the resistance was bypassed, after which a size 15 SS K-file was introduced and worked in a similar fashion. Subsequent radiographs were taken to understand the extent of bypassing of the fractured fragment achieved with the size 15 K-file. Once the fractured file was bypassed completely , sequentμm,14 s). Reduction in size of the lesion was markedly visible at the 1-year follow-up period . Following irrigant delivery, the tip was placed 1 mm short of the working length for each canal, activated for 30 seconds, and then removed. Drying of the canals was made certain with absorbent paper points (Dentsply Sirona), following which the master cone fit was checked and confirmed on a radiograph . Obturatp period .The mandibular third molar is the last tooth to erupt into the oral cavity, usually between 17 and 21 years of age or at a later stage in life, partially erupt or perhaps not erupt at all . Owing tThe mandibular third molar is indeed a cut above the rest with reference to anatomical variation . BarringAt 1 year follow-up, it was decided that a CBCT scan should be done to highlight the unique four-rooted variation of the mandibular third molar, encasing four distinct canals , 21. AddThe most common site of occurrence of separated instruments has often been reported in mandibular molars. The aforesaid statement is reckoned from the fact that compelling evidence has been accorded for the same, as disclosed by Shen et al., 2004, Cujé et al., 2010, and Nevares et al., 2012 –26. InteIn routine dental practice, by and large, it is uncommon to frequently come across retained instrument fragments in the root canals of endodontically initiated and/or treated teeth with a low rate of incidence being reported for the same. However, during a serendipitous encounter, adept knowledge, and dexterous proficiency in this regard succour to assess the limitations in hand and opt for the best suitable technique coupled with existing and/or emerging technologies available, capable of ensuring a better prognosis for the tooth in question, as evinced in the present case report. With reference to root canal aberrancies, “there's more to it than meets the eye,” as the root canal is an incessant conundrum unto itself. Having said that, the acronym “KODAC”-sound knowledge (K) of aberrant anatomy, keen observation (O) skills for locating shrouded canals, ever-zealous sense of determination (D), indispensable armamentarium (A) for scouting, enduring commitment (C) to follow-up such cases, holds significant credibility in the long-term successful management of complex root canal anatomies and mishaps of iatrogenic/anatomical origin.Existing literature reveals that the greatest percentage of instrument fracture is witnessed in the apical third of the root canal, probably due to inadequate patency and canal width –33. At tIn the present case report, from a clinical and radiographic point of view, four distinct canals were recognized. Following a CBCT examination, 3 mesial and 1 distal canal (3 M and 1D) were clearly discernible . General


The authors present the first case, to the best of our knowledge, of a preplanned suicide by self-waterboarding. Waterboarding (WB) is a military method of torture in which water is poured into the nostrils and the mouth of a victim, to evoke the sensation of asphyxiation by drowning. The victim was a 22-year-old male student, who was found dead and naked in the bathtub. His head was covered by a soaked canvas bag, and his hands were tied with two nylon ropes and a padlock. The water jet of the showerhead was specifically directed at the victim’s head, so that the canvas bag could be soaked with water. The cause of death was defined as the combination of asphyxiation by drowning with the direct suffocation provoked by the soaked canvas bag in the context of the waterboarding practice. Finally, the authors discuss the differential diagnosis regarding the modality (suicide versus homicide) through which this case of waterboarding was performed. The case is intended to be used as source data for similar forensic cases, where a multidisciplinary approach is advisable in such complex cases. The osition) , 4.This case report shows the forensic pathological description of a fatal case of waterboarding. The victim was a 22-year-old male student, who was found dead in the bathtub of his own house. The body was naked, the head was covered by a soaked canvas bag and both his hands were firmly tied with two nylon ropes and bound with a padlock. The water jet of the showerhead was specifically directed at the victim’s head, so that the canvas bag could be soaked with water. The prosecutor ordered an on-site forensic investigation, followed by a judicial autopsy with toxicological, histopathological, and genetic analyses.The evaluation of possible suicides is not, however, always straightforward, and it may be complicated by atypical death scene and autopsy findings. In forensic pathology, the differential diagnosis between homicides and suicides may be very challenging –7. In thA 22-year-old male student did not show up for an appointment in the first afternoon, and as a consequence his parents were contacted. Thus, they called the janitor of the apartment building where the young man lived, as he did not answer the phone. The janitor, who had an extra set of keys of all the flats, entered the man’s house, whose door was closed. The janitor heard the water flowing in the bathroom and found him naked and unconscious, lying on the bathtub. She promptly alerted the emergency services.Upon arrival of the emergency team, the body was lying naked in the bathtub. The head was completely covered by a soaked canvas bag, held around the neck by a white nylon rope, and reached by the water jet coming from the showerhead. The emergency team turned off the water, cut the white rope around the neck, and partially lifted the canvas bag to expose his face Fig. . The manThe family members were interviewed by the police. They reported that the victim did not suffer from psychiatric diseases or socio-economic difficulties. Furthermore, they reported that he had never showed suicidal proposals and/or attempts. A suicidal letter was not left by the victim. The prosecutor ordered a judicial autopsy at the Milan Institute of Legal Medicine 36 h after the on-site judicial investigation.Prior to autopsy examination, face, neck, wrists, hands, and external genitalia were swabbed in order to avoid any contaminations. Also, the free margin of the nails, the nylon ropes, the padlock, and the canvas bag were collected for a subsequent forensic genetic analysis, which was requested by the prosecutor.External examination indicated that the body was in good state of preservation , with rigor mortis presented both at the neck, upper, and the lower limbs (the corpse was refrigerated). Intense post-mortem lividity was present on the back and fixed; furthermore, there were no conjunctival petechial hemorrhages. A current mark was not documented on the body. At autopsy, the body did neither show blunt force injuries nor defensive wounds. In particular, the upper limbs did not show any injuries. The hyoid bone and both the laryngeal superior cornua were undamaged. A pinkish frothy fluid was observed in the trachea and the main bronchi, but no foam was present in his mouth or his nostrils. The lungs were markedly overinflated , filling the thoracic cavity. The surface was pale and crepitant, with subpleural petechiae. The pulmonary parenchyma was waterlogged, with some areas of intrapulmonary bleedings. Furthermore, a lot of red-tinged frothy fluid exuded from the bronchi on the cut section. Upon autopsy, bilateral hemorrhages within the petrous temporal bones were observed. About 50 cc of brownish fluid material were found in the stomach, without any food traces. The heart, the abdominal viscera, and the pelvis did not show any gross lesions, and nothing else was observed upon autopsy. Viscera specimens , biological fluids , hair, and nasal swabs were sampled for subsequent toxicological analyses. Samples of the brain, heart, lungs, stomach, liver, spleen, and kidneys were also collected for histopathologic examination. A specimen of psoas muscle was also sampled for forensic genetic analysis. All the analyses were authorized by the prosecutor.Regarding the forensic genetic analysis, the PCR amplification only revealed the victim’s DNA, which was compared with the sample of psoas muscle collected during the autopsy examination.Toxicological analyses were performed in accordance with the protocols adopted in the Milan Institute of Legal Medicine. Alcohol concentrations were analyzed by gas chromatography (GC) in specimens of femoral blood, gastric content, and the brain: all of them resulted to be negative. Specimens of urine and cardiac blood, tested by ELISA immunoassay, were analyzed for illicit psychotropic drugs, which were negative. In addition, no medicinal drugs and non-volatile toxic substances were found in urine, cardiac blood, or bile, which were analyzed by GC and liquid chromatography (LC). Finally, no drugs were detected in hair sample and nasal swabs.emphysema aquosum, since the edema fluid in the bronchi blocks the passive collapse that normally occurs at death, holding the lungs in the inspiratory position. The other organs did not show any abnormalities.Samples of the brain, heart, lungs, stomach, liver, spleen, and kidneys underwent standard post-fixative histopathologic examination. Slides were stained with hematoxylin and eosin (HE) and Masson’s trichrome staining (MT). Histologic slides of the brain, stomach, and kidneys showed post-mortem autolytic changes. Slides of the heart revealed wavy myocardial fibers, with a moderate fibrosis of the interstitium space. The spleen showed hyperemia, while the liver showed microvesicular steatosis. The pulmonary parenchyma showed a massive edema, with some areas of acute emphysema and hemorrhagic foci Fig. . This laFinally, the cause of death was identified as an asphyxiation by drowning in combination with direct suffocation caused by the soaked canvas bag, in the context of waterboarding practice. Toxic substances and natural diseases were not documented.To the best of our knowledge, waterboarding has never been used to commit suicides or homicides, but only for torturing prisoners. Therefore, waterboarding has been practiced for centuries. It was used by the Spanish Inquisition in the sixteenth century , during In the case presented, the possibility of a waterboarding fatality occurred in the bathtub was based on several data. In particular, the victim was found completely naked in the bathtub, and the hands were firmly tied with two nylon ropes and bound with a padlock. The head was covered by a soaked canvas bag, held around the neck by a nylon rope, and reached by the water jet coming from the showerhead, which was specifically inclined to the head. The external examination did not show any injuries. In particular, signs related to blunt force injuries were not documented. Furthermore, defensive cut wounds typically involving the upper limbs , 6 were In the case presented, toxicological analyses were all negative in reference to drugs and illicit substances. Toxicological investigations help forensic pathologists to establish whether the victim had taken medications, alcohol, or illicit drugs, which may alter the psycho-physical abilities of a healthy man, facilitating direct physical violence , 14 and Forensic genetic analysis only revealed the victim’s DNA. In addition, the police examined the security camera footage recorded in the apartment building where the victim lived. No suspicious activities were reported in the time period included within the estimation of the time of death. These findings were therefore highly suggestive of a suicidal WB fatality. The police also tried to reproduce the complex binding system of the victim. According to the police, the victim may have tied his wrists and his hands with the nylon ropes. Then, he may have put the canvas bag on his head; after that, he probably has fastened the canvas bag with the nylon rope. Finally, he might have bound with a padlock the two ropes, which were previously fastened all-around each hand, and opened the mixer tap of the shower with a knee or a foot. According to the medicolegal literature –21, selfSuicidal waterboarding is therefore definable as a primary and planned complex suicide , 23 sincThe authors presented the first case of suicidal waterboarding, although a clear and specific differential diagnosis with a homicide is not possible beyond any doubt. In forensic practice, this aspect is still challenging for the forensic pathologists. However, a multidisciplinary approach based on a thorough on-site investigation, autopsy examination, and laboratory analyses is highly advisable in such complex cases.


Colonoscopy is a commonly performed outpatient procedure with a low risk of complications. The most common complications seen in the postoperative period include hemorrhage and perforation. Infrequently, splenic injury can occur.A 72-year-old male presented with a one-day history of left upper quadrant pain following colonoscopy. During the procedure he had two polyps removed along the transverse colon near the splenic flexure. There were no complications during the procedure or in the immediate post-operative period. On presentation to the emergency department, abdominal tenderness was present in the left upper quadrant without rebound, rigidity, or guarding. Point-of-care ultrasound of the abdomen demonstrated mixed hypoechoic densities confined to the splenic capsule, and computed tomography of the abdomen and pelvis with intravenous contrast noted a grade II/III splenic laceration without active extravasation. The patient was admitted for serial abdominal examination and labs.Splenic injury following colonoscopy is a rare complication of colonoscopy. Emergency providers should be aware of this possible complication, and acute management should include basic trauma care and consultation for possible intervention, if warranted. Colonoscopy has become a routine diagnostic and treatment option for many colonic diseases and has a relatively low complication rate. The overall complication rate has been reported to range from 0.5% for routine colonoscopy and up to 1.8% for colonoscopy with polypectomy.A 72-year-old male presented due to left upper quadrant abdominal pain that radiated to the flank and constipation one day following a colonoscopy. He reported that he had not had a bowel movement or passed gas since the procedure. The indication for colonoscopy was chronic constipation. Following instructions from his surgeon, the patient had stopped taking clopidogrel and aspirin, both taken for moderate coronary artery disease, several days prior to the colonoscopy. During the procedure, the patient had two polyps removed along the transverse colon near the splenic flexure. Intraoperatively and postoperatively, there were no complications notedUpon arrival to the emergency department, his vital signs were as follows: heart rate 66 beats per minute; blood pressure 113/59 millimeters of mercury; respiratory rate 16 breaths per minute; and temperature 98.7 degrees Fahrenheit. Upon examination, the patient appeared in no acute distress due to pain, and his skin and conjunctiva were without pallor. Abdominal examination revealed hypoactive bowel sounds, and there was tenderness to palpation in the left upper quadrant. No rebound, rigidity or guarding were seen on physical exam. No ecchymosis was noted in the left upper quadrant or the left flank.A point-of-care ultrasound of the spleen demonstrated mixed hypoechoic densities within the splenic capsule . ComputeSplenic injury following colonoscopy was first described in 1974 and is likely under-reported in the current literature.7What do we already know about this clinical entity?Although complications following colonoscopy occur at a rate of 0.5% to 1.8%, splenic injury is quite rare.What makes this presentation of disease reportable?This paper highlights the usage of point of care ultrasound as a diagnostic modality in those who present with abdominal pain following colonoscopy.What is the major learning point?Although rare, splenic injury following colonoscopy should be treated much like a splenic injury following traumaHow might this improve emergency medicine practice?By keeping a broad differential diagnosis, the emergency medicine physician should employ early consultation and trauma intervention to improve patient outcomes.Typically, patients will present with abdominal pain or left shoulder pain (Kehr’s sign) on the same day as the procedure.Treatment should follow the guidelines for the management of blunt traumatic splenic injuries. In the unstable patient with a splenic injury, exploratory laparotomy should be considered as the first-line treatment modality. In stable patients with active contrast extravasation from the spleen on CT, interventional radiology angioembolization should be considered after consultation. Those without active extravasation on the CT should be admitted for serial hemoglobin levels and abdominal examinations.An important part of obtaining a complete history includes eliciting any recent procedures as well as surgeries, including those performed in an outpatient setting. Although rare, splenic injury following outpatient colonoscopy is a complication that the emergency physician should include in the differential diagnosis for patients who present in the postoperative period. Early consultation, intervention, and appropriate trauma management should be used to avoid immediate and long-term morbidity and mortality.


Acquired perineal hernia is a rare complication following extensive pelvic surgery. Radiotherapy is also a predisposing factor. Perineal hernia can cause chronic perineal pain, bowel obstruction, urinary disorders and a cosmetically disfiguring defect. The treatment of perineal hernia is surgical, usually consisting of mesh repair via an abdominal or perineal approach.We present a case report and a surgical video of a 42-year-old woman with history of a squamous cell carcinoma. This patient had 3 recurrences since the diagnosis and a symptomatic perineal hernia. Complete regression of the recurrent malignancy allowed us to treat the perineal hernia. We performed laparoscopic repair with prosthetic mesh in this patient who had undergone multiple surgeries and radiotherapy, while preserving the omental flap that was used to reconstruct the posterior part of the vagina.There is no consensus concerning the preferred surgical approach, perineal or laparoscopic, as no study has demonstrated the superiority of either of these approaches. Laparoscopic repair for an acquired perineal hernia is safe and feasible. However, further studies including randomized trials are required to precisely evaluate the best surgical approach and type of mesh.The online version contains supplementary material available at 10.1186/s12893-021-01237-9. Acquired perineal hernia is a rare complication following extensive pelvic surgery with a reported incidence rate ranging between 0.6 and 7% after abdominoperineal resection or pelvic exenteration . PerineaWe present a case report and a surgical video of a 42-year-old woman with perineal hernia. The manuscript has been written according to CARE guidelines. This patient presented with stage IIA squamous cell carcinoma of the cervix, initially treated by radiotherapy, chemotherapy and brachytherapy in December 2013. Surgery consisted of laparoscopic total hysterectomy and ovariectomy, together with pelvic and para-aortic lymphadenectomy. Early left paravaginal recurrence occurred in 2015 and was treated by resection of the left Bartholin gland. Another course of radiotherapy and chemotherapy was administered due to positive surgical margins (R1) of this resection. The patient presented another recurrence of her cervical carcinoma in February 2017 confirmed by pelvic CT scan and MRI. Due to the presence of a suspicious rectovaginal node, abdominoperineal resection with terminal colostomy was performed via a laparoscopic and perineal approach. We performed laparoscopic dissection of the left and right pararectal space to prepare an extralevator abdominoperineal excision and partial posterior colpectomy. We then performed radical posterior vulvectomy and a perianal incision at the lateral margin of the external anal sphincter and continued the dissection into the ischioanal fossa as far as the insertion of the pelvic floor muscles. We repaired the perineal defect and performed reconstruction of the posterior part of the vagina with an omental flap to preserve sexual function. After another course of chemotherapy and cycles of bevacizumab, the patient presented with her third recurrence two years later. Anterior pelvectomy was initially indicated due to a malignant mass infiltrating the right ischiopubic ramus and the right obturator internus muscle responsible for urethral retraction. This patient's case was discussed at a multidisciplinary consultation meeting and it was decided to treat her with chemotherapy. Complete regression of the recurrent malignancy allowed us to treat the perineal hernia  . FinallyProphylactic mesh is increasingly used after extralevator abdominoperineal excision (ELAPE) or abdominoperineal resection (APR) to reduce the incidence of secondary perineal hernia [In conclusion, laparoscopic repair for an acquired perineal hernia is safe and feasible. However, further studies including randomized trials are required to precisely evaluate the best surgical approach and type of mesh (Additional file Additional file 1. Video of the perineal repair.