Pancreaticoduodenectomy (PD) is rarely performed for pancreatic cancer with hepatic arterial invasion owing to its poor prognosis and high surgical risks. Although there has been a recent increase in the reports of PD combined with hepatic arterial resection due to improvements in disease prognosis and operative safety, PD with major arterial resection and reconstruction is still considered a challenging treatment.A 61-year-old man with back pain was diagnosed with pancreatic head and body cancer. Although distant metastasis was not confirmed, the tumor had extensively invaded the hepatic artery; therefore, we diagnosed the patient with locally advanced unresectable pancreatic cancer. After gemcitabine plus nab-paclitaxel (GnP) therapy, the tumor considerably decreased in size from 35 to 20 mm. Magnetic resonance imaging revealed a gap between the tumor and the hepatic artery. Tumor marker levels returned to their normal range, and we decided to perform conversion surgery. In this case, an artery of liver segment 2 (A2) had branched from the left gastric artery; therefore, we decided to preserve A2 and perform PD combined with hepatic arterial resection without reconstruction. After four cycles of GnP therapy, we performed hepatic arterial embolization to prevent postoperative ischemic complications prior to surgery. Immediately after embolization, collateral arterial blood flow to the liver was observed. Operation was performed 19 days after embolization. Although there was a temporary increase in liver enzyme levels and an ischemic region was found near the surface of segment 8 of the liver after surgery, no liver abscess developed. The postoperative course was uneventful, and S-1 was administered for a year as adjuvant chemotherapy. The patient is currently alive without any ischemic liver events and cholangitis and has not experienced recurrence in the past 4 years since the surgery.In PD for pancreatic cancer with hepatic arterial invasion, if a part of the hepatic artery is aberrant and can be preserved, combined resection of the common and proper hepatic artery without reconstruction might be feasible for both curability and safety. Surgical resection is essential for the long-term survival of patients with pancreatic cancer. However, in several cases, the tumor is unresectable at the time of diagnosis. In recent years, the progress in chemotherapy has been remarkable, and many reports of conversion surgery have been published –3. It haIn conversion surgery, preserving blood vessels that have been invaded before treatment is a risk of vascular injury during surgery and can leave cancer cells at the resection margins. Therefore, combined vessel resection may be performed. Although arterial reconstruction may be performed to maintain organ blood flow after arterial en bloc resection, it is a difficult procedure compared with portal vein (PV) reconstruction, resulting in serious complications, such as postoperative bleeding and ischemia due to vessel obstruction. On the other hand, it has been reported that combined resection of the hepatic artery can be safely performed without arterial reconstruction in pancreaticoduodenectomy (PD) when combined with preoperative arterial embolization or when there is collateral blood flow –10.Here, we report a case of LAPC with an aberrant artery of liver segment 2 (A2) that was treated with conversion surgery combined with hepatic arterial resection without reconstruction.A 61-year-old man with no significant medical history presented to our hospital with back pain that started a week prior to his visit. Physiological and laboratory examinations were unremarkable except for elevated serum carbohydrate antigen 19-9 (CA19-9) and s-pancreas-1 antigen (SPan-1) levels . Contrast-enhanced abdominal computed tomography (CT) and gadoxetic acid-enhanced magnetic resonance imaging (MRI) revealed the presence of a 35-mm hypovascular tumor in the head and body of the pancreas, with dilatation of the main pancreatic duct and atrophy of the pancreatic tail. The tumor was observed to be in contact with the entire length of the common hepatic artery (CHA), the proximal portion of the proper hepatic artery (PHA), the gastroduodenal artery (GDA), and the root of the splenic artery (SPA) . After two treatment cycles, the tumor decreased in size from 35 to 20 mm. While CT revealed that the tumor was still in contact with the CHA, PHA, and SPA, contrast-enhanced MRI revealed a gap between the tumor and these arteries   Fig. . MoreoveNineteen days after embolization, we performed PD, PV resection with reconstruction, hepatic arterial resection without reconstruction (to preserve the aberrant A2), and D2 lymphadenectomy. The tissues around the CHA and the root of the SPA that were invaded before chemotherapy became extremely stiff; however, those around the embolized PHA were not very stiff. Therefore, the CHA was transected at its root. The distal part of the hepatic artery was transected at the root of the right, middle, and left hepatic arteries. The bile duct was transected below the bifurcation. The PV, superior mesenteric vein (SMV), and splenic vein were transected (4 cm in length), and end-to-end anastomosis of the PV and SMV was conducted with mobilization of the right colon and ileum , the tumor was defined as T2N1M0, stage IIB. No carcinoma cells were detected in the surgical margin (R0). Histologically, this tumor was categorized as Evans grade I , infiltrative type, ypT3, int, INFb, ly1, v1, ne0, mpd0, ypCH0, ypDU0, ypS0, ypRP0, ypPV1 (PVsp), ypA0, ypPL0, ypOO0, ypPCM0, ypBCM0, ypDPM0, ypN1a (3/11), ypM0, ypStage IIB according to the Japan Pancreatic Society classification, 7e I Fig. .Fig. 5Path day after surgery revealed the presence of a small ischemic area in liver segment 8, no liver abscess developed. The postoperative course was uneventful, and the patient was discharged 17 days after the surgery. He received S-1  as adjuvant chemotherapy for a year and is currently alive with no evidence of recurrence and without any ischemic liver events and cholangitis within the last 4 years since his surgery.Although liver enzymes levels were slightly increased and CT performed on the 7Although the prognosis of patients who are initially diagnosed with unresectable LAPC remains to be poor, there are some cases of LAPC that have been successfully treated with conversion surgery after systemic chemotherapy or chemoradiotherapy, resulting in long-term survival –13.In this case, the patient’s tumor was considered unresectable because it had invaded the CHA, the proximal portion of the PHA, the GDA, and the root of the SPA, as revealed by initial examination. We performed systemic chemotherapy consisting of GnP. After two cycles of GnP therapy, the tumor considerably decreased in size, tumor marker levels decreased to the normal range, and no distant metastases were observed. Therefore, we planned for conversion surgery. The progression-free survival of patients treated with GnP has been reported to be approximately 6 months , 15. We The liver receives arterial blood flow not only from the hepatic artery but also from the collateral arteries of the surrounding structures. Intrahepatic arterial blood flow communicates via the interlobar hepatic artery at the hepatic hilus and the intrahepatic translobar artery –22. The In patients with an aberrant hepatic artery, if the blood flow from the aberrant hepatic artery and hepatic arterial collateral circulation can be preserved, the risk of ischemic complications after PD with hepatic arterial resection can be reduced. According to previous reports, the prevalence of an abnormality in which a part or whole of the left hepatic artery (LHA) branches from the left gastric artery is approximately 12%–13% , 27. AbeIn our case, angiography confirmed good arterial blood flow to the whole liver from the aberrant A2 and the Rt. IPA immediately after hepatic arterial embolization. The postoperative course was uneventful, with only a small infarct observed in the liver. Although interruption of hepatic arterial flow is commonly well tolerated, as in our patient, this is not always the case. Therefore, patients should receive treatment while ensuring safety. In a previous case, liver necrosis occurred after cutting off a segmental artery of the liver . AlthougIn PD for pancreatic head and body cancer with hepatic arterial invasion, if a part of the hepatic artery is aberrant and can be preserved, combined resection of the CHA and PHA without reconstruction after preoperative embolization might be feasible for both curability and safety.


Primary lymphomas of appendix are extremely rare tumors. The incidence is 0.015% out of all gastrointestinal lymphomas; furthermore, limited data is available in literature. The appendiceal neoplasms are most commonly presented as acute appendicitis followed intestinal obstruction, intussusception or perforation. We present a case of a 22 year-old male patient who presented with acute appenditis and underwent emergency laparotomy. On abdominal exploration, swollen and enlarged appendix measured 3cm was present for which appendectomy were performed. The histopathological examination of appendectomy specimen revealed a Burkitt's Lymphoma. The patient received R-COPADEM protocol of chemotherapy. Primary gastrointestinal lymphoma is a extremely rare neoplasm without guidelines for therapy. •Burkitt lymphoma is an aggressive non-hodgkin b-cell lymphoma.•The occurrence of primary Burkitt's lymphoma of appendix is extremely rare.•The appendiceal neoplasms are most commonly presented as acute appendicitis.•The diagnosis of kimura disease is confirmed by surgical biopsy.•The diagnostic of Burkitt's lymphoma was only made after histopathological examination, so should be done.•The surgery and chemotheray constitue a best traitement for burkitt's lymphoma of appendix presenting as acute appendicitis. Burkitt's lymphoma is a mature B-cell non-Hodgkin lymphoma. Only 1–4% of gastrointestinal tract tumors are classified as primary Non Hodgkin Lymphomas . The lar1.1A 22-year-old man presented with a 48-h history of abdominal pain located in the lower right quadrant. His physical examination revealed tenderness in the right lumbar and right iliac fossa, consistent with signs of acute appendicitis. His body temperature was 39.5 °C. Laboratory examination revealed white cell count of 15,500/mm3. An abdominal ultrasonography revealed a mass in the right lower abdomen.While abdominal CT/scan was perfomed and showed a fluid collection in the right iliac fossa measuring 6.5cm*6cm, a swollen appendix is identified reaching a diameter of 13 mm , mesente2The lymphomas can be divided in Hodgkin and non-Hodgkin and the Burkitt's lymphoma is an aggressive non-Hodgkin B-cell lymphoma . The gas3Primary lymphoma of the appendix is an extremely rare pathology. there are unclear guidelines for treatment. Acute appendicitis is a frequent presentation of primary appendiceal lymphoma. All appendectomies must be undergo the histopathological examination. The surgery and chemotherapy constitute a best treatment for Burkitt's lymphoma of appendix presenting as acute appendicitis.I declare on my honor that the ethical approval has been exempted by my establishment.Ahmed Ballati: Corresponding author writing the paper, Abdelilah Elbakouri: writing the paper, Mounir Bouali: study concept, Khalid Elhattabi: correction of the paper, Fatimazahra Bensardi: correction of the paper, Abdelaziz Fadil: correction of the paper.Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient’s parents.Researchregistry5198.DOCTEUR AHMED BALLATINone.Not commissioned, externally peer reviewed.The authors declare having no conflicts of interest for this article


Repeat laparoscopic surgery has become increasingly common. However, reports of liver resection after pancreatoduodenectomy are scarce, and we report the first successful case of a patient who underwent laparoscopic liver resection after laparoscopic pancreatoduodenectomy.A 65-year-old man underwent laparoscopic pancreatoduodenectomy for ampulla of Vater adenocarcinoma. According to the American Joint Committee on Cancer (8th edition) staging guidelines, the tumour was labelled as stage IIIB (fT2N2M0). Twelve months later, a computed tomography (CT) scan revealed liver masses (in segments 3 and 5) and swollen para-aortic lymph nodes. After six chemotherapy courses of gemcitabine with cisplatin, the CT scan showed the disappearance of the para-aortic lymph nodes and progression of liver metastases. Nineteen months after the initial surgery, the patient underwent laparoscopic partial liver resection of segment 5 and left lateral sectionectomy. First, we performed the operation in the left half lateral decubitus position. In this position, the portal vein was isolated safely without hindering the hepato-jejunal anastomosis, although the adhesions around the hepato-jejunal anastomosis were dense. Therefore, we were able to perform liver transection safely with vascular inflow control. The operation duration was 235 min, and the volume of blood loss was 100 g. Macroscopically, the resected margins were negative. The patient was uneventfully discharged 12 days after the second operation. Afterwards, drainage was needed because of an intra-abdominal abscess. Currently, he has been alive for 8 months postoperatively, receives chemotherapy to suppress para-aortic lymph node metastases, and has not had another recurrence.Liver resection after pancreatoduodenectomy can be performed safely with an innovative body position to isolate the portal vein, which is a key point of the surgery. A laparoscopic approach for liver resection after pancreatoduodenectomy is a feasible option. The laparoscopic approach has been used in cases of repeat surgery , 2. HoweCitrobacter freundii, Klebsiella pneumoniae, Enterococcus gallinarum, and Streptococcus constellatus, were identified in the drainage fluid. This additional drain was removed after the abscess healed. Currently, the patient has been alive for 8 months after LLR, and his postoperative CA19-9 levels have decreased to the normal range (36.6 U/mL). Eight months after the second operation, he underwent a chemotherapy regiment that was the same as before the operation, gemcitabine plus cisplatin, to suppress para-aortic lymph-node metastases as planned, and has not had another recurrence.A 65-year-old man underwent laparoscopic pylorus-preserving PD with modified child reconstruction for ampulla of Vater adenocarcinoma. We performed standard pylorus-preserving PD for periampullary tumours with six ports. Lymph-node dissection of the caudal half of the hepatoduodenal ligament was performed. Pancreaticojejunostomy and duodenojejunostomy were performed via mini-laparotomy (7 cm), and hepaticojejunostomy was performed laparoscopically. We did not use antiadhesive drugs. In the postoperative course, drainage was needed due to a pancreatic fistula. Macroscopically, papillary tumours spread from the ampulla of Vater to the distal bile duct. Histopathologically, the tumour was moderately differentiated tubular adenocarcinoma that invaded the sphincter of Oddi with four nodal metastases, and all margins were free of tumour cells. According to the American Joint Committee on Cancer (8th edition) staging guidelines, the tumour was labelled as stage IIIB fT2N2M0) [N2M0 [2a,LR after PD is rare because of the poor prognosis of peripancreatic tumours. A few limited cases have been reported to date , 4, 6–8.The adhesions after laparoscopic surgery are often loose in comparison to those after laparotomy , 2, 9. TFirst, we adopted the left lateral decubitus position to identify the portal vein at the hepatic hilum and to perform partial resection of segment 5. In this position, the burden of the jejunal loop, which is located in front of the portal vein, was released to the left side of the portal vein, and we could approach the portal vein from the right side, avoiding the pancreatic fistula region. Therefore, removal of the adhesions and isolation of the portal vein were easier to perform in this position than in the supine position. Then, for left lateral sectionectomy, the patient was placed in a supine position. In this position, the portal vein was hidden beneath the hepato-jejunal anastomosis, as illustrated in Fig. In our case, if the adhesions around the portal vein and hepatic artery were more dense than expected, we planned to resect the liver parenchyma without vascular inflow control to give up isolation of these vessels. However, the adhesion on the right side of the portal vein was somewhat loose. Therefore, we succeeded in isolating the portal vein with little sharp cuts and much blunt peeling of the adhesion. On the other hand, the adhesion around the pancreaticojejunostomy, which is close to the hepatic artery, was extremely severe. Therefore, we did not pursue complete isolation of the hepatic artery for fear of injury to this vessel. Furthermore, occlusion of the hepatic artery was only half.As a result, the preferred procedure of LLR was performed with a blood loss of 100 g through innovative and strategic body positions, a breakthrough for isolating the portal vein. To the best of our knowledge, LLR after LPD has not been reported in the English literature, and only one report was related to LLR after open PD (but provided no details) . TherefoAn infectious complication of the raw surface of the liver is one of the main issues concerning hepatectomy after PD , 6. EnteThe standard treatment for liver metastases from ampulla of Vater adenocarcinoma is chemotherapy with gemcitabine plus cisplatin , 11. HowIsolation of the portal vein, which is buried in the most dorsal portion of dense adhesions, is a key point for LR after PD. LLR after PD can be performed safely with an innovative body position to isolate the portal vein. If the initial operation is laparoscopic, LLR after PD can be an option.


Fibrodysplasia ossificans progressiva (FOP) is a disorder causing progressive heterotopic ossification of muscles, tendons, and ligaments. Invasive procedures such as surgery should be avoided, because physical stimulation causes heterotopic ossification.A 40-year-old Japanese man with FOP was transported to our hospital with sudden abdominal pain. Emergency surgery was performed because a computed tomography scan showed the presence of intraabdominal free air. We diagnosed peritonitis due to perforation of Meckel's diverticulum and performed a small intestinal resection. The day after surgery, airway obstruction was recognized, and tracheostomy was required. Six months after surgery, a strangulated small bowel obstruction developed, and a second laparotomy was performed. As the patient continued to have difficulty swallowing, we constructed a gastrostomy at the time of the second surgery. He was discharged with no complications.Ossification of the abdominal incision wound due to surgical invasion was suspected, but it did not occur in the short term.Two laparotomies could be performed safely in a patient with FOP. Invas2A 40-year-old Japanese man had been diagnosed with FOP at the age of 5 years. He had no family members with FOP. He had widespread joint and muscle ossification and immobility. However, since his fingers could move, he could use aids such as walking sticks to perform his daily life activities.He was transported to our hospital with sudden abdominal pain. Assessment by computed tomography (CT) scan showed intraabdominal free air . We diagWe were able to initiate the laparotomy as usual with an electric scalpel. However, his abdominal wall remained stiff, even after muscle relaxant administration, making it difficult to explore the abdominal cavity. We found a perforation of Meckel's diverticulum and performed a partial resection of the small intestine. When closing the wound, we found it difficult to contain the fascia. The fascia was closed with a monofilament-absorbing thread and a single ligature suture, and then the skin was closed. We did not perform extubation in the operating room, because the tension of the closed wound was so high that we feared that the suture would tear due to coughing during removal of the endotracheal tube.The following day, the endotracheal tube was removed. However, the patient was soon re-intubated due to difficulty in expectorating sputum. Upper airway obstruction was confirmed at the time of reintubation, and a tracheostomy was performed. Because of his compromised swallowing ability, nasal tube feeding was performed. The patient was discharged after rehabilitation.Six months after the initial surgery, the patient had sudden abdominal pain and vomiting and was transported to our hospital. We diagnosed the condition as strangulated small bowel obstruction and performed an emergency laparotomy. Preoperative CT showed no ossification in the previous surgical scar . The sur3The worldwide prevalence of FOP is estimated at approximately one in two million. The median estimated lifespan of individuals with FOP is 56 years. During the first decade of life, most children with FOP develop episodic, painful inflammatory soft tissue swellings (flare-ups). While some flare-ups regress spontaneously, most transform soft connective tissues, including aponeuroses, fascia, ligaments, tendons, and skeletal muscles, into mature heterotopic bone [Very few reports ,8 have dFuruya reported that in FOP, only skeletal muscle is ossified, with smooth muscle and cardiac muscle are not. Consequently, swallowing and cardiac function are not often affected . HoweverPignolo et al. found that HO is associated with FOP . HO has In the future, it is anticipated that the life expectancy of patients with FOP will be prolonged due to the progress of medical treatment, and the number of cases requiring laparotomy will increase. Therefore, it is necessary to obtain information regarding the postsurgical progress of patients with FOP.4Ossification of the abdominal incision due to surgical invasion was suspected, but it did not occur in the short term.All authors have no conflicts of interest.This research did not receive any specific grant from any funding agency.The approval of our institutional ethics committee is unnecessary for a clinical case report.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Study conception and design: Okamoto.Surgical team: Tazaki, Shintakuya, Hirano.Critical revision of manuscript: Sasaki, Takahashi, Nakamitsu.All authors have read and approved the final manuscript.This case report was not registered.Nobuyuki Okamoto.Not commissioned, externally peer-reviewed.


Solitary or multiple lipomas are considered common tumors that can occur anywhere in the body; however, mesenteric lipoma is a rare entity that is well known to present with signs and symptoms of small bowel volvulus. Hereby, we present a case of a 54-year-old male patient with multiple comorbidities who was suffering from chronic abdominal discomfort and gradual increase of his abdominal distention over many years without seeking any medical attention. The patient was seen by a general practitioner after complaining of an inflated abdomen, as he described his condition. After several imaging studies, he was diagnosed with one of the largest mesenteric lipomas in the literature. Mesenteric lipoma should be present in the differential diagnosis of any abdominal tumor. Magnetic resonance imaging plays a major role in differentiating benign from malignant lipomas. Lipomas are formed from adipose cells that lead to the creation of an encapsulated soft tissue mass. It is mainly benign in nature and can be seen mostly in the cephalic part of the body . MesenteWe present a case of a 54-year-old male patient with a medical history of hypertension, dyslipidemia, benign prostatic hyperplasia (BPH), and right testicular cancer diagnosed and managed by orchiectomy followed by radiation therapy about 23 years ago, with complete remission. The patient complained of chronic abdominal distention without any signs of obstruction associated with abdominal discomfort and reflux. For many years before the presentation, he was taking antispasmodics, proton pump inhibitors (PPIs), and laxatives for symptomatic relief. Upon examination by a general practitioner, an ultrasound of the abdomen and laboratory tests were done for further evaluation. The ultrasound revealed a huge lobulated intra-abdominal mass over the periumbilical region ; howeverLipoma is the most common mesenchymal and soft tissue tumor, has benign behavior and morphology, and is composed of mature white adipocytes with uniform nuclei resembling normal white fat.Lipomas are usually subcutaneous and are found in the trunk and proximal extremities and less commonly on the hands, feet, and face. In rare cases, they may be found in the oral cavity, breast, pancreas, and intestines. There is an increased incidence of lipomas in patients with diabetes mellitus, hypercholesterolemia, and obesity, as found in our patient –5. HowevMesenteric lipoma is mainly detected in adults between the ages of 40 and 60 years old .While it is usually asymptomatic due to their soft consistency, symptoms of small bowel obstruction mainly occur late and do not appear until the mass gets very large or is located near the intestinal lumen . Some auOn the top of the differential diagnosis, come dermoid cyst, liposarcoma, lymphangioma, lipoblastoma, lymphangiolipoma, and neuroblastoma .Mesenteric lipoma can be found incidentally during any abdominal imaging. Plain abdominal radiographs have no diagnostic value. Ultrasound may be used as a primary technique for the diagnosis of mesenteric lipoma as in our case; however, it is operator dependent and may misidentify mesenteric lipoma with usual mesenteric fat as seen with the case reported by Cha et al. . Till noTreatment of mesenteric lipoma is mainly done by the complete resection of the tumor without affecting, if possible, the bowel loop. Laparoscopic surgery was accepted by many authors for the treatment of mesenteric lipomas ; howeverIn conclusion, mesenteric lipoma is a rare entity. It should be considered in the differential diagnosis of chronic vague abdominal pain and distention and rarely does it present with an acute abdomen; it can reach a relatively great size, as in our case which is considered one of the largest mesenteric lipomas reported in the literature.


Background: Metastasis to soft tissue is rare, and the pathogenesis remains unclear. Soft tissue metastases (STMs) have varied presentations; existing reports are few. Herein, we report a case of STMs of the shoulder with a rich characterization. Case presentation: A 93-year-old man presented to our hospital with pain and swelling of the left shoulder for one week. Magnetic resonance imaging (MRI) showed a T1 low-intensity and T2 high-intensity mass. We suspected a primary sarcoma and performed a needle biopsy. However, on histopathological examination, the findings were suggestive of lung adenocarcinoma. Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography-computed tomography also revealed FDG accumulation in the right lung, thus confirming the diagnosis. Conclusion: Oncologists should keep in mind that STMs of lung cancer may resemble soft-tissue sarcomas at the time of initial diagnosis. Metastasis to soft tissue is rare, and its pathogenesis is unclear . MetastaSoft tissue metastases are indicative of terminal-stage cancers ,5. Soft Soft tissue metastasis originating from lung cancer is rare, with a reported overall prevalence of 2.3% . Soft tiHerein, we report the case of an elderly patient who developed lung cancer metastasis to the soft tissue of the left shoulder, which was diagnosed before the primary lesion with pathological images and positron emission tomography-computed tomography (PET-CT) findings.A 93-year-old man noticed a swelling and pain in his left shoulder one week prior to his consultation at our hospital. He came because of a rapid increase in the pain and size of the mass. The size of the mass at presentation was approximately 10 cm × 8 cm. The skin overlying the mass was red and tender. The pain prevented movement of his left shoulder; the abduction angle was only 20°. Magnetic resonance imaging (MRI) showed a low intensity on T1-weighted images and high intensity on T2-weighted images A,B. We sAfluorine-18 fluorodeoxyglucose PET/CT (18F-FDG-PET/CT) was performed. It revealed a mass in the left shoulder with 18F-FDG accumulation and a maximum standardized uptake value of 18.4 A. In addThe liver, brain, bone, and kidney are the most frequent sites of lung cancer metastasis ,4. To thThe mechanisms of metastasis to soft tissue like muscles include hematogenous and lymphatic spread ,13. TrauSoft tissue metastases are painful in 83% of cases and palpable in 78% . In addiOur patient had a relatively large mass, which was painful and palpable, but not ulcerative. It is important to differentiate an unknown primary cancer from primary malignancies, such as soft tissue sarcomas, if the patient presents with only soft tissue metastases at the time of initial diagnosis, like in our patient.On MRI, soft tissue metastases present as low-signal images on T1-weighted sequences and high-signal images on T2-weighted sequences, with poorly defined margins ,18. SoftHistopathological examination is useful for examining the primary site of the cancer and determining the specific histological type ,21,22. C18-F-FDG-PET/CT is useful for detecting soft tissue metastasis and primary cancer lesions ,25. In aPrevious studies have reported that the survival of patients with soft tissue metastases ranges between months and three years after diagnosis . ConsequThe oncologist should keep in mind that lung adenocarcinoma may present as a soft tissue sarcoma at the time of initial diagnosis.


Approximately 1 percent of the tumors observed in the upper urinary tract are primary tumors of the ureter. The exact diagnosis is done by a histologic study. Most cases need surgery, which is done by complete resection of the tumoral segment of the ureter.This study presents a 13-year-old boy who referred to Ali Asghar pediatric hospital with complaints of right flank pain and hematuria for four months. The ultrasonography revealed moderate-grade hydronephrosis. The retrograde urography confirmed a 1.5 cm lesion with filling defects in the proximal segment of the right ureter. The abdominal CT-scan confirmed a 1.5 cm filling defect lesion with a smooth margin in the right proximal ureter adjacent to the ureteropelvic orifice. On cystoscopy, a sessile mass developed in the proximal portion of right ureter and providing pronounced dilation of the ureter and ipsilateral hydronephrosis. Histopathology examination revealed a benign neoplasm composed of a delicate fibrovascular core covered by normal-appearing urothelium. The patient underwent a successful proximal segment resection of the ureter by surgery.Benign tumors of the ureter are much less frequent than malignant ones. Mostly, they involve the lower third of the ureter. Pain, hematuria, and hydronephrosis are the most clinical signs. The final diagnosis can be established with the histologic examination. The choice treatment in is segmental ureterectomy.Primary ureteral papilloma is extremely rare in the child. The histopathology study is essential for ruling out malignancy. The recurrence and progression of ureteral papilloma are controversial. Urothelial papilloma is a benign exophytic neoplasm that generally does not progress ,2. The p2A 13-year-old boy presented in July 2019 with right flank pain and intermittent macroscopic hematuria for four months. On past medical history, there are no records of trauma, renal disease, or renal stone. During the examination, the pulse rate 80 beats per minute with a regular rhythm, and the blood pressure was 120/70 mmHg. On physical examination, the patient's vital signs were stable. The patient mentioned a feeling of pain and tenderness in the right flank. No other reportable hints represented on examination. The ultrasonography investigation identified a 1.5 cm heterogeneous hyperechogenic ipsilateral lesion located in the upper segment of left ureter emerging near the ureteropelvic junction. Ultrasonography shows dilation of the right ureter and renal pelvis with moderate hydronephrosis observed A. The re3Overall, primary benign neoplasms of the ureters are evidenced by the few instances in the medical literature. Approximately 1 percent of the tumors observed in the upper urinary tract are primary tumors of the ureter. About 250 cases of primary ureteral tumors have reported in the literature . The ure4Since primary urothelial papilloma of the ureter is rare in children, the Clinical findings and biologic implications of the tumor are still obscure. Therefore, the risks of local recurrence and progression of this lesion are still uncertain. The study, in more cases and long term clinical follow-up, give us a chance to understand the best diagnostic and treatment methods.None.The research did not receive any funding.This case report was approved by the Research Ethics Committee of the Ali asghar pediatric Hospital.Written informed consent was obtained from the parents of patient for publication of this case report.Maryam Rahbar: described in the case report, concept and design of study, acquisition of data, drafting the manuscript, revising the manuscript, and approving the final version of the manuscript.Mahtab Rahbar and Seyed Javad Nasiri: described in the case report, revising the manuscript, and approving the final version of the manuscript.Not applicable.Mahtab rahbar.Not commissioned, externally peer-reviewed.


Rectal duplication cyst is extremely rare. Most of the cases diagnosed before two years old. Adult onset rectal duplication cyst usually contains malignant formation. Then complete tumor resection is needed for the disease to prevent malignant change.A 52-year-old man was referred to our hospital due to bloody stool. Colonoscopy showed 20-mm of sub-mucosal tumor at low rectum. Biopsy revealed no specific findings. Abdominal computed tomography showed that a 20-mm low density mass at posterior of lower rectum. As the existence of malignant lesion was unassailable, we planned two team, trans abdominal and trans-anal, laparoscopic low anterior resection. Perioperative course was good. Macroscopically, rectum had a submucosal cystic mass fulfilled mucinous content. Histologically, cyst wall was covered with heterotopic ciliated epithelium and composed of smooth muscle.Trans-anal total mesorectal excision (ta-TME) was introduced as beneficial approach for rectal malignancies.Complete resection was possible by TME was necessary for patients with adult rectal duplication cyst, and synchronous trans-abdominal and trans-anal approach is a promising option. Some Trans-anal total mesorectal excision (ta-TME) was introduced as beneficial approach for low rectal cancer ,6. The aIn this case report, we described adult rectal duplication cyst resected by ta-TME.This work has been reported in line with the SCARE criteria .2A 52-year-old man was referred to our hospital due to bloody stool. He received medication due to schizophrenia. He had no allergies, family history, and surgical history. His vital sign was stable. Physical examination demonstrated no abdominal pain. On digital examination, there was a smooth rubbery mass located 6 cm from the anal verge. No inflammation and anemia were observed by laboratory data. His tumor markers including carcinoembryonic antigen and cancer antigen19-9 were not elevated. Colonoscopy showed 20-mm of sub-mucosal tumor at low rectum a. The tuR Path Trans anal Access Platform  to anal canal. A standard 10 mm-camera and conventional laparoscopic instrument were used . They transected inferior mesenteric artery and vein. Then splenic flexure was full mobilized. To perform ta-TME, we introduced GelPOINTere used . The tumere used a that shere used b. Histolere used c. Fortun3Rectal cystic lesions are rare condition which include epidermoid cyst, dermoid cyst, enteric cyst, rectal cystic hamartoma, teratoma and duplication cyst. The feaHistopathological feature of this disease contains of a following congenital anomalies: the presence of smooth muscle and epithelial lining, and both structures closely attached to gastrointestinal tract and sharing a common wall ,14. In tMost of rectal duplication cysts were benign. However, some previous reports showed malignant changes especially for adult patients ,14. ReceHowever, TME sometimes could not be success due to narrow pelvis, obese, and large tumor . Moreove4Complete resection was possible by TME was necessary for patients with adult rectal duplication cyst, and synchronous trans-abdominal and trans-anal approach is a promising options.None.None.None.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Tetsuro Tominaga and Takashi Nonaka conceptualized the study. Akiko Fukuda, Masaaki Moriyama, Syouzaburou Oyama, and Shigekazu Hidaka collaborated in the patient’s care. Kazuhiro Tabata made a pathological diagnosis.Terumitsu Sawai and Takeshi Nagayasu provided input on the manuscript.This case report does not correspond to “first in man study” i.e. the first time a new device or surgical technique.Tetsuro TominagaDepartment of Surgical OncologyNagasaki University Graduate School of Biological Sciences1-7-1 Sakamoto, Nagasaki 852–8501, JapanPhone: +81−95-819−7304 Fax: +81−95-819−7306E-mail: tetsuro.tominaga@nagasaki-u.ac.jpNot commissioned, externally peer-reviewed.


A new type of epileptogenic tumor, the polymorphous low-grade neuroepithelial tumor of the young (PLNTY) was firstly reported by Jason T. Huse et al. at 2016. After that, only 1 case of PLNTY was reported by article. The radiological characteristics of PLNTY have not been concluded. The objective of our study was to report 3 cases of PLNTYs in details and to analyze the image characteristics and genetic alterations of PLNTYs by reviewing our cases and articles.There were 3 cases diagnosed as PLNTY by pathology in our hospital during the last 10 years, with the average age of 15. They were all suffered from different degrees of epilepsy. All of them underwent magnetic resonance (MR) imaging and 2 of them underwent computer tomography (CT) imaging. The PLNTYs are all appearing as a solid or solid-cystic cortical mass with little mass effect and unclear boundary with normal brain tissue. They are all shown as hyperintensity in T2WI and iso−/hypointensity in T1WI with slight or no enhancement after contract enhanced in MR imaging. The “salt and pepper sign” in T2WI and grit calcification in CT images might be specific characteristics of PLNTY. All of them recovered after excision of the tumors. The gene tests revealed fibroblast growth factor receptors 3 (FGFR3)-TACC3 fusion and FGFR3 amplification in one case, and the B-Raf proto-oncogene (BRAF) V600E mutation in another case.In the image, the partial ill-marginated cortical mass with “salt and pepper sign” in T2WI or grit calcification in CT imaging might be the typical imaging characteristics of PLNTY. We also prove that the BRAF V600E mutation as well as the FGFR2 and FGFR3 have a close relationship with PLNTY. Low grade neuroepithelial neoplasm commonly presents with clinical seizure onset on early life, which is a group of brain heterogeneous tumours with a broad spectrum and variable histomorphological and genetic alteration features. Of them, the common entities include dysembryoplastic neuroepithelial tumors (DNET), gangliogliomas, oligodendroglioma, pleomorphic xanthoastrocytoma, infantile low-grade glioma and so on , 2. In 2A 14-year-old girl with seizure for 1 year was referred to the hospital with the stable symptoms of confusion, twitching limbs, deviated mouth, cyanosis of lips, urinary and fecal incontinence when the epilepsy happened. The EEG found out the epileptoid discharge in the left temporal lobe. MRI showed an irregular lesion with partial blurry boundary located in the left temporal lobe. The lesion appeared as relative hypointensity in T1WI and hyperintensity in T2WI with the “salt and pepper sign”, with slightly enhancement. Then she received surgery. At gross specimen inspection, the tumor was seen as a soft mass with greyish white section. At microscopy, the tumor exhibited oligodendroglioma-like cellular component with moderate polymorphic nuclei and multiple grit calcification. Immunolabeling for Olig2, Vimentin, CD34, S-100, Syn were positive; and GFAP, NF, IDH1, P53, NeuN, EMA, B-raf were negative; Ki67 < 1%. Total RNA extracted from Formalin-fixed and paraffin-embedded (FFPE) material was analyzed for fusion transcripts using anchored multiplex polymerase chain reaction (PCR)-based methodology (ArcherDx) and revealed FGFR3-TACC3 fusion in this case [A 15-year-old boy was admitted to hospital with the chief complain of repeated tetany of the left upper limb with loss of consciousness for half a year. The head CT was done and showed a mass with grit calcification located in the right temporal lobe. Then he was transferred to our hospital and receive the brain MR, which showed a mass located in the right temporal lobe with clear boundary, which appears isointensity in T1WI, hyperintensity in T2WI and T2-FLAIR sequence and slightly patchy enhancement. The “salt and pepper sign” could also be seen in T2WI. After the surgery, pathology proved the mass to be combined with uniform oligodendroglioma-like component with discrete calcospherules. And the immunolabeling for CD34, Vimentin, and Olig-2 were positive, but negative for IDH-1, EMA, SOX10, NeuN, EMA, P53and MGMT. The B-raf V600E mutaion was identified in this case by molecular test with mutation-specific immunohistochemical staining. This patient was totally free from the epilepsy symptoms under the control of anti-epilepsy medicine in the 3 months’ follow-up.A 16-year-old boy suffered from paroxysmal convulsion of angulus oris for 2 years and progressed to the whole body for half a year. A non-enhanced CT imaging showed a solitary-cystic mass with hyperattenuation calcification located in the right frontal lobe. Then he underwent conventional MRI scanning including diffusion weighted imaging (DWI), diffusion tensor imaging (DTI) and H1-magnetic resonance spectrum (H1-MRS). MR imaging revealed a solitary-cystic mass with uniform T1WI signal, slight increased T2WI signal with “salt and pepper sign” and slightly enhancement of the solitary part. DWI proved the mass did not have restricted diffusion. In DTI, the white matter fiber tracts appeared as being slightly compressed due to the small range of peripheral edema but still being integrated. H1-MRS demonstrated a slightly declined NAA (N-Acetyl Aspartate) peak and an elevated Cho (Choline) peak, which revealed slight decrease of nerve cell and increase of the gliocytes. He received surgery and the mass was removed completely. At gross specimen inspection, the mass appeared as a unencapsulated gray-white mass with unclear boundary of peripheral brain tissue. Under microscopy, the tumor showed infiltrative growth pattern with predominant oligodendroglioma-like component with moderate cellular pleomorphism, and absence of both tumor necrosis and mitosis. The immunostaining test showed that the tumor was positive for Vimentin, CD34, and Olig-2, but negative for IDH-1, EMA, SOX10, NeuN, EMA, P53and MGMT. It was the pity that this case didn’t get the gene tests. Till the follow-up in 36 months after the surgery, the patient still was free from the epilepsy without medicine.All of the cases have completed central pathological review and met the PLNTY criteria of the following: 1) infiltrative and nodular growth pattern; 2) invariable presence of oligodendroglioma-like cellular component with more or less polymorphic cellular elements including pleomorphic and spindle cells; 3) intense immunolabeling for cluster of differentiation 34 (CD34) [The CT, MR and pathology images are shown in Figs. A heterogenous group of brain tumors is associated with early epilepsy in children and young adults. The vast majority of these tumours are low grade (WHO grade I or WHO gradeII) brain tumor, and exhibit large spectrum of morphological variants. The common recognized entities are called long-term epilepsy associated brain tumours (LEAT), which consist of pilocytic astrocytoma, ganglioglioma, pleomorphic xanthoastrocytoma (PXA), DNET, angiocentric glioma, pediatric oligodendroglioma and so on  . Most o1-MRS, no restricted diffusion in DWI, and compression rather than disruption of the fiber tracts in DTI, which all suggest the PLNTY to be a low grade, less aggressive neoplasm.The clinical features and locations of the three cases are assembled and shown in Table The pathologic features of PLNTY also support the imaging characteristics. Two (case 1 and 3) of them prominently show an infiltrative growth pattern with adjacent tissue involvement and subpial extension, and partly exhibit sharp borderline. And case 2 has a completely well-defined borderline. The infiltrated growth patterns may explain the unclear boundary with normal brain tissue in radiology. Grit calcification can be seen in 12 of 13 cases with pathology reports, which support the relevant sign in CT and MR imaging.As reported in the seminal article by Jason T. Huse et al., most of the PLNTYs had either BRAF alternation or FGFR fusion. BRAF is a crucial regulator of the MAPK pathway. And FGFR is an upstream regulator. The mutations these genes will all involve the MAPK oncogenic pathway, just like the other pediatric low-grade gliomas . In 9 caBy reviewing all LEATs in our cohort, we found all PLNTYs were misdiagnosed as DNET, in that both having a similar appearance in both radiology and pathology. Indeed, PLNTY and DNET has many characteristics in common. As the epileptogenic tumors, the DNET and PLNTY are all characterized by a predominantly cortical location and by drug-resistant partial seizures as the clinical manifestation . They boThe other differential diagnoses should include other cortical originated lesions like FCD, gangliogliomas and oligodendroglioma. FCD is another major cause of drug-resistant epilepsy. Its imaging features are varying. In general, the extent of the lesion is smaller than the other epileptogenic tumors. Focal cortical thickening, blurry gray white matter interface, focally increased signal on T2WI and the “transmantle” sign are the MR characteristics of FCD , 12. IntGangliogliomas is another common tumor which can cause chronic temporal lobe epilepsy in adolescent. Typical gangliogliomas showed as cystic-solitary tumor with ring-enhancement or solid-enhancement and arc calcification. Specially, it always appears as isointense to the gray matter in T1WI . The proOligodendroglioma is a kind of WHO grade II epilepsy-associate tumor. But it is predominantly occurring in adults than in children or adolescents. It has a cortical-subcortical location and mostly located in the frontal lobe. Gyriform calcification is a characteristic of oligodendroglioma. Though it can also appear as iso- or hypointensity in T1WI and heterogeneous hyperintensity in T2WI as the other cortical-based tumors, minimal to moderate enhancement and increased perfusion can distinguish it from other low-grade gliomas , 15. TesIn summary, we have reported 3 cases of a distinctive, low grade neuroepithelial tumor associated with MAPK signal pathway, and propose the radiological features. Our cases and current reported cases suggest that the partial ill-marginated cortical mass with hyperintensity with “salt and pepper sign” in T2WI or grit calcification in CT imaging might be the typical imaging characteristics of PLNTY. And classical genetic alterations including the BRAF 600E mutation as well as the FGFR2/FGFR3, have been found close relationship with PLNTY, which are commonly seen in LEATs. The clinical behavior of the three current described cases of PLNTYs was non-aggressive with no evidence of recurrence or metastasis (follow-up ranged from 6 to 10 months). This tumor should be considered a low-grade malignancy (WHO gradeI). We hope that this report prompts others to recognize similar tumors helping to create a more complete understanding on their radiology and molecular genetics.


Sarcomatoid carcinoma of the gallbladder or gallbladder carcinosarcoma is anexceedingly rare malignancy. Unfortunately, patients typically present withadvanced disease at diagnosis. Symptoms may include abdominal pain, jaundice,anorexia, nausea, weight loss, and a palpable abdominal mass. This malignanttumor has a poor prognosis, and treatment options include surgical resection,radiation, and chemotherapy. We detail the case of a 57-year-old male whopresented with diffuse abdominal pain and jaundice. Computed tomography scan ofthe abdomen and pelvis showed a large mass within the gallbladder, intrahepaticductal dilation, gastrohepatic lymph node enlargement, and liver lesionsconcerning for metastatic disease. A core needle biopsy from one of the liverlesions revealed poorly differentiated sarcomatoid carcinoma of the gallbladder.He was assessed to have stage IV disease and deemed not to be a surgicalcandidate. Palliative chemotherapy was planned; however, treatment was neverstarted due to the development of cholangitis with sepsis. The patientultimately opted for hospice care and passed away shortly thereafter. In fact, to date, only 108 cases of gallbladder carcinosarcoma havebeen reported in the medical literature worldwide.2 Patients typically present with abdominal pain, jaundice, anorexia, nausea,weight loss, and occasionally a palpable abdominal mass.3Gallbladder carcinoma is an extremely rare malignancy with an annual incidence in theUnited States of 1–2 cases per 100,000 persons.4Gallbladder carcinosarcoma is more common in females and presents at a mean age of68.8 years. Japanese ethnicity is associated with longer survival (mean = 19.9 vs11.5 months in non-Japanese). These tumors have a poor prognosis  and often metastasize to the liver, lymph nodes, and peritoneum.A 57-year-old homeless, Caucasian male with no known significant past medical historypresented to an outside emergency department with 2 months of diffuse abdominalpain, nausea, vomiting, decreased appetite, and 40 pound weight loss. Prior to thesesymptoms, he was a physically active, lifetime nonsmoker with no history of alcoholor illicit drug abuse.Physical exam revealed diffuse jaundice and abdominal tenderness. His labs weresignificant for an elevated alkaline phosphatase of 195 IU/L and total bilirubin of10.0 mg/dL. Computed tomography (CT) scan of the abdomen and pelvis showed a 6.2-cmmass within the gallbladder with intrahepatic ductal dilation, an adjacent 4.7-cmmass with gastrohepatic lymph node enlargement, and numerous liver lesionsconcerning for metastatic disease  and 3. TThe patient was subsequently transferred to our hospital where he arrived withworsening right upper quadrant (RUQ) abdominal pain, jaundice, and nausea. Physicalexam revealed hepatomegaly, RUQ firmness, and generalized abdominal tenderness onpalpation. CT of the abdomen and pelvis redemonstrated the large gallbladder funduslesion with porta hepatis and periportal lymphadenopathy, local tumor invasion,liver metastases, as well as gastrohepatic and retroperitoneal lymphadenopathy.Oncology was consulted and initially recommended palliative chemotherapy withdoxorubicin (adriamycin), ifosfamide, and mesna (AIM regimen). The day after portplacement for chemotherapy, though, the patient developed fevers with worseningabdominal pain and was started on broad-spectrum antibiotics given the concern forsepsis due to cholangitis. Culture of biliary fluid indicated heavy growth ofCandida albicans, Enterococcus faecalis, Enterobacter cloacae, Klebsiella oxytoca,and Enterococcus casseliflavus. Infectious disease was consulted and his antibioticregimen was adjusted per their guidance. Due to the active infection, chemotherapywas delayed. Subsequent labwork revealed an uptrending bilirubin, prompting a repeatCT followed by a magnetic resonance cholangiopancreatography (MRCP). Sadly, thesestudies demonstrated progressive local tumor invasion with extrahepatic obstructionas well as an increased number of metastatic liver lesions  and B.Repeat cholangiogram showed flow only to the external portion of the biliary drain;the internal portion now completely occluded by tumor. Unfortunately, his clinicalstatus continued to deteriorate with worsening abdominal pain and rising bilirubin.Ultimately, he opted for hospice care and was transferred to inpatient hospice wherehe passed away shortly thereafter.4 CT of the abdomen and pelvis is an important part of the workup as it canelucidate the size of the tumor and metastasis to nearby organs. Diagnosis ofsarcomatoid carcinoma of the gallbladder is ultimately made with histopathology,which shows tumor composed of both malignant epithelial and mesenchymal(sarcomatous) components.Gallbladder carcinosarcoma can be a diagnostic challenge due to its non-specificpresentation. This malignant tumor is more common in females and presents at a meanage of 68.8 years.4Prognostic factors associated with improved survival include tumor size less than5.0 cm, early-stage disease, and Japanese ethnicity. Median survival neverthelessremains poor at only 5.5 months.4A meta analysis of 67 patients with sarcomatoid carcinoma of the gallbladder by Zhanget al. found the epithelial component was most commonly adenocarcinoma (79.2%) andleast commonly squamous cell carcinoma (9.4%). The mesenchymal component was mostcommonly spindle cell type (44.6%) and least commonly osteoid (5.4%). The averagetumor size was found to be 6.9 cm. Gallstones are reported in over 70% of cases ofgallbladder carcinosarcoma. Though not associated with specific findings on imagingor tumor markers, it is typically much larger in size than a gallbladderadenocarcinoma.6Cholecystectomy is performed when tumor is confined to gallbladder, whilelocoregional spread of disease may necessitate resection of liver and adjacenttissues as well as lymph node dissection. Despite resection, postsurgical prognosisremains poor with high mortality due to micrometastasis and local recurrence.Okabayashi et al.6 examined 36 patients with carcinosarcoma who underwent surgical resectionwith intent to cure and found the 1, 2, and 3-year survival rates to be 37.2%,31.0%, and 31.0%, respectively. The role of chemotherapy and radiation, be it in anadjuvant or palliative setting, remains poorly defined. In the present case, the AIMregimen was considered due to success in treating soft tissue sarcomas.7 Wada et al.8 reported on a patient who received 3 years of gemcitabine after curativeresection and was still alive at the 5-year mark. Unfortunately, our patient’s tumorwas unresectable due to its advanced state at presentation and chemotherapy couldnever be initiated due to an ongoing infection.The first-line treatment for gallbladder carcinosarcoma is surgical resection;however, due to the often advanced state of the disease at diagnosis, this isfrequently not possible.Sarcomatoid carcinoma of the gallbladder is an exceedingly rare disease.Consequently, there is limited information on the disease process and no consensusregarding its treatment. For early-stage cases, surgical resection offers the bestprognosis and is potentially curative, though many still develop local recurrence ormetastasis. Unfortunately, most patients present with advanced disease and are oftennot surgical candidates. The role of chemotherapy and radiation in this populationremains undefined and warrants further study. In the present case, the patient wasnot a surgical candidate due to his heavy tumor burden with locally advanced,invasive disease. Palliative chemotherapy was planned; however, our patient wasnever able to receive therapy due to complications from the underlying diseaseprocess.


Osseous metaplasia in nasal polyps is rare but benign. To exclude dangerous lesions, sending the entirety of histological samples is mandatory in cases presenting with clustered densities on CT scan. Microdebrider should not be used for this surgery. Osseous metaplasia in nasal polyps is rare but benign. To exclude dangerous lesions, sending the entirety of histological samples is mandatory in cases presenting with clustered densities on CT scan. Microdebrider should not be used for this surgery. He did not have any other symptoms. The patient had a history of grass and birch pollen allergy which was confirmed by skin prick tests several years ago and was not treated. He did not undergo prior nasal surgery and did not present any peculiar antecedents. Fiberoptic examination revealed a complete obstruction of the left nasal cavity and the nasopharynx by several polyps which occupied the middle and superior meatus as well. Computed tomography scans showed a complete filling of the left nasal cavity that extended into nasopharynx and the left posterior ethmoidal cells. Some central clustered densities were also described in the ethmoid and nasal fossa. There was no bone erosion Figure . Systemi3While squamous metaplasia is frequent in nasal polyps,None of these patients benefited from an earlier sinonasal surgery.The differential diagnosis of sinonasal pathologies with highly radiodense materials includes rhinolith, mycetoma, inverted papilloma with calcifications, chondrosarcoma, osteosarcoma, fibro‐osseous lesions, and seldomly sinonasal adenocarcinoma with metaplastic ossification.4Osseous metaplasia in nasal polyps is a unique and benign disease that seems to be characterized by a unilateral location. Contrary to nasal polyposis, it does not tend to relapse after a complete surgical removal. Endoscopic sinus surgery is the only treatment currently recommended. To exclude potentially dangerous lesions and confirm the diagnosis, sending the entirety of histological samples is mandatory in cases presenting with clustered densities on CT scan. For this reason, microdebrider should not be used for this surgery.The authors have no conflict of interest.QM: wrote the case report. All authors read and approved the final manuscript.The scientific publication of this clinical case was approved by the ethics committee of the University Hospital Center of Charleroi.Written informed consent was obtained from the patient for the publication of this report and any accompanying.


Papillary fibroelastoma is a benign cardiac tumour that most commonly presents as an incidental finding on imaging but may present with an acute neurological event due to embolic phenomena. We report a 51-year-old female who presented with focal neurology of the right hand that lasted for 30 minutes. Her initial investigations including CT-brain were unremarkable, and given her low-risk profile for stroke she was discharged for routine outpatient workup of possible transient ischaemic attack. Transthoracic echo detected a large mobile mass attached to the left ventricular wall. This was mistakenly diagnosed as a left ventricular thrombus, for which she was commenced on warfarin. After three months on warfarin without reduction in the size of the mass, cardiac MRI was performed. The scan was repeated as the initial imaging failed to demonstrate the tumour. This was followed by positron emission tomography which suggested a benign mass of the left ventricle. The patient underwent surgical excision of the tumour and developed post-pericardiotomy syndrome. Histopathology confirmed papillary fibroelastoma. Though rare, cardiac neoplasm may remain a differential diagnosis for acute neurological presentations in non-classical patients.  Papillary fibroelastoma (PFE) is one of the benign, primary, cardiac neoplasms, and accounts for <10% of all these tumors. They are small neoplasm of valve apparatus usually found incidentally on imaging, such as echocardiography, or at autopsy . Here weA 51-year old lady presented to her local hospital emergency department with an episode of right-hand weakness which came on during office work and lasted for 30 minutes. There were no other lateralization signs. She denied any cardiac symptoms, previous embolic event, miscarriage, or any history suggestive of vasculitis. Her systematic review, past medical history, family history, drug and social history were non-contributory. The clinical examination revealed no neurological deficits and the other systems examination were unremarkable. Computerized tomography (CT) showed no acute pathology. Routine blood work including full blood count, renal function, electrolytes, coagulation, and thyroid function test were all normal, excepting a mildly elevated cholesterol and borderline D-dimer. A provisional diagnosis of TIA was considered, and she was commenced on aspirin and a statin. The following investigations were arranged as an outpatient workup for stroke/TIA: Holter Monitor, Carotid Doppler and Transthoracic Echocardiography (TTE). During outpatient work up the patient remained symptom free. Holter Monitor, Carotid Dopplers, repeat electrocardiogram (ECG) and chest X-ray (CXR) were all unremarkable. However, TTE revealed a dense mobile mass measuring 2.6 x 1.7 cm attached to the distal septum of the LV suspicious with thrombus  2-3, and admitted for further inpatient workup. Without obvious wall motion abnormalities or arrhythmia, the patient was investigated for secondary causes of thrombus in the form of thrombophilia screen, tumour markers, and CT thorax abdomen and pelvis for evidence of malignancy. Again these investigations revealed no abnormalities. The patient was discharged and outpatient cardiac magnetic resonance imaging (MRI) was arranged. Repeat TTE after three months of anticoagulation showed no reduction in the size of the LV mass  which confirmed the lesion location and suggested low metabolic activity favoring a benign lesion Figure . The patFive weeks after operation, the patient represented to the Emergency Department clinically unwell complaining of episodes of shortness of breath with increasing frequency and severity accompanied by chest discomfort. On assessment, she was hemodynamically unstable with low blood pressure 54/39), tachycardia, and low oxygen saturation. Cardiovascular examination revealed raised jugular venous pressure (JVP), muffled heart sounds and bilateral pedal edema. Investigations showed severe cardiomegaly on CXR (Figure , tachycaImmediate CT-guided pericardiocentesis drained 900 ml of serous fluid Figure . She wasPrimary cardiac tumours are considered to be rare, with a prevalence of 0.001-0.3% according to autopsy series done in UK . PFE is The presence of this tumour in the LV can be challenging to differentiate from other intracardiac pathologies. Though our patient had no underlying ischemic heart disease, she was managed as LV thrombus. The fact that she presented with an embolic event, together with the location and hypermobility of the mass, supported the presumed diagnosis.Histologically, PFEs are avascular frondlike structures that are composed of fibroelastic tissue surrounded by endocardium . The patFor symptomatic patients, the most common presentation of PFE reported in the literature is a cerebrovascular event -4. This Cardiac MRI has well-known advantages as a diagnostic tool over echocardiography due to its exquisite sensitivity to tissue differentiation. In spite of this, cardiac MRI struggled in this case to identify a mass seen easily on TTE and ultimately required multiple imaging sessions and expert consultation and interpretation. In contrast, TTE picked up the tumour easily, providing valuable information about its location, size, and motion, but ultimately delayed the patient’s diagnosis due to a lack of sensitivity to the tissue structure of the mass. It is reasonable to conclude that echocardiography remains the modality of choice for the initial imaging investigation of heart structure and function but that in non-classical cases advanced imaging such as CMR and PET scanning may provide additional insight .This patient had a stormy course and five weeks after cardiac surgery she developed post-pericardiotomy syndrome manifesting as a life-threatening cardiac tamponade with hypovolemic shock, multi-organ failure, and elevated INR. PPS is one of the fatal consequences and least discussed complications of cardiac surgery. It carries an incidence of 10-40% [We report a middle-aged woman without obvious cardiovascular risk factors who presented with TIA related to underlying benign cardiac PFE tumor that was confirmed by histopathology after surgical resection. Echocardiography was of value as a first choice imaging modality. It successfully identified the source of her neurological deficit as a left ventricular mass giving rise to an embolism. However, advanced imaging including cardiac MRI and PET scanning was necessary to correctly identify her cardiac pathology as a benign tumour necessitating prompt surgical intervention. Serious postoperative complications of cardiothoracic surgery are common and both patient and clinicians should be aware of symptoms suggestive of post-pericardiotomy syndrome.This case emphasizes that in non-classical patients without obvious risk factors for cardiovascular disease or with poor responses to standard therapies, an open mind and advanced imaging can be more than a fishing exercise.


Pregnancy in the rudimentary horn is rare and a life-threatening. Rupture of pregnant rudimentary horn in the second trimester is a usual presentation. Early diagnosis and fast management are necessary to decrease the mortality and the morbidity of this pathological entity. This report confirms the diagnostic and therapeutic difficulties of the pregnant rudimentary horn. An emergency laparotomy was taken, and ruptured right rudimentary horn was diagnosed. A hemi-hysterectomy was carried out. The patient's postoperative follow-up was uneventful, and she left the hospital 5 days after. The unicornuate uterus associated with a rudimentary horn is a rare uterine malformation that can lead to several obstetric complications. The incidence of pregnancy in a rudimentary horn is 1/76,000 . The conA 32-year-old patient, G3P2, with 2 living children from two spontaneous pregnancies. She had an uneventful vaginal delivery, respectively, at 37 weeks and 39 weeks of gestation. The children had a normal growth. The woman had no pathological obstetric history.She was admitted in a situation of hemorrhagic shock, discolored conjunctiva with generalized abdominal defense in a pregnancy of 16 weeks.The patient also reports the concept of epigastralgia for a week. Pelvic ultrasound showed an empty uterus and an intra-abdominal fetus without cardiac activity  and whosUterine malformations, as unicornuate uterus type with rudimentary horn, are due to an abnormality in the development of one of the two Müllerian duct. The unicornuate uterus is class II according to the American Fertility Society's classification of Müllerian anomalies and represents the most common malformation of its kind . When itPregnancy on a rudimentary noncommunicating horn is rare . Just a The prognosis for pregnancy on a rudimentary horn remains dark. Only early diagnosis can prevent uterine rupture on rudimentary horn and improve management in order to reduce maternal mortality and morbidity. A careful abdomino-pelvic examination during the first trimester of pregnancy and the deviation of the normal-sized uterus with latero-uterine mass palpation should suspect a uterine abnormality. This examination is only valuable during the first trimester when the uterus and the rudimentary horn still develop in the pelvis. Some reported cases have been diagnosed by magnetic resonance imaging (MRI) and ultrasound; the sensitivity of which is 26% . This seConfirmation of the diagnosis is often surgical at laparoscopy or laparotomy. Treatment is based on excision of the rudimentary horn and its fallopian tube , 12. A hThis case is reported to highlight the diagnostic difficulties and to reiterate the need to introduce the possibility of rudimentary horn pregnancy in the differential diagnosis of recurrent abdominal pain during pregnancy. Early diagnosis and fast management reduce the morbidity and mortality of this pathological entity. Treatment is surgical, consisting of resection of the rudimentary horn.


A 60-year-old woman presented with six months of abdominal pain, weight loss and diarrhea for which she underwent bidirectional endoscopies that were unremarkable. Over the next two weeks, she developed non-cirrhotic portal hypertension and presented with esophageal variceal bleeding. A diffuse large B-cell lymphoma encircling her celiac axis with a tumor thrombosis of the superior mesenteric, splenic and portal veins was found to be the cause of her portal hypertension. An esophagogastroduodenoscopy (EGD) was performed to control her variceal bleeding. She was started on R-CHOP  chemotherapy and after three cycles her symptoms have subsided, and a CT scan has shown shrinking mesenteric lymphadenopathy. A portal vein thrombosis (PVT) is when a thrombus occludes the portal vein partially, or completely, though such phenomenon can extend to include both the splenic and mesenteric veins. Untreated, the consequences of a PVT can be devastating and include bowel ischemia and portal hypertension . The etiA 60-year-old Caucasian woman with no significant past medical history presented to our gastroenterology ambulatory clinic with complaints of chronic lower abdominal pain and diarrhea for the past six months. She had no personal history of malignancy, and her family history was significant only for a brother with prostate cancer. She described her abdominal pain as crampy in nature, exacerbated by food, radiating to the left side and relieved by defecation. She had been having significant diarrhea up to 10-20 episodes daily which were non-bloody and watery. In an attempt to control her bowel movements, she had been taking up to four Imodium tablets daily with some improvement. She also noted a weight loss of 30-35 pounds in the past three months which she attributed to early satiety and the fact that she had been self-restricting her diet to include liquids only. She reported subjective fevers in the evenings and having night sweats over the past six months but denied any nausea or hematochezia.Laboratory values were unremarkable without any new electrolyte imbalances, leukocytosis and thrombocytopenia, and her hemoglobin was at her baseline of 10 g/dL. Her carcinoma embryonic antigen (CEA) and carbohydrate antigen (CA 19-9) values were normal. She underwent esophagogastroduodenoscopy (EGD) and colonoscopy which were normal, along with normal duodenal and gastric biopsies. Plans were made to proceed with abdominal imaging and return to clinic afterwards.While waiting for further investigation, approximately two weeks later, she presented to our hospital with complaints of two days of melena and her hemoglobin was found to be 7.6 g/dL while all her other labs remained unremarkable. On physical exam, her abdomen had become diffusely tender to deep palpation and a firm mobile mass could be felt superior to the umbilical region. There was no obvious cervical or axillary lymphadenopathy. An EGD was repeated and revealed grade II lower esophageal varices with red wale signs, suggestive of recent bleeding, and endoscopic variceal band ligation was done Figure .A CT scan of the abdomen and pelvis was performed and showed a 7.2 cm x 2.5 cm heterogeneously enhancing soft tissue mesenteric mass with necrosis surrounding the celiac trunk and the superior mesenteric artery. It also revealed an additional extensive tumor thrombus extending from the mesenteric mass to involve the superior mesenteric, splenic and portal veins Figures . She underwent a CT-guided biopsy of this mass which showed high-grade diffuse large B-cell lymphoma (DLBCL) NHL with a Ki-67 of 80%. Morphologically, no granulomas or Reed-Sternberg cells were seen and further immunostaining performed showed positivity for LCA, CD20, PAX-5 , CD10 (diffuse), BCL-2 (diffuse) and BCL-6 (about 30%), while being negative for CD3, CD5, CD20, CD23, cyclin D1, MUM1, c-MYC, AE1/AE3, CAM 5.2, CK7 and CK20, suggesting NHL DLBCL Figure .A positron emission tomography (PET)-CT was performed and demonstrated an 18 F-fluorodeoxyglucose (FDG) avid mass with surrounding mesenteric lymphadenopathy and no evidence of disease elsewhere Figure .Our patient was started on R-CHOP  chemotherapy immediately. After three cycles of her chemotherapy regimen, her symptoms have subsided without any further evidence of gastrointestinal bleeding. A repeat CT scan showed that her mesenteric lymphadenopathy has begun to shrink, though the PVTT remains unchanged. She has been maintained on propanalol for secondary prophylaxis of esophageal varices and has experienced no further gastrointestinal bleeding. She continues to follow with hematology oncology for the management of NHL. She is also scheduled for a repeat EGD to assess for any remaining varices needing further obliteration.This case describes an unusual etiology of esophageal variceal bleeding secondary to non-cirrhotic portal hypertension from an extensive PVTT caused by an NHL malignancy surrounding the celiac trunk. Current medical literature yields only seven previously reported cases of NHL-associated PVTT, of which four were specifically DLBCL -10. ThisLocalized NHL, despite its various presentations, is an exceedingly uncommon cause of a PVTT as such pathology is more often seen secondary to pancreatic adenocarcinoma, hepatocellular carcinoma, renal cell carcinoma and cholangiocarcinoma . A localWe present a case of a patient with a malignant PVTT with associated non-cirrhotic portal hypertension and esophageal variceal bleeding secondary to localized NHL around the celiac axis which is exceedingly rare. As such thrombosis was suspected to be primarily from extrinsic tumor compression and intravascular invasion, she has been started on R-CHOP chemotherapy. After three cycles of treatment, her symptoms have subsided entirely, and a repeat CT scan shows evidence of shrinking mesenteric lymphadenopathy though the PVTT remains in place. With further treatments, we hope to see further remission of her NHL and full resolution of her PVTT. Although the etiologies of a PVT can be extensive, and often multifactorial, localized NHL can be considered as part of the differential diagnosis.


Case Summary. A seven-year-old boy presented with right distal forearm and wrist pain with restricted supination for 4 years. X-ray showed ring and arc calcifications in the distal forearm at the interosseous area. MRI also confirmed a well-defined soft tissue lesion with areas of calcifications. A diagnosis of a cartilage-forming lesion or a peripheral nerve sheath tumour was suggested. The lesion was completely excised. Histology showed a lesion composed of intersecting fascicles of spindle cells with stromal calcification having immunohistochemical features of a leiomyoma.  Deep somatic leiomyomas arising in skeletal muscle are extremely rare in children, especially in the extremities. Around half of them show calcifications. We present a rare case of a calcified leiomyoma of the distal forearm in a child.  Although soft tissue calcifications can be seen in a plethora of conditions seen in daily orthopaedic practise, a high index of suspicion should be maintained for rare conditions like deep somatic leiomyoma. Leiomyomas are benign soft tissue tumours rarely seen in the extremities. Representing 4.4% of all soft tissue tumours, they maybe calcified in around half of the cases . It is aA seven-year-old Sri Lankan boy presented with a gradually worsening right distal forearm and wrist (dominant side) pain for four years. He was previously well and had no constitutional symptoms. He also denied having any numbness or tingling sensation in the involved area of the upper limb. The pain and functional limitation were interfering with his daily activities and schooling. There was no family history of malignancies. There were no obvious lumps noticed by the child or the parents. He was from a middle-income family living in the Colombo suburbs and was the only child. The cause of the child's pain had not been thoroughly investigated previously. On examination, there was no obvious lump or overlying skin changes detected. There was moderate tenderness over the distal forearm. Pronation was normal (0-90°), while supination was restricted (0-20°). Neurovascular examination of the right hand was normal. All blood investigations and inflammatory markers were within normal limits. Plain X-ray showed ring and arc type calcifications in the distal forearm at the interosseous area, in close proximity to the metadiaphyseal region of the ulna . The medSurgery was performed under a bloodless field via the trans-FCR approach . The lesLeiomyoma is a benign tumour of smooth muscle origin usually occurring in the areas of the body composed of smooth muscles, such as the uterus or the gastrointestinal tract. When seen in soft tissues, it usually involves the dermis and subcutis, and very rarely, the deep soft tissue. It is classified as cutaneous leiomyoma (leiomyoma cutis), angiomyoma (vascular leiomyoma), or leiomyoma of deep soft tissue . HistoriThe significance of our case lies in its rarity and the diagnostic dilemma it entailed due to the nonspecific radiological appearance. Calcified appearance in soft tissue may give rise to diagnostic confusion and may point towards familiar musculoskeletal conditions. The ring and arc calcifications in our case initially pointed towards a benign or malignant cartilage-forming pathology. Among other conditions that can be considered are calcified haematoma, myositis ossificans, tumoural calcinosis, tuberculous lymphadenitis, pilomatrixoma, calcifying fibrous pseudotumour, synovial sarcoma, mesenchymal chondrosarcoma, and extraskeletal osteosarcoma , 9, 13.Histologically, these are composed of mature-appearing smooth muscle cells with abundant eosinophilic cytoplasm. In order to diagnose soft tissue leiomyomas, lesions should have no cytological atypia and no coagulative necrosis. They should also be minimal to amitotic (<1 mitoses/50 hpf) . ImmunohDeep somatic leiomyomas arising from skeletal muscle are extremely rare in children, especially in the extremities. A calcified leiomyoma of the distal forearm in a child has not been previously recorded in published literature. It should be considered in the differential diagnosis of any extensively calcified deep soft tissue lesion in children. Histopathological/immunohistochemical confirmation is needed to exclude its more common malignant counterpart.


The NUT midline carcinoma is a rare tumor mostly reported in the midline of upper aerodigestive tract and mediastinum. Children as well as adolescents are affected without a gender distribution. A standard treatment is not established. So far, there exists no reported case of a pregnant female suffering from NUT midline carcinoma with musculoskeletal manifestation.A 34-year-old woman was referred to our outpatient clinic by the general practitioner during her 31st week of pregnancy suffering from shoulder pain and dyspnea. So far, dyspnea was interpreted as a typical pregnancy-related symptom. However, a chest X-ray showed a tumor mass in the right lung in close relation to the scapula. Further examinations found metastases in different areas of the body. No pregnancy-related complications were detected by obstetric examination. After an interdisciplinary perinatal case discussion, cesarean section was directly followed by an open biopsy of the right side scapula tumor lesion. A NUT midline carcinoma was diagnosed by immunohistochemistry. Due to disseminated tumor disease in multiple non-resectable locations, a palliative systemical chemotherapy was started by the oncological outpatient clinic.This report presents the case of the very rare NUT midline carcinoma under pregnancy which made interdisciplinary case discussions indispensable for therapy planning. The NUT midline carcinoma is a rare tumor mostly reported in the midline of the skull, upper aerodigestive tract, and mediastinum –3. OtherA 34-year-old woman was referred to our outpatient clinic during her 31st week of pregnancy suffering from shoulder pain of the right side after lifting her 11-month-old first born. During the first pregnancy, one and a half year ago she started noticing dyspnea which was still present at the time of her presentation in our clinic. At that time, this symptom was considered as pregnancy-related therefore no special examination was arranged. Several months later the patient became pregnant again. She was still reporting of dyspnea especially at physical activity and new symptoms, cough and hemoptysis, had appeared. Due to persistent symptoms, the general practitioner arranged a chest X-ray that showed a tumor mass in the right lung in close relation to the scapula  with normal amniotic fluid and normal feto-placental perfusion of a 34-year-old gravida 2 para 1 (one spontaneous delivery 1 year ago) with no pregnancy-related complications. A diaplacental cancer cell transmission seemed unlikely for the type of expected tumor.MRI scans /carboplatin (AUC 6) was started by the oncological outpatient clinic  translocation in fluorescence in situ hybridization (FISH) . A monocThis report presents the case of a rare NUT midline carcinoma as tumor entity and emphasizes the need of interdisciplinary case discussions. Especially the additional factor of a pregnancy under this rare malignancy without specific therapy regimen until now had to be considered and required a highly personalized diagnostics and treatment planning. The case also illustrates that persistent or atypical symptoms should always be taken seriously and lead to supplementary diagnostics to exclude severe diagnoses.


A 59-year-old male presented with a two-month history of abdominal pain and was found to have an obstructing cecal mass. Colonoscopy and biopsy confirmed invasive adenocarcinoma. Immunohistochemical analyses for mismatch repair (MMR) proteins revealed the loss of MLH1 as well as PMS2 in cancerous nuclei, which makes the tumor MMR deficient. Negative germline testing for MMR proteins ruled out the Lynch syndrome. After negative staging computerized tomography scan for distant metastases, he underwent ileocolectomy with ileotransverse colonic anastomosis. Final pathological analysis revealed poorly differentiated adenocarcinoma with signet ring features, negative margins, and 3/22 lymph nodes positive, classified as stage IIIB (T4aN1bM0). Adjuvant chemotherapy with modified FOLFOX  was started without the use of any growth factor support. After cycle 9 of 12, he developed mild transaminitis, carcinoembryonic antigen elevation, and interval development of two heterogeneously enhancing hepatic lesions. Biopsy of both of these lesions revealed extramedullary hematopoiesis (EMH), with no evidence of metastatic disease. He completed adjuvant chemotherapy without complication, and these liver lesions have decreased in size during the follow-up period of almost two years thus far.EMH is extremely rare in patients with colon cancer. Contributing factors include therapy-specific (growth factor support), bone marrow suppression secondary to chemotherapy and radiation therapy, and tumor-specific factors (cytokine and growth factors released by the tumor). To the best of our knowledge, this is the first case report of EMH in an MMR deficient colon cancer patient on adjuvant FOLFOX. MMR-deficient tumors show signs of a high degree of infiltration with CD8+ cytotoxic T lymphocytes as well as helper T cells, leading to increased production of cytokines, such as interferon-γ. This could be a potential etiology behind EMH in our patient who was MMR deficient. The role of the MMR-deficient state in the development of EMH should be explored further. Extramedullary hematopoiesis (EMH) is defined as hematopoiesis occurring in areas outside of the bone marrow, most commonly the liver and spleen. This process is physiologic during fetal development but pathologic in adult life and is usually a compensatory mechanism secondary to bone marrow malfunction . It is mA 59-year-old Caucasian male presented with a two-month history of intermittent generalized abdominal pain and one week of diarrhea with bright red blood per rectum. His past medical, surgical, and family history was unremarkable. Contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis showed an 8.2 x 7.6 x 9.0 cm cecal mass that involved terminal ileum, causing a small bowel obstruction, with multiple prominent lymph nodes noted in the right lower quadrant, without evidence of bowel perforation or distant metastasis. A colonoscopy revealed an obstructing cecal mass and biopsy confirmed invasive adenocarcinoma, positive for CK20, CDX2, and SATB2, but negative for CK7, compatible with colon primary. Immunohistochemical analyses of the biopsied colonic adenocarcinoma for mismatch repair (MMR) proteins revealed the loss of MLH1 and PMS2 in cancerous nuclei, making the tumor MMR deficient  level was within the reference range at 1 ng/ml (0-3 ng/ml) and high sensitivity C-reactive protein was significantly elevated at 47.5 mg/l (0-5 mg/l). A laparoscopic ileocolectomy with ileotransverse colonic anastomosis was performed without any complications. Pathological analysis of the surgical specimen revealed poorly differentiated adenocarcinoma Figure  with sigHis pathological staging was classified as stage IIIB (T4aN1bM0) according to the 7th edition of the American Joint Committee on Cancer staging guidelines. His CEA level postoperatively was 2.6 ng/mL. After resection of the primary tumor, he was started on adjuvant chemotherapy with modified FOLFOX6  for a total of 12 cycles after multidisciplinary tumor board discussion.Over the initial five months of his adjuvant chemotherapy, he was noted to have a minimal but persistently rising CEA level from 2.6 ng/mL at the start of chemotherapy to 7.3 ng/mL after completing 9 of 12 planned cycles of chemotherapy. His complete blood count at this time was within the reference range. His aspartate aminotransferase (AST) was 46 IU/L and alanine aminotransferase (ALT) was 43 IU/L, mildly elevated since the start of chemotherapy. As a result of the rising CEA, a CT scan of the abdomen and pelvis with intravenous contrast was obtained, which revealed interval development of two heterogeneously enhancing masses in the right and left hepatic lobe, concerning metastatic disease Figure , 3B.The MRI Figure , 4B showBoth lesions exhibited delayed enhancement on MRI, which is not consistent with metastatic colon cancer. CT guided percutaneous needle core biopsy of both liver lesions revealed extramedullary hematopoiesis with peliosis. More specifically, the hepatic parenchyma demonstrated marked sinusoidal dilation, congestion, and hemorrhage with associated clusters of immature erythroid and myeloid precursors with rare megakaryocytes in the dilated sinusoids Figure . Some of the sinusoids were devoid of endothelial lining Figure . There wHe has no new findings on imaging since treatment ended. His labs at last visit included white blood cells 5.9 (4-10 thou/cu mm), hemoglobin 15.7 (13-16.5 g/dL), platelets 281  25 (0-37 IU/L), and ALT  29 (0-50 IU/L). His CEA peaked at 7.3 ng/mL after cycle 9 of modified FOLFOX6 and then slowly trended down and has remained below the reference range (< 3 ng/mL).To the best of our knowledge, this is the first case report of EMH in a colon cancer patient with a deficiency in MMR genes getting adjuvant chemotherapy.EMH occurs when hematopoietic stem cells migrate out of the bone marrow to other areas of the body, typically as a result of bone marrow dysfunction or suppression. It is most often seen in hematological diseases but not frequently reported in the setting of solid tumor malignancies. The reasons for EMH in this subgroup of patients are not fully understood. Contributing factors include therapy-specific (growth factor support), bone marrow suppression secondary to chemotherapy and radiation therapy , and tumEMH in the setting of malignant solid tumors provides a diagnostic challenge that requires careful consideration and a high index of suspicion. EMH commonly involves the liver, spleen, and, occasionally, the lymph nodes. EMH can be microscopic or form masses  that appEMH is rare in colon cancer patients but requires a high degree of suspicion to avoid potentially toxic and unnecessary chemotherapy or other local therapy. Physicians should be aware of these phenomena and should keep a low threshold to perform a biopsy when in doubt. Patients who undergo chemotherapy for colon cancer typically do not require the use of recombinant growth factor support; moreover, the FOLFOX regimen has not been directly linked to causing EMH either, which makes a discovery in our case more unique. The role of the MMR-deficient state in the development of EMH is unclear and should be explored further.


Physicians working as first-level responders in emergency departments (ED) often encounter patients, of any age group with shortness of breath (SOB). Definitive diagnosis is quite challenging once the underlying pathology is rare and unusual and/or the ED physicians recommend and rely on non-specific investigations.A 29-year-old female presented to the emergency department with sudden onset of shortness of breath and upper abdominal pain radiating to the left shoulder. Diagnosis of Bochdalek hernia was made clinically coupled with radiological findings of CXR and computed tomography (CT) by the surgeon on-call, while it was missed by an emergency care physician on her first visit.Herniation of the abdominal contents into the thoracic cavity via the Bochdalek opening, commonly known as Bochdalek hernia is seen and diagnosed most commonly accidentally in early life. Adult cases of symptomatic Bochdalek hernia has been reported in the literature. These patients usually present with non-specific symptoms, thus pose a diagnostic challenge for an emergency care physician.The report of this case highlights the notion that such rare causes of acute onset dyspnea and upper abdominal pain pose a diagnostic challenge for novice emergency care physicians especially in situations where he/she does not ask for second-line help in general and recommend and rely on a non-specific investigation in specific. Diagnosing the underlying pathology is most challenging in situations where the underlying pathology is rare and unusual, especially for ED physicians who rarely encounter such rare scenarios.One of the extremely rare causes of shortness of breath and upper abdominal pain is sudden onset herniation of the abdominal contents into the thoracic cavity, a condition commonly known as Bochdalek hernia that was first reported by a Czech anatomist Vincent Alexander Bochdalek  in 1848.Herein we report a young female patient with Bochdalek hernia associated with the retrocardiac spleen that was managed surgically. This work is reported in line with the SCARE criteria guidelines for case reports .2A 29 years old female, physician by profession presented to the emergency department with a history of aggressive vomiting five weeks back followed by left upper abdominal, a single episode of loose motion, subcostal pain radiating to left shoulder associated with shortness of breath (SOB) and was unable to take full inspiration. The patient has a history of heartburn, early satiety, indigestion, and food regurgitation six years ago and diagnosed and managed as gastroesophageal reflux disease in her native country.The primary evaluation shows a toxic looking afebrile patient with vitals as; respiratory rate-27/min, pulse 87/min. Along with first-level management, abdominal ultrasonography (US) and initial laboratory workup were done in ED with no abnormal findings and the patient discharged home after the primary management independently and not asking surgeon on-call help. Upon no improvement, the patient revisited the ED where chest x-ray (CXR) as primary imaging modality was requested by surgeon on-call that showed raised right hemidiaphragm with no well discernible outlines, air-filled bowel loops above the hepatic shadow, a chilaiditi's sign, with no mediastinal shift a, thus aFollowing CXR, a non-contrast CT requested showing stomach and parts of the colon in the right thoracic cavity a along wSevere vomiting, a few weeks earlier was the triggering event in the patient that led to the initiation of the clinical picture. After initial stabilization, the patient was transferred to a regional tertiary care facility for cardiothoracic surgeon evaluation and management where via open thoracotomy, contents reduced and fortunately there was no vascular compromise. Repair done. Post-operative chest x-ray shows normal findings b. The pa3During embryonic life the pleuroperitoneal folds fail to close, resulting in an opening called Bochdalek opening through which the abdominal contents herniate into the thoracic cavity commonly known as Bochdalek hernia. The condition is most commonly manifest in early weeks of life while adult cases of symptomatic Bochdalek hernia (ABH) have also been reported in the published literature. The four types of congenital diaphragmatic hernia include parasternal hernia of Morgagni-Larrey, peritoneo-pericardial hernia, eventration of the diaphragm and the posterolateral hernia of Bochdalek  commonesMany patients remain asymptomatic until adult life or may present with chronic symptoms of abdominal or respiratory such as recurrent abdominal or chest pain, early satiety, and fullness after meal or vomiting ,8. Poten4Rare and unusual causes of acute onset dyspnea in adults with or without abdominal pain pose a diagnostic change for novice emergency care physicians. A high index of suspicion, clinical expertise and second-line help coupled with a basic radiological investigation like CXR and advanced radiological services such as CT scan are useful in dealing with patients with dyspnea and upper abdominal pain to reach a definitive diagnosis and plan case-specific management.The Authors declare that they have no Conflict of Interest.Nil to declare.As it is a case study, thus no prior ethical approval obtained.Written Informed Consent taken from patient for publication of this case with accompanying images.Liaqat A. Khan: Conceptualization, data interpretation, writing, reviewing and editing of the manuscript.Ali M. Al-Neami: Conceptualization, reviewing and editing the draft.Ayman F. Soliman: Acquisition of data, reviewing the manuscript.Alaa A.M. Khaled: Roles/writing, original draft.Mohammed I.H. Tawhari: Editing the original draft.Yahya A. Athlawy: Reviewing the final draft.All authors approved the final version of the manuscript.As this is a case report and not an interventional study, this manuscript is exempt from registration.Ali M. Al-Neami.Not commissioned, externally peer-reviewed.