Cemento-ossifying fibromas are rare, benign lesions of the head and neck regions. The origin of these lesions can be traced to the periodontal ligament, because its cells are able to form cement, lamellar bone, or fibrous tissue.A rare case report of a young Caucasian female with a COF is described including follow-ups. She remained untreated for several years despite early radiographic findings of the lesion without a definitive diagnosis. The patient ultimately underwent radical surgery and the whole lesion was removed. The subsequent histological examination confirmed the clinical diagnosis of a COF. Since then, the patient has been under regular clinical and radiological follow-ups.This rare case report of a COF, documented over 18 years, shows the importance of consecutive therapy after radiologic and clinical findings, as such lesions continue growing and may subsequently lead to severe medical conditions. Therefore, complete surgical resection of COFs is advised to achieve good results in terms of health and recurrence.Long-term follow-up of patients is required as recurrences can occur for up to 10 years following treatment. Well-planned radical and wide surgical resection of these lesions has proven not only to be effective in eliminating the aetiological factors, but can also achieve decent bone regeneration and aesthetic results with almost no deformation in the surgical site. It is fIn general, COF is more prevalent in females between 30 and 40 years old and is more common in the mandible (70 %) than in the upper jaw  . It is uCemento-ossifying fibromas are round or ovoid, slow growing masses that usually affect the adjacent teeth and can cause root resorption . PermaneThe origin of COF is considered unknown. Wenig et al. suggested that past traumata or local irritants are possible causes for the development of a COF .The term “cemento-ossifying fibroma” was issued by the fourth edition of the WHO classification of 2017, describing it as a benign mesenchymal odontogenic tumour .Two subtypes of COF are reported in the literature based on age (adult or juvenile), histological content (cementoid or osteoid), and histological pattern (psammomatoid or trabecular) , psammomThe psammomatous type is primarily found around the paranasal sinuses and orbits. It has small uniform spherical ossicles resembling psammoma bodies. The trabecular type is found mostly in the jaws and is characterised by fibrous trabecula .Juvenile ossifying fibromas (JOF) are further categorised as juvenile active ossifying fibromas and juvenile aggressive ossifying fibromas, which occur in children younger than 15. The appearance of more than three subtypes in a single lesion is not uncommon, for example, within psammomatoid juvenile cemento-ossifying fibromas .According to the site of origin, a COF can be classified as a peripheral cemento-ossifying fibroma (PCOF) or a central cemento-ossifying-fibroma (CCOF).An early diagnosis and consecutive therapy can prevent complications such as pathological fractures. Complete surgical removal of the lesion remains the gold standard . RegularThe aim of this case report is to describe the slow but permanent growth of a COF and the clinical, radiological, and histological characteristics. To the best of our knowledge, there is no such case in the existing literature of a cemento-ossifying fibroma documented over such a long period of 18 years, including preoperative and postoperative time.The patient was managed at our academic institution. The present case is reported in accordance with the SCARE criteria .2We report the case of a 19-year-old Caucasian woman diagnosed with a cyst in her upper jaw, expanding from regions 23–26.The first orthopantomogram was conducted in January 2001 by her local dentist during a routine examination. The orthopantomogram revealed a large radiolucent, multilocular periapical lesion expanding from regions 23–26, reaching into the maxillary sinus. The edges of the lesion appeared sclerosed .Fig. 1A,The involved teeth showed no signs of root resorption and all tested positive for vitality. The patient had an unremarkable drug, family, and psychological history and showed no clinical symptoms or pain, which is considered a typical characteristic of COF.The attending dentist referred the patient to the General Hospital in Vienna (AKH) and a biopsy was performed. During the operation, tooth 24 had to be extracted.The following analysis of the specimen combined with the clinical and radiological findings led to the diagnosis of a solitary bone cyst.Unfortunately, the patient refused any further treatment, including a cystectomy.The patient did not reappear from 2001 until 2007 due to the absence of any clinical symptoms or pain. In late 2007, she was referred to the General Hospital in Vienna, Department of Maxillofacial Surgery.She was suffering from intraoral swelling on the left side of her maxilla and complained about a strong feeling of dull pressure in the left eye region. During the ensuing 6 years, the already large cyst had expanded even further, pushing apart the roots of the adjacent teeth. Throughout the clinical oral examination, painless swelling of the left maxilla (regions 24–26) was observed. All of the patient’s teeth, including those inside the lesion, reacted positively to the vitality check.A newly taken orthopantomogram showed the now massive extension of the tumorous lesion, covering almost the entire part of the left maxillary sinus. The lesion had a diameter of approximately 3.4 × 3.2 cm.After informing the patient about the findings and upcoming treatment, she provided consent for the necessary operation. A preoperative computer tomography scan showed a 3.4 × 3.2 × 2 cm distension within the left maxillary sinus . The marTwo weeks later, the patient underwent surgery under general anaesthesia by the head of the Department of Maxillofacial Surgery. The lesion was removed using an intraoral approach, and a mucoperiosteal flap was placed from regions 23–28. After bone windowing, the tumour was removed completely .Fig. 3A,The patient received postoperative antibiotics, a non-steroidal anti-inflammatory agent, and a proton pump inhibitor and was discharged after a few days.The resected 3.4 × 3.2 × 2 cm specimen was histopathologically examined. Microscopically, the bone section was deformed by a cystic lesion filled with blood, and the cyst wall of the loose connective tissue was covered with granulation tissue of different ages.Each trabecula was lined with distinct and thick osteoblast segments in different places. The osseo-trabecula had sections of dense cellular lesions consisting of small spheres of a cementitious material bounded by plump, fuzzy cells with many vascular gaps in between .Fig. 4A,This morphological description of the lesion matched a solitary bone cyst plus focal sections of cemento-osseous dysplasia. There were no signs of malignancy.The patient attended regular follow-up appointments. Six months after surgery, she remained symptom-free and was in the ninth week of pregnancy.During a regular follow-up CT in 2009, new cystic changes were found within the left maxilla from regio 22–24. Another cystectomy was performed under general anaesthesia by the head of the Department of Maxillofacial Surgery at the University Hospital St. Pölten.Using an intraoral approach, an incision from region 22–26 was preformed and the raised mucoperiosteal flap was carefully extended to expose the incisal nerve. After bone windowing the cystic like lesions were revealed and then removed in several fragments. A fibrin sealant, Tachosil®, was used on the operated tissues to stop the bleeding. This minimally invasive approach enabled the patient’s rapid recovery with no complications.The patient was given postoperative antibiotics, a non-steroidal anti-inflammatory agent, and a proton pump inhibitor and was discharged in stable condition a few days later.The removed fragments were histologically examined and showed a calcified material that consisted of various differently sized and generally small spherical basophilic cement elements with cellular fibrous stroma. The final diagnosis was revised to cemento-ossifying fibroma with cystic formations matching a solitary bone cyst.A radiological follow-up in 2010 showed no signs of recurrence.The residual sinus walls were clearly sclerosed. In addition, inflammatory residual remnants less than 1 cm were found in the surgical site. The partially lytic, partially sclerosed changes in the alveolar process of the left maxilla remained, with increasing sclerosing at regions 22 and 23. The local status of the teeth remained unchanged.Since then, the patient has been under regular clinical and radiological follow-up.DVTs taken in 2016, 2017, and 2019 showed insignificant changes in the left maxilla.To date, approximately 10 years after the second operation, there have been no signs of recurrence and the patient is clinically symptom-free. Moreover, the patient is satisfied with the outcome of treatment.3In summary, this kind of lesion was first described in 1872 by Menzel as a type of ossifying fibroma in the mandible. Since 1968, cementum informalities containing tumours have been categorised as COFs . The terAccording to the 2017 WHO classification, the term “cemento-ossifying fibroma” was categorised as a type of mesenchymal odontogenic tumour . If boneThere are two types of ossifying fibromas, central and peripheral. The central type arises from the cells of the periodontal ligament in the apical area, causing the expansion of the lamina dura. The peripheral type occurs in the soft tissues of the teeth-bearing areas .Similarly, solitary bone cysts (SBCs) appear clinically symptomless and are often discovered accidently. The SBC is a benign cavity in the bone that classifies as a pseudocyst without lining epithelium. SBC is either empty or is filled with fluid  and is aA similar disease described in the literature is the aneurysmal Bone Cyst (ABC). In contrast to the SBC, however, the ABC shows a clearly more aggressive clinical behaviour . SurgicaJuvenile ossifying fibromas (JOFs) commonly occur aggressively during the beginning of adulthood when patients are undergoing hormonal and biological changes. This applies to our patient, as she was 19 years old when the cyst was first discovered.In 2002, El-Mofty presented the most relevant classification, identifying 2 categories according to their histological criteria: trabecular juvenile ossifying fibroma (TrJOF) and psammomatoid juvenile ossifying fibroma (PsJOF). The site of occurrence is a clinical feature that can help differentiate the two subtypes. PsJOF primarily occur in the paranasal sinus area, and TrJOF tend to occur more in the maxilla. In general, mandibular and extracranial involvement is rare .The management and prognosis of JOFs are uncertain. In some cases, there are minimal symptoms, and in other cases, especially in very young patients, the tumour has very local behaviour with a high recurrence rate (30–58 %), Therefore, it is recommended that these locally aggressive neoplasms be treated with wide surgical resection rather than conservative curettage .For many years, the origin of COFs was considered the periodontal ligament . HoweverThe lesion can develop from the periodontal membraneAlso, he mesenchymal cells within the mesodermal germ layer can differentiate and develop into multiple cell types producing a complex tumour . These tThe aetiology of COFs is yet unknown, but trauma may act as a predisposing factor, which suggest a connective-tissue-reactive aetiology rather than a neoplastic aetiology . It has Clinically, COFs are usually painless, spherical, or ovoid, intra-bony symptomless, slow growing masses. However, in certain cases, pain or paraesthesia may be present if the adjacent nerve is affected.COFs can also cause sinus obstruction, facial deformity, proptosis, and intracranial complications, although they can remain symptom-free without affecting the vitality of the surrounding teeth or causing any signs of necrosis during early stages of development. In some rare cases, the lesions can grow massively, causing significant cosmetic and functional deformities .In general, the lesions are firm in consistency, subject to the degree of mineralisation within. Intra-orally, the lesions are covered with normal mucosa with no signs of associated adenophathies .A distinguishable difference between COFs and FDs was described by the first edition of the WHO classification, in which COFs presented with clear and well-defined margins in the jaws and a transition zone less than 1 mm, while FDs had poorly defined margins .COFs are either uni- or multicystic lesions or mixed-density lesions . The radMature lesions appear with symmetrical opacities bordered by smooth and contour peripheral osteo-condensation and an "eggshell" radiological appearance .COFs presenting in the jaws can with sufficient clinical and radiographic information be diagnosed with fair certainty into one of the subcategories of fibro-osseous lesions and cannot be confirmed as COFs based on histological evidence alone . DespiteThe radiologic differentiation of central cemento-ossifying fibroma from Gorlin cysts and Pindborg tumours is difficult if not associated with impacted teeth, with which they have a high association; the final diagnosis is based on the histologic appearance ,14.The most common method in managing COFs is surgical excision. Small and well-defined lesions can be excised via enucleation and curettage, whereas large expanding lesions require radical surgery within healthy margins and aesthetic recontouring . WhetherThe prognosis for such lesions is considered good, while the recurrence rate is estimated to range between 0% and 28 % of cases ,26,42. T4This persistent follow-up of this rare compound case helped describe the histological, clinical, and radiological features of this lesion for a long period of time, which can help clinicians managing similar lesions to achieve good clinical, aesthetic, and functional results. Well planned, radical, and wide surgical resection of such lesions has proven not only to be effective in eliminating the aetiological factors, but can also achieve decent bone regeneration and aesthetic results with almost no deformation at the surgical site.The authors declare that there is no conflict of interest.This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.The ethical approval has been exempted by our institution.The patient received a thorough explanation of this report gave her oral and written informed consent to be included in this report as well as for publication of these case, anonymous data, and pictures. A copy of the written consent is available for review on request.Sarmad Aburas, Patrick Bandura and Ali Al- Ibraheem :study concept and design, writing the paper.Marius Meier and Sebastian Berger: data collection, analysis and discussion of data.Dritan Turhani: final approval of the version to be published.Not applicable. No research study involved.The corresponding author is the guarantor of submission.Not commissioned, externally peer-reviewed.


The Roux-en-y gastric bypass (RYGB) surgery is one of the most common and successful weight loss procedures. Procedure mortality is low, but intestinal complications account for a high percentage of associated morbidity. Internal hernias remain one of the most common complications while volvulus and intussusception are rare.A 22-year-old woman with a past surgical history of laparoscopic RYGB six years prior presented with a 12 -h history of abdominal pain. Exploratory laparotomy revealed concomitant volvulus, internal hernia and intussusception at the J-J anastomosis which was reduced without need for bowel resection. Her post-operative course was unremarkable and she was discharged home five days later.Many previous cases of intussusception related to RYGB surgery have required treatment with bowel resection secondary to delayed surgical intervention. Due to high variability in clinical presentation of post-RYGB obstruction, a high index of suspicion is necessary for prompt recognition. Early surgical intervention may prevent the need for bowel resection and improve patient outcomes.This case represents an unusual complication of RYGB involving intussusception, internal hernia and volvulus that was successfully managed without need for bowel resection due to early identification and surgical intervention. RYGB inInternal hernia is a relatively common cause of bowel obstruction in post-RYGB patients. Development involves a loop of bowel that herniates through a mesenteric defect acquired during the surgery. Such defects are more commonly experienced via a retrocolic approach and therefore higher rates of internal herniation have been shown to occur 3.5–5.6 %). Incidence of internal hernia after RYGB has been shown to decrease when a mesenteric defect is closed intra-operatively and an antecolic approach is utilized (0.9–4.5 %)  %. Incid,8. Due tIntussusception is a rare complication of RYGB  and has unique development in these patients compared to the standard intussusception in the adult population. In bariatric patients, the intussusception often occurs in a retrograde manner without a “lead point” and is typically located at the common channel to the jejunojejunostomy site. Clinically, patients present with signs and symptoms of small bowel obstruction including abdominal pain, nausea and vomiting with CT Imaging showing a “target sign” approximately 81 % of the time . TreatmeVolvulus is another cause of bowel obstruction in RYGB patients. Volvulus in this population is known to be caused by placement of a stitch between the roux limb and the excluded stomach in attempt to prevent kinking at the gastrojejunostomy anastomosis. Patient presentation can involve abdominal pain with distention, nausea and vomiting. CT scan of the abdomen and pelvis provides the best imaging, and treatment involves surgical exploration and manual correction.The 30 day mortality rate for a RYGB is between 0.09-0.12 %, increasing to 4 % if the patient is over the age of 65 .2A 22 year old woman with a past medical history of morbid obesity treated 6 years prior with laparoscopic roux-en-y gastric bypass presented to our emergency department with a 12 h history of severe, periumbilical abdominal pain. She stated that her pain had been gradually worsening throughout the day and was now 10/10. She denied any nausea or vomiting but did admit to decrease in oral intake and decreased flatus since her last bowel movement occurring one day prior to her presentation. She denied any trauma or trigger for the pain. Her overall post-RYGB weight loss totaled 20 kg.3 = 21). Due to these findings, the patient was sent immediately for a CT of the abdomen and pelvis with intravenous contrast which showed findings compatible with small bowel obstruction in the left upper quadrant at the anastomotic site  and metabolic acidosis (HCOtic site , A–B. Thtic site .Fig. 1A.Diagnostic laparoscopy with expectation of surgical correction was attempted emergently due high suspicion of significant multifocal pathology based on presentation, laboratory, and imaging and concern for imminent bowel ischemia, rupture, etc. A large left upper quadrant mass of bowel was visualized but was unable to be reduced laparoscopically due to its size. After conversion to open laparotomy, a 10 × 10 cm discolored and hyperemic mass of bowel A–B was r3Intestinal complications are a rare but serious cause of morbidity in patients after RYGB surgery. Often, these complications evolve rapidly necessitating surgical resection of necrotic bowel. Such significant bowel involvement could also necessitate restructuring of the jejunojejunal anastomosis altogether, which would further worsen complications and patient outcome. Nelson et al. reviewed causes of small bowel obstruction in 784 patients who underwent RYGB and found an overall rate of 3.2 %. They also noted differences in causative factors between laparoscopic and open approaches . In openImaging modalities are often insufficient in diagnosing SBO in RYGB patients due to variation in postoperative anatomy. In a study of 574 RYGB patients, CT scan was found to be falsely negative in 44–50 % of patients after diagnostic laparoscopy showed 74 % having an internal hernia and 55 % with incarcerated bowel. Three percent of those with incarcerated bowel ultimately required either bowel resection or conversion to open laparotomy . In the J-J anastomosis should be considered as definitive treatment for prevention of recurrent intussusception [Intussusception occurs in only 0.6-0.7 % of patients who have undergone bariatric surgery . In the sception . This waA retrospective study of volvulus occurrence showed that out of 199 cases of RYGB, only 4 cases of Roux limb volvulus were identified with all cases related to a stitch being placed between the roux limb and the gastric remnants . The onlA high index of suspicion and early surgical intervention are essential in preventing bowel resections in patients with a history of RYGB presenting with signs and symptoms of SBO. In our patient’s case, she was emergently taken for CT within 60 min from presentation and ultimately to the OR within 3 h from initial presentation. Initial laparoscopy was beneficial for preliminary visualization of the intestinal defects which guided a more-focused subsequent exploratory laparotomy for adequate correction. Our timely intervention allowed for adequate reduction of her intestinal pathology without need for resection, jejunojejunal re-anastomosis, and with minimal sequela. Since volvulus and intussusception are both rare and difficult to diagnose complications of RYGB, getting the patient to the operating room as quickly as possible is of utmost importance to prevent such complications. While each individual pathology has been shown to occur in post-RYGB patients, this is, to our knowledge, the only documented case of concurrent volvulus, intussusception and internal hernia presenting as a complication of RYGB surgery. Due to rapid diagnosis and early surgical intervention, our patient did not require bowel resection and was able to be managed without additional complications.4To our knowledge, this is the only documented case of a triad of internal hernia, volvulus and intussusception in a patient with a history of RYGB presenting with symptoms of small bowel obstruction. Rapid surgical treatment is key to preventing bowel infarction necessitating resection which can lead to short gut syndrome, adhesions and other complications. Presentation of small bowel obstruction in a patient with a history of RYGB is variable, and while CT scans and physical examination may be helpful, the definitive diagnosis must be made intraoperatively with emergency surgery as imaging modalities are often insufficient.No conflicts of interest.This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.Not commissioned, externally peer-reviewed.This is a case report study. This report was conducted in compliance with institutional ethical standards. Informed written consent and ethical approval has been obtained and all identifying information was omitted.Informed written consent has been obtained and all identifying information is omittedAdel Elkbuli, Dessy Boneva, Kristen Santarone – Conception of study, acquisition of data, analysis and interpretation of dataAdel Elkbuli, Dessy Boneva, Kristen Santarone - Drafting the articleDessy Boneva, Mark McKenney – Management of caseAdel Elkbuli, Kristen Santarone, Kyle Kinslow, Dessy Boneva, Mark McKenney – Critical revision of article and final approval of the version to be submittedThis is a case report study.Dessy BonevaMark McKenney..


Patients with prolonged inflammatory bowel disease have a greater risk of colorectal cancer, known as colitis-associated cancer. Here we describe an unusual case of colitis-associated cancer.The subject is a 41-year-old male who has not presented digestive symptoms and has an appreciable medical history. He consulted a nearby doctor with left flank pain. A colonoscopy revealed a lateral spreading tumor (granular-type) in his descending colon. With a clinical diagnosis of cancer, D3 left hemicolectomy was performed and a small intestine stoma was constructed. The pathological diagnosis of the tumor was mucinous adenocarcinoma, pT4a(SE), pN2a, which was associated with dysplasia in the surface area. Post-operative ileus was prolonged and the endoscopic examination revealed longitudinal ulcers in the ileum. These ulcers responded quite well to the administration of infliximab, confirming the final diagnosis of Crohn’s disease. Pathological re-examination revealed that the tumor was dysplasia-associated type, and another dysplasia was confirmed near the tumor. Furthermore, mural scars and sporadic lymphoid aggregates were noted in the colon tissues, which suggested pre-existing Crohn’s disease. The patient died of peritoneal dissemination of cancer on day 207 after surgery.The present case was diagnosed as colitis-associated cancer with clinically latent Crohn’s disease, who developed clinically manifest Crohn’s disease only after surgery. Our review of literature revealed no cases comparable to ours. The cause of Crohn’s disease has not been elucidated, and it is regarded as a multifactorial disease for which environmental factors, genetic factors, and immunological abnormality are compounded . The incThe patient is a 41-year-old male. His chief complaint is left flank pain. He has no medical history/family history.The subject consulted a nearby doctor with left stomachache and fever as chief complaints in 1 month prior to the surgery. Diverticulitis of the descending colon splenic flexure was doubted in CT and the subject was hospitalized. A colonoscopy revealed an irregular flat elevated lesion on the splenic flexure. The subject was transferred to our hospital for examination and medical treatment.The height is 175 cm, body weight 54.6 kg, pulse 66 beats/m, body temperature 36.3, and blood pressure 114/76 mmHg. The abdomen was slightly distended, and mild left stomachache was recognized. The stool frequency was 1 time/day.In blood biochemistry examination, values were as high as 22.5 ng/ml in CEA and 81.0 U/ml in CA19-9 tumor markers.Significant hyperplasia (4 cm) of the colon mucous membrane was observed on the descending colon splenic flexure and it was accompanied by elevation of surrounding adipose tissue density. The surrounding lymph nodes swelled up to around 5 mm. Since strong hyperplasia was seen in the mucous membrane, it was thought as reactive enlargement accompanied by inflammation. The finding that indicates distant metastasis was not seen in the liver and lung Fig. .Fig. 1aA semicircular, lateral spreading tumor of granular-type  was observed in the descending colon splenic flexure Fig. a.Fig. 2Notable abnormality such as irregular ulcer and scar or bamboo joint-formed appearance was not recognized.Biopsy was performed twice for the lateral spreading tumor of granular-type of descending colon. The tumor was diagnosed pathologically as a tubular adenoma without evidence of malignancy. However, we judged that the lesion in the descending colon was a cancer based on the elevated CEA level and CT findings. We also considered the possibility of coexistence of inflammatory lesion near the tumor because of an edematous change of the mucosa Fig. b. TherefD3 left hemicolectomy and loop type stoma construction were performed. No abnormality was confirmed in the small intestine such as thickness, fistula, mass, and adhesion to abdominal wall during the operation.Gross examination confirmed that the main tumor was a laterally spreading tumor (granular-type) in the descending colon Fig. a, b. No The ileus state was prolonged for over 40 days after the surgery. On day 55 endoscopies were performed to newly find orbicular ulcers in the terminal ileum Fig. a, b. We Prevalence and incidence rates of Crohn’s disease in Asian countries have been increasing similar to western countries . HoweverThe most important issue of the present case is the diagnosis of Crohn’s disease. Clinically manifest findings and symptoms were noted only after the surgery. On day 77, longitudinal ulcers were detected by the endoscopy. The possibility of tuberculosis or cytomegalovirus infection was excluded by laboratory data as mentioned in the case presentation. Drastic improvement of ulcers by infliximab administration finally confirmed Crohn’s disease. Retrospective analyses also confirmed the following findings that suggest the presence of Crohn’s disease near cancer, e.g., mucosal edematous changes by endoscopy before the surgery and histopathological findings, i.e., irregular thickening of the muscularis mucosae, fibrosis in the submucosa and muscularis propria, and sporadic formation of lymphoid aggregates in the submucosa and subserosa in the colon tissue. These suggest the presence of clinically latent Crohn’s disease before surgery.The diagnosis of colitis-associated cancer included the followings: association of dysplasia in the surface area of the main tumor and detection of another dysplasia near the main tumor. Taken together, we could be able to diagnose the present case as colitis-associated cancer with clinically latent Crohn’s disease who developed clinically manifest Crohn’s disease after surgery.There are only a few reports of clinically latent Crohn’s disease in a western country and Japan .Rodríguez-Lago I reported that retrospective analysis of 31005 colonoscopies revealed previously asymptomatic 110 patients were diagnosed as ulcerative colitis . SimilarWe presented here an exceptional case of colitis-associated cancer who developed clinically manifest Crohn’s disease only after the surgery. To identify such cases, careful clinical and histopathological analyses would be important.In summary, we described a very rare case of a colitis-associated cancer with clinically latent Crohn’s disease. If the patient with no abdominal symptoms showed abdominal mass with surrounding effusion in abdominal CT, it is important to recognize that there might be the malignancy in the mass.The dissociation abdominal symptoms and CT findings might be the key findings of the clinically latent Crohn’s disease with colon cancer. Surgeons should examine such case carefully and observe the intestine attentively with suspicion of IBD.


Nuck’s hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck’s canal from September 2016 to January 2020 at the Department of Surgery of Charité Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck’s hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck’s hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck´s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon’s skills. If inguinal channel has been widened by the presence of a Nuck’s hydrocele, a mesh plasty, as performed in hernia surgery, should be considered. The canal of Nuck was first described by the Dutch anatomist Anton Nuck in 1691. As the female fetus develops, the ligamentum rotundum of the uterus descends down to the ipsilateral labia majora, extending through the inguinal canal. Along with the round ligament, a peritoneal evagination also descends, which is known as the canal of Nuck. The homologous structure in men is called the processus vaginalis [More precise embryologically, the processus vaginalis—in women named canal of Nuck—becomes clinically apparent within the 12th week of gestation. Normally it obliterates from the seventh month of gestation to one year of age. Persistently open canals of Nuck present most often in girls before the age of five ,4. The NType 1: there is no communication between hydrocele and peritoneal cavity. It mostly appears as an encysted mass without hernia defect in children. Examples for this type are the intra-abdominal protruding forms. In adults, we assume the fascia transversalis along with the ligamentum rotundum is thinned out because of the hydrocele, mimicking a direct hernia .Type 2: the hydrocele communicates with the peritoneal cavity, thus mostly resulting in an indirect hernia .Type 3: or combined type has an encysted part that does not communicate with the peritoneal cavity and another that does. Its appearance resembles an hourglass and commonly causes a hernia .Classification divides the Nuck hydroceles into three types : Type 1:To have a successful clinical outcome after surgery, complete excision of the hydrocele is recommended . FollowiIn our case series, we present six patients aged 29 to 44 with hydrocele of the canal of Nuck. Four of them received a Transabdominal Preperitoneal Patch Plasty (TAPP), one had an open hernia repair using the Lichtenstein method and another one an open hydrocelectomy along with a fascial suture, because there was no defect of the abdominal wall. We aim to share our experience on this rare condition and demonstrate that both types of hernioplasty can be performed for repairing a hernia caused by a Nuck hydrocele according to localization. Furthermore, we reviewed the case reports and case series published so far and compared their results and conclusions.From 2016 to 2020, six cases of Nuck’s hydroceles presented to our Department of Surgery at Charité Universitätsmedizin Berlin. We retrospectively analyzed the collected data in all of these cases with regard to patient demographics, presenting symptoms, diagnostic workup, operative procedures and postoperative course.The literature search was conducted with PubMed and Google Scholar using the following keywords: “nuck”, “nuck’s hydrocele”, “surgery”, “nuck hernia” and “canal of nuck”. In addition, we cross-checked reference lists from eligible publications and relevant review articles to identify additional studies. The inclusion criteria contained case reports or case series, with the main diagnosis of a “nuck’s hydrocele” or “nuck cyst” and included a surgical therapy. Exclusion criteria for case reports was the absence of any surgical therapy.Surgical procedure: both conventional and laparoscopic approaches were used for exploration. Laparoscopic hydrocelectomy and TAPP:2) pneumoperitoneum. The peritoneum was opened above the spina iliaca anterior superior which then revealed a hydrocele of the canal of Nuck and an indirect hernia. The hydroceles were excised laparoscopically and a TAPP with a 10 × 15 cm polypropylene mesh placed over the hernia and glued with 1ml of fibrin before suturing the peritoneal flap.Open access methods were used to place a laparoscopic trocar into the umbilicus for carbon dioxide  showed a hypointense and hyperintense cystic structure, respectively, without septation of the left groin of 5.6 × 3.7 cm size. A clinically inapparent cyst on the contralateral side was also found . The punThe patient then presented herself at our surgical outpatient clinic for further examination. We re-evaluated the case and diagnosed a Nuck’s hydrocele on both sides. Intraoperatively, a left-sided Type 2 hydrocele was seen, which could be confirmed by the histopathological finding of a mesothelial covered cystic lesion. The early postoperative period was uneventful and the patient was discharged home the day after surgery in satisfactory condition. Thus far, the patient remains asymptomatic in our routine follow-up. Surgical treatment of the asymptomatic right-sided cyst will also be performed in the course of time in case of discomfort.The demonstrated image material in A chart of the cases is shown in The selected studies included ten case reports and two retrospective case series. Overall, 39 cases of Nuck Hydroceles have been described in those publications. All patients presented with inguinal swelling. Two patients underwent emergency surgery (5%). The diagnosis was made by Ultrasound (33 patients—85%), Ultrasound and MRI (3 patients—8%), one case with CT and MRI (2.6%) and one case only by clinical examination (2.6%). Of all patients, 26 (67%) underwent laparoscopic hydrocelectomy and high ligation, one patient was treated by laparoscopic TAPP repair (2.6%) and another with laparoscopic total extraperitoneal (TEP) repair (2.6%). Nine patients underwent conventional surgery (23%) and a mesh was implanted in a further three patients (8%). Four patients showed a hernia (10%)—a subdivision in two groups (children and adults) resulted in no case of hernia defects in children but four adults (67% in the adult group). All patients had an uneventful follow-up and showed no recurrence.An overview of the articles that were included in this review of the literature is shown in The hydrocele of the canal of Nuck in the context of an inguinal swelling is a rare finding and as such it has to be named correctly in terms of terminology after a reliable diagnosis is made. Publications from the nineteenth century show that such cases were often misinterpreted and thus diagnosed and treated as an ordinary inguinal or femoral hernia . For manA variety of masses can be found in the female inguinal region. In summary, the differential diagnosis includes hernia, lymphadenopathy, abscess, Bartholin’s cyst, neurofibroma, sarcoma, liposarcoma, Burkitt lymphoma and posttraumatic/postoperative hematoma . PatientFurthermore, it is reported that pathologies in the canal of Nuck could be more frequent than previously assumed and should play a more important role in the differential diagnosis of groin pain . The mosSymptoms can be acute or chronic and infections of the hydroceles are also possible ,13,14. AThe hydrocelectomy would be the first surgical step followed by the hernioplasty in case of a hernia. TAPP and Lichtenstein are equivalent and can be used as therapy without any noteworthy limitations ,10,13. MWe can report that all our patients have benefited from the treatment in terms of their symptoms and, so far, we report no recurrence of the hydroceles. The maximum postoperative hospital stay was two days and the follow-up six months postoperatively has been uncomplicated. We are now sensitized by the experiences we have made in our clinic, mostly through random findings, and we believe that our case series could be used as a benchmark for further studies with larger case series and possibly register data. Therefore, although being rather rare, Nuck’s hydroceles should be included in the differential diagnosis of inguinal swelling. Taking the classification into consideration, we recommend a conventional approach for the encysted, external type 1 and a laparoscopic approach for the intra-abdominal type 2 Nuck’s hydroceles. Type 3 has to be evaluated individually as it is challenging and the surgical outcome is depending on the surgeon’s skills. A fascial augmentation with mesh, as performed in inguinal hernia surgery, should be considered if inguinal channel has been widened or fascial fibers are damaged by the presence of a Nuck hydrocele.


Lichen planus is an idiopathic lichenoid dermatosis that has many variants, such as the follicular form, which is clinically and histologically characterized by follicle involvement. Usually the most typical dermoscopic feature of lichen planus is the presence of whitish lines, also called Wickham striae (WS), which histologically correlate with orthokeratosis above the zones of wedge-shaped hypergranulosis . WS are Other features that can be observed at dermoscopic analysis are the presence of gray-blue dots, peppering, red lines due to the presence of vascular structures, comedo, milium-like cysts, and blue-white veils in the center .A dark-skinned man of African origin, aged 33, who has been living in Italy for the past 10 years, came to our attention after a 1-year history of a pigmented lesion on his face. This lesion was previously treated as actinic keratosis with diclofenac sodium 3% gel, but this treatment had not been successful. On examination, the area of concern showed irregularly flat, dark brown macules with defined limits on nasolabial folds. The lesion showed 2 slightly elevated darker infiltrated and palpable areas, 1 on the left side of the upper lip and 1 under the nostril . The patDermoscopy showed the typical pseudonetwork pattern with gray-brown perifollicular pigmentation, reticulated hyperpigmentation and 2 areas of darker irregular pigmentation, and obliteration of follicular openings .According to the dermoscopic features, the recent onset of the lesion, and its increased size, two 4-mm punch biopsies were taken for histopathological examination under the suspected diagnosis of atypical melanocytic lesion.The final clinical and histopathological diagnosis  was follThe particular site of the face and the dark skin of our patient can hide some typical features of follicular lichen planus and can mimic some typical features of melanocytic lesions. The pathognomonic WS may not be visible in pigmented skin and WS may not be appreciated on lichen planus lesions when the patient has been receiving topical treatment such as topical steroids or salicylic acid.Dermoscopic analysis of our case showed a gray pseudonetwork with asymmetrical pigmented follicular openings. This pattern, however, is common to numerous pigmented lesions, both melanocytic and not melanocytic lesions, which often makes a correct diagnosis difficult.Moreover, the presence of a milky pink erythema in a part of the lesion and the obliteration of some follicular openings can mean a progression of malignant lentigo .Our case shows all typical dermoscopic features of a melanocytic lesion on the face. Therefore, the preoperative clinical diagnosis was of an atypical melanocytic lesion.The presence within the lesion of a dermal nevus made the dermoscopic diagnosis even more difficult. In fact, the overall dermoscopic appearance of our lesion revealed the 4 most important features of malignant lentigo in progression: asymmetric pigmented follicular openings, dark rhomboidal structures, slate-gray globules, and slate-gray dots.This case shows the difficult clinical and dermoscopic differential diagnosis of pigmented lesions on the face, mostly with darker skins, and shows that it is important to consider also lichenoid dermatitis as a possible differential diagnosis in the management of pigmented lesions of the face.


We report a case of small bowel obstruction without perforation and peritonitis caused by inspissated barium sulfate for gastric cancer screening and surgically treated 26 hours after the onset of abdominal pain. A 55‐year‐old Japanese man presented with abdominal pain. He had a history of robot‐assisted laparoscopic prostatectomy 2 years ago. He did not have constipation. He underwent an upper gastrointestinal series (GIS) at our hospital for cancer screening 1 day previously. He used laxatives and had a small stool. By the afternoon, he was suffering from abdominal pain, abdominal distention, and nausea. The following morning, his abdominal pain had not improved.3, but were otherwise unremarkable. Abdominal x‐rays showed a small bowel loop and niveau (Figure On admission, he was mildly ill. His abdomen was soft and distended, with no tenderness, and a normal bowel sound was noted. Laboratory data showed an elevated white blood cell count of 13 400/mmu Figure . CardiovThe intra‐intestinal pressure was reduced by means of an ileus tube prior to the operation. The operation was performed the same day, approximately 26 hours after the initial onset of the abdominal pain. In the operation, the small bowel adhesions were observed in the supraumbilical region. We separated the adhesions and suctioned the barium. We did not perform small intestinal resection because there was no leakage of barium into the abdominal cavity and the serosal surface of the small intestine was normal. The ileus tube was retained. He was discharged 10 days later without perioperative problems.In Japan, the main procedure for gastric cancer screening is GIS, since being carried out as a national program in 1983. Bowel obstruction and perforations are reported in four and three of 1.1 million patients, respectively. However, bowel obstruction can easily lead to perforation and peritonitis. In addition, the reported mortality rate of barium peritonitis is 29%.The present patient was surgically managed for a bowel obstruction without perforation caused by inspissated barium, 26 hours after the onset of abdominal pain. Previous cases have shown that the mean day of bowel obstruction was ~3.0, and most patients had perforations when they presented to the hospital. Some cases develop perforation during observation.Patients who have a previous history of surgery may develop adhesions and are at risk of bowel obstruction. One study reported that the elderly population comprise a high‐risk group for barium‐induced intestinal obstructions, as they tend to forget to take laxatives after GIS.The other authors have stated explicitly that there are no conflicts of interest in connection with this article.MA and JK managed the patient. MA, HI, and JK wrote the manuscript. All authors have approved the final manuscript.The informed consent was obtained to publish this case report.


Polypoid endometriosis is a rare form of endometriosis that corresponds to a benign variant but which systematically mimics malignant tumors. Magnetic resonance imaging (MRI) is the preferred imaging modality for these lesions. We present herein a case of a 43-year-old female with recent pelvic pain and longstanding dyspareunia related to polypoid endometriosis of the Douglas pouch. MRI found an infiltrative lesion 6 cm in diameter with intermediate signal on T2-weighted imaging, cystic hemorrhagic spots, and fibrous surrounding rim of nodular portion. There was no functional sign of malignancy . The patient underwent total abdominal radical colpohysterectomy with bilateral salpingectomy and ovarian transposition was performed. Histopathological examination found a multinodular endometrial-type polypoid mass arising from the serosa of the cervix, with cystic area and fibrous surrounding tissue. In the case presented, MRI findings were useful for preoperative diagnosis that altered patient management by supporting a complete but reasonable surgical resection that yielded relief of symptoms. Polypoid endometriosis is a rare form of a very common disease affecting women of reproductive age that mimics a neoplasm on clinical, surgical, and gross examination A 43-year-old nulliparous woman consulted for mild metrorrhagia that had started 3 months earlier, she also suffered from recent pelvic pain and longstanding dyspareunia. Her medical history was unremarkable. Physical examination found a complete obliteration of the Douglas pouch with a hard and enlarged supravaginal cervix. MRI (1.5T) showed a lobulated nodular mass up to 6 cm in diameter, arising from the Douglas pouch with a large extrinsic infiltration of the posterior wall of the cervix, the posterior vaginal fornix, as well as perirectal and pericervical fat . The masPolypoid endometriosis is a benign variant of endometriosis that systematically mimics malignant tumors due to its infiltrative pattern. The ovaries, colon, and uterine serosa are among the most common locations affected by polypoid endometriosis Informed written consent for publication was obtained from the patient. The case report was in accordance with the 1964 Helsinki declaration and later amendments, and informed patient was obtained. All the authors significantly contributed to this work and agree with its content.


Unilateral lower quadrant pain is a common presenting complaint in the emergency room with a wide differential. It is important to consider fallopian tube torsion in the differential, especially in premenopausal women, as fertility-sparing detorsion, especially in a woman with a previous salpingectomy or other fertility-affecting surgery, is essential. This case report is of a 25-year-old woman with worsening left lower quadrant abdominal pain over 24 h found to have an extraovarian cystic mass. When taking into consideration the patient with a history of contralateral fallopian tube torsion secondary to a paraovarian cyst, now presenting with left lower quadrant abdominal pain and a cystic extraovarian mass, immediate laparoscopic evaluation was warranted. Immediate intervention revealed an isolated fallopian tube torsion and resulted in surgical preservation of fertility. •Recurrent paratubal cyst resulting in isolated fallopian tube torsion•Immediate fallopian tube detorsion as fertility sparing procedure•Gross necrotic appearance of adnexa does not require salpingectomy/oopherectomy. She had a past medical history of PCOS and a surgical history of a right salpingectomy secondary to a right paraovarian cyst resulting in an isolated necrotic torsed fallopian tube at 13 years of age.Physical exam revealed an obese female with normal vital signs. Abdominal exam was significant for left lower quadrant pain on deep palpation, with no rebound or guarding present. Bimanual examination revealed similar pain at left adnexa but otherwise benign with no vaginal bleeding, cervical motion tenderness or otherwise palpable masses. Of note, the physical examination was performed after patient had already received 975 mg of acetaminophen, 600 mg of ibuprofen and three doses of 2 mg morphine by emergency room providers.9/l with an otherwise normal complete blood count, comprehensive metabolic profile and urinalysis. Transvaginal and transabdominal ultrasound revealed a simple left adnexal cyst 1.5 × 1.2 × 1.4 cm and a 4 × 3.8 × 4.1 cm mildly complex cyst, both of which appeared to be extraovarian. Arterial and venous waveforms were documented for both ovaries. Fluid in the endocervical canal was also noted.Laboratory evaluation was significant only for a white blood cell (WBC) count of 12.85 × 10The patient's surgical history was significant for a similar presentation to the emergency department at 13 years of age. Upon review of the medical record that was available, a nurse at triage noted the patient was complaining of right lower quadrant pain that worsened over the day and stated that the patient was “doubled over in triage”. Unfortunately, no provider note could be found regarding physical examination and history of presenting illness. A CT examination of the abdomen and pelvis had revealed a 5.1 × 4.4 cm right ovarian cyst with trace amount of surrounding fluid . OtherwiThe decision was made to take the patient to the operating room for a diagnostic laparoscopy as there was enough clinical suspicion for either an ovarian, adnexal or tubal torsion based on the physical exam, ultrasound finding of extraovarian cysts and the patient's significant surgical history. Laparoscopically, a left-sided 4 cm paratubal cyst was removed and a left fallopian tube without signs of necrosis was de-torsed four times in a clockwise fashion . The ova3This case shows the importance of having a low index of suspicion as well as an emergent plan to action, especially with regard to preservation of fertility for a suspected tubal torsion. Even though the incidence of an isolated tubal torsion is 1 in 1.5 million ,3, to haThis patient, as in other case reports, presented symptoms that were vague and nonspecific. Pelvic pain and nausea were the main symptoms and were also the most common symptoms in other cases of isolated tubal torsion .UltrasouThis patient experienced both outcomes regarding fertility-sparing surgery. At 13 years old, based on the operative report, laparoscopic gross evaluation of the right fallopian tube deemed it to be unsalvageable. Factors that have been found to be correlated to adnexal necrosis were onset of symptoms over 10 h prior to surgery and age > 40 . FortunaTo conclude, isolated tubal torsion is a rare phenomenon but can have significant consequences for a woman's future fertility. Awareness of this condition is important and prompt laparoscopic intervention can help preserve fertility. Attempt at detorsion even if the fallopian tube appears necrotic should be performed in select cases.


Sarcoma is a malignant tumor arising from the mesenchymal tissues such as striated skeletal and smooth muscles, adipose tissue, bone, cartilage, and synovial tissue. The synovial subset of primary pulmonary sarcoma is very rare and is only described in a handful of cases. Our case describes the diagnostic approach and treatment regimen for a 49-year-old male with no significant past medical history. The diagnosis of a primary pulmonary synovial sarcoma was made through the use of endobronchial ultrasound (EBUS), transbronchial needle aspiration (TBNA), histologic analysis, and immunostaining. The treatment utilized a multimodal approach including resection, chemotherapy, and radiotherapy. Sarcoma is a malignant tumor arising from the mesenchymal tissues such as striated skeletal and smooth muscles, adipose tissue, bone, cartilage, and synovial tissue. Synovial sarcoma is a rare malignancy of mesenchymal origin constituting about 8% of all sarcomas . SynoviaA 49-year-old male with no significant past medical problems presented in the emergency department (ED) with acute chest pain along with dyspnea that had been ongoing for three weeks. The chest pain was described as radiating to his upper left back, pleuritic and progressively worsening over the past two days. Family history was significant for mesothelioma in the paternal grandfather and pancreatic cancer in the paternal grandmother. Vital signs were stable except for mild tachycardia and complete blood count (CBC)/comprehensive metabolic panel (CMP) results were within normal limits.The chest X-ray in the ED showed an anterior mediastinal mass. Computed tomography (CT) revealed a large well-circumscribed bilobed low-density mass completely encasing but not obstructing or infiltrating the distal left main bronchus or the left upper lobe bronchial branches Figure  and posiDue to the patient's history of smoking, primary lung cancer was considered and the patient underwent bronchoscopy with endobronchial ultrasound (EBUS). Bronchoscopy showed excellent cleanout of the left upper lobe bronchus with scant mucus but no obvious endobronchial mass. EBUS revealed a large hypoechoic mass in the left secondary carina. Transbronchial needle aspiration (TBNA) was done and the initial pathology report revealed a relatively non-specific spindle cell neoplasm. The biopsy samples were consistent with synovial cell sarcoma, and the histologic findings are detailed in Figure Immunostaining was positive for Bcl-2. Calretinin, CAM5.2, CD34, WT1 and AE1/AE3 profiles were negative. Samples sent out for diagnosis confirmation were positive for synovial sarcoma based on morphological findings and a positive t(X:18) ) translocation. Due to the marginal resectability of the tumor, the patient completed four cycles of chemotherapy with adriamycin and ifosfamide and had a good therapeutic response to the neoadjuvant therapy before surgery. A 5.7 cm x 4.8 cm x 6 cm tumor was removed along with two positive intrapulmonary lymph nodes. After surgery, the patient proceeded with radiation therapy. Unfortunately, the patient had a new subcutaneous abdominal nodule which was concerning for metastatic disease and is currently scheduled for a biopsy of the nodule for a possible metastatic lesion.Sarcomas in the pulmonary system are most commonly secondary to metastasis from extrapulmonary sarcomas. Primary pulmonary sarcomas are rare. The mesenchymal tissue in the pulmonary system can differentiate into synovial sarcoma, leiomyosarcoma, or histiocytoma which are also the most commonly observed primary pulmonary sarcomas .Primary pulmonary synovial sarcoma is a unique tumor as there is no synovial tissue located in the pulmonary system. The tumor usually arises from the pluripotent mesenchymal cells which then differentiate into synovial tissue. It is usually seen in the fourth or fifth decade of life with equal sex distribution. There is no predilection for the right or left side of the lung, but it is most commonly seen in the apex of the lungs . SmokingA chest X-ray of a primary sternal sarcoma typically shows a well-defined uniform homogeneous mass lesion with round, lobulated borders. A CT scan of the chest with contrast typically shows heterogeneous enhancement due to the presence of a necrotic, cystic, or friable portion of the tumor interspersed with a solid enhancing component of the tumor . On MRI,Endobronchial ultrasound (EBUS) and transbronchial needle aspiration (TBNA) have been increasingly used to assist in diagnosis due to frequent tumor proximity to the major airways, as seen in our patient. On gross examination, the tumor appears gray-white or tan with a soft fleshy to firm rubbery consistency and is well-circumscribed, with or without a capsule. Necrosis and hemorrhage can also be observed within the tumor . On histDiagnosis is also aided by immunostaining. Monophasic synovial sarcomas usually stain positive for vimentin, Bcl-2, CD-99, TLE, FLi-1, and S-100. In our patient, immunostaining was positive for Bcl-2, and tests for calretinin, CAM5.2, CD34, WT1, and AE1/AE3 were negative. Cytogenetic testing for the t(X:18) )p11;q11) translocation has high sensitivity and is considered to be the gold standard ;q11 tran. This trThere is no standard recommendation for the optimal management of patients with primary synovial sarcoma. When feasible, resection of the tumor as early as possible remains the standard of care followed by chemoradiation . SynoviaPazopanib, an oral vascular endothelial growth factor receptor inhibitor has been effectively used in patients with synovial sarcoma of any location. As most primary synovial sarcoma tumors also contain an SS18-SSx fusion oncogene, several new therapeutic agents targeting the oncogene have been developed and are currently in initial trials . Primary synovial sarcoma is an extremely rare intrathoracic tumor seen usually in young adults. When a primary tumor is in the chest, it usually presents with a large intrathoracic mass without any bone or mediastinal involvement. They can be accurately diagnosed with transthoracic EBUS and TBNA. Histologic analysis and immunostaining of tumor biopsy can help identify the tumor type. Most synovial sarcoma tumors also show a fusion oncogene which helps in obtaining an accurate diagnosis. Treatment is based on a multimodal approach including resection, chemotherapy, and radiotherapy.


Introduction: Ectopic pregnancy in a non-communicating rudimentary uterine horn is a rare gynecological condition associated with a high risk of uterine rupture and important maternal mortality and morbidity. A surgical excision of the rudimentary horn is the standard treatment, usually performed by laparotomy in the second trimester.Methods: A 36-year-old woman, secundigravida and nulliparous, was admitted to the emergency obstetric unit with acute pelvic pain. The ultrasound found an ectopic pregnancy at 15 weeks gestational age with fetal cardiac activity. As her hemodynamic status was stable, a diagnostic laparoscopy was performed and confirmed the development of the pregnancy in a left rudimentary uterine horn.Results: We report a total laparoscopic removal of a pre-ruptured rudimentary uterine horn containing a second trimester ectopic pregnancy, using a vessel-sealer device. To our knowledge, only three other cases of successful laparoscopic treatment of second trimester rudimentary horn pregnancies have been reported in the literature.Conclusion: Laparoscopy is an efficient and safe surgical option for treating rudimentary horn second trimester pregnancy in patients with hemodynamic stability. The rudimentary horn is found in 0.5% of women . PregnanA 36-year-old symptomatic woman, secundigravida and nulliparous, was admitted to the emergency obstetric unit at 15 weeks of gestation with a new onset acute pelvic pain.The pregnancy was spontaneous with normal physical examination and harmonious evolution. The prenatal ultrasound of the first trimester has not suspected an ectopic pregnancy and the patient was totally asymptomatic until her admission to the emergency at 15 weeks of gestation.When she was admitted to the emergency her hemodynamic status was stable. Physical exam revealed generalized abdominal tenderness dominating the left lower pelvic quadrant, no vaginal bleeding and a closed unique cervix, with no signs of a threatened miscarriage.Transvaginal and transabdominal ultrasound showed an empty uterine cavity with no blood in the peritoneal cavity. There was a gestational sac with a viable embryo with a biparietal diameter of 35 mm. The gestational sac was next to the uterus, leading to diagnosis of a left tubal ectopic pregnancy of 15 weeks gestational age. As her hemodynamic status was stable, urgent diagnostic laparoscopy was decided.Laparoscopy was performed using the Veress needle technique. The needle has been introduced in the palmer's point in the left upper abdomen to prevent any uterine injury. We have used one 5-mm supra-umbilical, one 5-mm suprapubic and two 5-mm ports in the left and right quadrants.Both fallopian tubes and ovaries were normal, but a right hemi-uterus was found. The pregnancy was located in a left pre-ruptured rudimentary horn, surrounded by a 1 liter of hemoperitoneum. We associate the hemoperitoneum to the pre-rupture of the rudimentary horn prior to surgical management probably occurred at the meanwhile between the admission of the patient in the emergency unit and her transport to the operation room.The surgery findings classified the Mullerian abnormality of the woman as V0C0U4a according to ESHRE classification .No endometriosis was observed . We follWe performed a circumferential ligature with two tight knots around the attachment of the rudimentary horn to the hemi-uterus using Vicryl for absorbable suture. The separation between the two knots was completed using the LigaSure® device . There was no bleeding during this separation. We should have performed a dye blue test in order to confirm no communication with the hemi-uterus but we suppose that there was no communication according to our perioperative findings. There was no defect in the myometrium of the hemi-uterus left in place after sectioning the attachment .The rudimentary horn with the pregnancy was removed with an endoscopic bag through the previous abdominal incision extended to 3 cm in the left pelvic quadrant. With a gentle traction against the abdominal wall the fetus was removed intact. The rudimentary horn was extracted using mechanical morcellation under direct visualization into the endoscopic bag.Blood loss estimation was 2 liters and the patient received a blood transfusion of two units, during the 180 min surgery, with no intra-operative complications.The patient was discharged healthy on the first post-operative day. Follow-up was uneventful.Histopathology confirmed a rudimentary horn of the uterus with a marginal hematoma.No associated renal anomaly was diagnosed post-operatively.Hemi-uterus is defined by the normal development of one unilateral müllerian duct with or without a rudimentary contralateral horn. In cases of partial development of the contralateral müllerian duct, the rudimentary horn is characterized by a functional or non-functional cavity. The contralateral part could also communicate or not with the hemi uterus .The rare congenital abnormally of a hemi-uterus with rudimentary horn is usually detected during the investigations of infertility, recurrent abortions, endometriosis, hematometra, dysmenorrhea, preterm deliveries, intra-uterine growth restriction, and uterine rupture. Only 10% of these rudimentary horns communicate with the main uterine horn and 35% of them have a cavity which rarely includes a functional endometrium .It has been described that rudimentary horn pregnancies are extremely rare and they are reported at 1:76,000–1:160,000 pregnancies . It seemEarly diagnosis of a pregnant rudimentary horn is challenging while the diagnosis is often missed on the prenatal ultrasound in the first trimester. It is reported that the sensitivity of the ultrasound is 26% and that it decreases with the advanced maternal age . The ultThe rate of uterine rupture in rudimentary horn pregnancies is almost 80%  associatThe surgical approach consists of the total excision of the symptomatic rudimentary horn and the removal of the ipsilateral fallopian tube in order to avoid the risk of a further ectopic tubal pregnancy .The laparoscopic removal of the rudimentary uterine horn is described as successful with neither intraoperative nor postoperative complications . The firKnowing the two types of attachment of the rudimentary horn to the hemi uterus seems to be essential for the efficient surgical approach. The rudimentary horn is either broadly attached to the hemi uterus or minimally connected by a fibrous band. In each case the cleavage plane has to be well defined either at the beginning of the surgery or by radiological images before the surgery because the approach depends on the extension of the attachment of the rudimentary horn to the hemi uterus .Suturing the myometrial defect can also be challenging to avoid a further uterine rupture. Good quality sutures are described as in “V” shape allowing to perfectly face the two edges of the myometrium . Modern The management of a pregnancy in a rudimentary horn will also help us to establish a therapeutic strategy for the obstetrical future of the concerned patients. We recommend a c-section in case of childbirth, no pregnancy before 1 year and we propose an ultrasound follow up at 1 month and at 6 months postoperativly.Pregnancy in a rudimentary uterine horn is extremely rare and requires a precise surgical management. Laparoscopic approach of a second-trimester rudimentary horn pregnancy is a feasible and safe method.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.KC and AF carried out manual search, draft of manuscript and revision according to other author's suggestions, and submission. JD carried out critically revision of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Meningiomas typically manifest on magnetic resonance imaging (MRI) as iso- to hypointense on T1-weighted imaging and iso- to hyperintense on T2-weighted imaging. After contrast administration, they usually homogeneously enhance and exhibit a visible dural tail. Meningiomas with atypical findings may be misdiagnosed.We report a 50-year-old female patient with a pathologically diagnosed fibrous meningioma  that exhibited ring enhancement on MRI.Meningiomas may rarely present with ring enhancement on MRI. The natural history and mechanisms of cystic degeneration and enhancement in the various types of meningioma require further study. Meningiomas are a common primary intracranial tumour andaccount for 13.0–19.0 % of all surgically treated intracranial tumours . Most caA 50-year-old woman with no significant medical or family history presented with a headache of 15 days duration. Physical and neurological examinations were unremarkable. Routine blood testing was normal. Head CT showed an abnormal left frontal-parietal hypodense lesion that appeared iso- to hypointense on T1WI and iso- to hyperintense on T2WI. Signal hyperintensity was present in the surrounding brain on T2WI and fluid attenuated inversion recovery sequences, consistent with mild oedema. On contrast-enhanced T1WI, ring enhancement was seen with a slightly thickened cystic wall and dural tail sign. Cerebrospinal fluid was visible between the lesion and the underlying graymatter, suggesting an extra-axial lesion . The patient recovered well without neurological deficits.Meningiomas are the most common non-glial cell-derived brain tumour. Their annual incidence is approximately 6 per 100,000 persons, and the male-to-female ratio is approximately 1:2 . Most meEven if contrast-enhanced brain CT provide useful information of intracranial disorders, enhanced brain MRI represents the gold standard technique for the assessment and characterization of malignant and benign lesions . Common As reported in previous studies, ring enhancement in meningiomas may be related to necrosis, haemorrhage and cystic degeneration in the centre of the tumour , 9. Intr


Mantle Cell Lymphoma (MCL) is a non-Hodgkin lymphoma accounting for 2.5% of lymphoid neoplasms in the United States. Primary gastrointestinal (GI) lymphomas account for 1–4% of all GI malignancies, with few reports of primary mantle cell lymphoma presenting as a single colonic mass and none to our knowledge with colon-colonic intussusception as the presenting finding. Accurate and timely diagnosis is imperative because MCL has rapid progression and early chemotherapeutic intervention results in improved patient outcomes. This work is reported in line with the SCARE criteria [1] for case report publication.A 61-year-old male presented with 1 month history of nonspecific right sided abdominal pain. Computed Tomography (CT) of the abdomen identified an intussuscepting mass in the proximal ascending colon and an additional 8 mm hepatic lesion. Colonoscopy identified a large mass in the corresponding area of colon identified on CT. Histology and immunohistochemistry of biopsied specimen diagnosed MCL.Planned surgical intervention was deferred and the patient was referred for oncologic treatment. We report the first case to our knowledge of MCL presenting as colon-colonic intussusception and discuss the work-up of this rare lymphoma that clinicians may be required to diagnose and manage.This report serves as a reminder to maintain a broad differential inclusive of uncommon diseases and unanticipated pathology. Practicing with a thorough understanding of medical principles and clinical acumen is essential for optimal patient care and, as demonstrated in this case, preventing a potentially unnecessary surgical intervention thus delaying appropriate chemotherapy. Excessive lymphocyte proliferation is driven by over expression of protein Cyclin D1 due to a chromosomal translocation of t11;14)q13:q32) resulting in the fusion of CCND and Immunoglobulin heavy chain genes. MCL most commonly presents in the adult population, with initial symptoms including lymphadenopathy, fevers, night sweats, fatigue, and weight loss. MCL represents approximately 2.5% of lymphoid neoplasms in the United States [ resultinq13:q32) Herein, we present a case of primary mantle cell lymphoma presenting as a single colonic mass causing colon-conic intussusception, which to our knowledge has never been described in the literature, as well as review the staging and current treatment guidelines of primary gastrointestinal MCL. This work is reported in line with the SCARE criteria for case report publication .2A 61-year-old otherwise healthy Caucasian male presented to the emergency department for evaluation of 1 month history of generalized intermittent abdominal pain with occasional dark blood with bowel movements. He denied fever, chills, weight loss, diarrhea, or obstructive symptoms. He had no family history of gastrointestinal, hematologic, or malignant diseases. He underwent screening colonoscopy 12 years prior which was unremarkable. Physical examination yielded no significant findings. Complete blood count and basic metabolic panel were within normal limits. An abdominal and pelvic computed tomography (CT) scan demonstrated a proximal colon-colonic intussusception with appearance of a mass at the leading edge of the intussusceptum with diffuse mural thickening in the intussusceptum and the intussuscipiens with extensive mesenteric lymphadenopathy . FindingIn office 3 days later, the patient reported continued intermittent sharp abdominal pain and denied obstructive symptoms. With a presumed diagnosis of colonic malignancy, work-up was pursued in accordance with National Comprehensive Cancer Network (NCCN) guidelines. Carcinoembryonic Antigen level was 0.5 ng/mL. Staging CT chest demonstrated a 12 mm hyper-enhancing focus in liver Segment 8. Colonoscopy identified a traversable, fungating, non-circumferential 10 cm cecal mass and a 15 mm pedunculated descending colon polyp . Cold foBiopsy histology demonstrated marked expansion of colonic lamina propria by a lymphoid infiltrate composed predominately of small, mature appearing lymphocytes. Immunohistochemical (IHC) staining identified the abnormal lymphocytes to be CD20+, CD5+, BCL2+, Cyclin D1+, and SOX11+ B-cells with proliferation index of 30–40% by Ki-67+ nuclei  diagnosiThis case was presented at hospital tumor board which recommended cancellation of surgery and oncologic referral.3Mantle cell lymphoma is a non-Hodgkin lymphoma representing 2.5% of lymphoid neoplasms in the United States and 7–9% of lymphoid neoplasms in Europe . High KiMCL pathophysiology is well established, characterized by a chromosomal translocation , present in >95% of cases. This translocation between immunoglobulin heavy chain (IgH) gene and the CCND1 gene yields an unregulated overexpression of protein Cyclin D1 driving cell proliferation. Cyclin D1 detection serves as a hallmark for histopathologic diagnosis, with cells also demonstrating intense surface IgM/IgD, which is more frequently lambda restricted . Cells hThe Ann Arbor Staging Classification is used for MCL staging . The claThe National Comprehensive Cancer Network (NCCN) guidelines  delineatMCL prognosis is generally poor despite aggressive therapy with median overall survival of 3–5 years . Nearly Intussusception is typically seen in children resulting from lymphoid hyperplasia of the terminal ileum. Intussusception in adults is rare with an overall annual incidence of 2–3 cases per 1,000,000 in the general population . When diDaniel et al. described a case of a single mass colonic primary mantle cell lymphoma in 2016; however, their patient did not have intussusception [Matsueda et al. described a single patient with primary MCL as a single protruding lesion of the small intestine causing ileocecal intussusception as the presenting symptom [Grin et al. described two additional cases of ileocolic intussusception attributed to MCL mass lesions, however their reported patients were diagnosed with MCL prior to experiencing intussusception [To our knowledge, this is the first reported case of primary gastrointestinal MCL presenting as colon-colonic intussusception. sception . Matsued symptom . Grin etOur case is unique in that the initial complaint of abdominal pain was caused by colon-colonic intussusception, which was the initial presenting sign of his underlying MCL.4This case of intussusception attributable to primary colonic MCL as a single mass lesion adds to the literature describing another variable clinical presentation of primary gastrointestinal MCL. Although quite uncommon, primary colonic MCL ought to be included in the differential diagnosis of a single mass lesion in the colon. As demonstrated in this case, adequate tissue sampling of colonic masses is paramount to clarify the diagnosis and direct the treatment strategy. This case serves as a reminder to maintain a broad differential inclusive of uncommon diseases and atypical pathology. Maintaining and practicing a thorough understanding of medical principles through work-up, diagnosis, and treatment is essential for optimal patient care and, as demonstrated in this case, preventing an unnecessary surgical operation, which may delay the appropriate chemotherapeutic intervention.The authors state that they have no conflict of interest for this report, declarations of interest: none.There was no study sponsor and no funding provided for this project.This case report is exempt from ethical approval at our institution.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.Brandon Smith: Conceptualization, Methodology, Writing- Original draft preparation, reviewing and editing.Kyle Reilly: Conceptualization, Writing- Original draft preparation.Elena Baker: Writing- Original draft preparation, reviewing.Amy Deeken: Reviewing.Adrian Dan: Supervision, Writing- revising and editing.This is not human subjects research.Adrian G. Dan, MD.Not commissioned, externally peer-reviewed.


A 57-year-old patient had presented 5 years earlier with progressive bilateral hearing loss. At the time a magnetic resonance imaging (MRI) of the head had been performed, which excluded structural abnormalities of the inner ear as well as the presence of vestibular schwannoma. In retrospect, superficial siderosis of the brainstem and the cerebellum could be detected on the corresponding MRI Fig. . Since tAxial diffusion-weighted  is the most common primary neoplasm (WHO grade I) of the conus medullaris and cauda equina 83%) . It is c% . It isOn MRI, the tumor is well delineated with a round or ovoid shape and can be indistinguishable from other tumors. Characteristically MEs occur within a span of 2–4 vertebral segments. They have a lobulated, soft tissue sausage-like appearance that might provoke a bony scalloping or even osseous lytic destruction in the adjacent vertebrae. Due to its rich mucin content it is almost always hyperintense on T2-weighted images and T2-hypointense margins of the tumor can indicate superficial siderosis. Myxopapillary ependymomas have the greatest bleeding tendency of all ependymoma subtypes and may appear with proliferated vessels subsequent to hypervascularity [Paragangliomas are hypervascularized neuroendocrine tumors arising from the neural ectoderm. The spine is a rare site of this slow growing tumor (WHO grade I) with an incidence of 3–4% of all cauda equina tumors . The aveOn imaging, the tumor is predominantly encapsulated, heterogeneously hyperintense on T2, sometimes displaying cystic areas indicating previous hemorrhages. Size usually ranges between 10 mm and 50 mm and bony remodeling may be present . HallmarParaganglioma of the cauda equina share a great number of imaging features with myxopapillary ependymoma and it can be very difficult to distinguish between the two entities.Spinal hemangioblastomas (HBL) are highly vascularized WHO grade I tumors that can occur sporadically in 20% of spinal hemangioblastomas or present in association with von Hippel-Lindau disease in 80% of cases . Most spThe MRI findings can have a wide spectrum of tumor presentations. Small tumors may present with a uniform intense enhancing nodule, predominantly in a subpial or intramedullary location. Larger lesions may show heterogeneous enhancement and tend to have flow voids related to enlarged feeding or draining vessels, indicating hyperperfusion of the lesion. An HBL is associated with syrinx in 40% regardless of the size of the tumor . Spinal In conclusion, the present case has imaging features of intradural extramedullary HBL, but the lack of additional signs and symptoms of a von Hippel-Lindau syndrome makes the diagnosis less likely.Intradural extramedullary metastases are very rare and account for 5–10% of all spinal metastases with the lumbosacral region being the most common localization . They moThe MRI findings of spinal metastasis vary greatly. A solitary focal round/ovoid mass with strong contrast enhancement is common. Presence of multiple lesions makes the diagnosis more likely. Meningeal spreading, the so-called meningeal carcinomatosis can present with multiple contrast enhancing nodules, a “sugar coating” of the dura/nerve roots or complete filling of the dural sac . MetastaIn patients over 50 years of age, metastases always have to be considered as a potential differential diagnosis. Even though a hypervascularized spinal metastases is a possible cause for subarachnoid blood, a chronic infratentorial siderosis, as in this case, would tend to rule out this diagnosis.Zellballen  staining revealed a tumor with a moderate density, fresh bleeding and residuals of older bleeding Fig. a, b. Thelen Fig. a. These len Fig. c. The ceIn immunohistochemical reactions, the cells showed positivity for vimentin Fig. a and theWith PanCK positivity, TTF1 negativity and a neuroendocrine differentiation, a neuroendocrine neoplasm of the digestive system was discussed as a differential diagnosis. We therefore performed additional immunohistochemical stainings for EP4 and CDX2, but only a few tumor cells were labelled by EP4. The reaction for CDX2 remained completely negative. Furthermore, the exclusively intradural tumor manifestation and the characteristics of a paraganglioma  speak against the presence of a neuroendocrine tumor. Furthermore, it was shown in recent publications that paragangliomas of the cauda equina are positive for cytokeratin markers , 15.Zellballen) and show a delicate capillary network. Paraganglioma are graded as WHO grade I. The entity is fairly uncommon in the CNS with the most common CNS localization being the cauda equina/filum terminale. Adults are affected by paragangliomas, with a male predilection. Single paragangliomas are thought to have a benign course. In contrast, multiple paragangliomas or a co-occurrence with other neoplastic processes, e.g. pituitary tumors or renal cancer, imply a genetic predisposition and therefore warrant further investigation [The World Health Organization (WHO) classification of tumors of the CNS defines paraganglioma as a neuroendocrine neoplasm arising in specialized neural crest cells associated with segmental or collateral autonomic ganglia or paraganglia . Paragantigation , 17.


Tuberous sclerosis (TS) is a rare genetic disorder of autosomal-dominant inheritance. Mutations on either of the two genes Tuberous Sclerosis Complex 1 (TSC1) or Tuberous Sclerosis Complex 2 (TSC2) play a role and result in hamartomas involving many organs, like the brain, heart, kidneys, skin, lungs, and liver. This case report is about a four-year-old boy with facial angiofibromas, hypo-pigmented skin lesions on the lower back and dorsum of the right wrist, and previous history of seizures who was referred to the radiology department of the Korle Bu Teaching Hospital for Magnetic Resonance Imaging (MRI) of the brain. The MRI of the brain revealed subependymal giant cell astrocytomas, subependymal nodules, and cortical tubers. Ultrasonography of the abdomen also showed multiple angiomyolipomas and multiple simple cysts in both kidneys. The aim of this case report is to present the imaging findings and create awareness that this rare genetic disorder does exist in Ghana and advocate for formation of support groups for parents with children with tuberous sclerosis. Tuberous sclerosis (TS), also known as epiloia, is a rare genetic disorder of autosomal-dominant inheritance with a prevalence ranging from one in 6,000 to one in 12,000. Both sexes and all ethnic groups can be affected . It is aIt is known that mutations on either of the two genes, TSC1 and TSC2, which encode for the proteins hamartin and tuberin, respectively, are the causes of TS. These proteins are tumor growth suppressors, which are agents that regulate cell proliferation and differentiation . The claWe present the radiologic findings of a four-year-old boy with multiple facial angiofibromas who was referred to the radiology department of the Korle-Bu Teaching Hospital with a provisional diagnosis of TS.A four-year-old boy weighing 25kg was referred from the out-patient dermatology clinic of the Korle-Bu Teaching Hospital to the radiology department for brain MRI with a provisional diagnosis of TS. The physical examination in the radiology department revealed multiple skin lesions (angiofibromas) Figure  on his lAfter satisfactory assessment of his renal function and basic laboratory workup which included liver function tests, routine urine examination, complete blood count and hemoglobin, the following unenhanced brain MRI pulse sequences: T1-weighted (T1W) axial, T1 sagittal, fluid-attenuated inversion recovery (FLAIR) axial, T2-weighted (T2W) axial, diffusion-weighted imaging (DWI) axial, apparent diffusion coefficient (ADC), T2W axial FatSat and T1W axial FatSat were acquired using Toshiba Achieva 1.5 Tesla MRI Scanner under sedation. Intravenous gadolinium-based contrast medium (Magnevist) with a dose of 4mg/ml was administered and T1 FatSat sequence of the brain was repeated in the three orthogonal planes to assess enhancement patterns of the brain lesions that were visualized on the unenhanced images. The brain MRI showed two fairly defined, rounded, T1, T2 and FLAIR isointense (isointense to grey matter) subependymal masses approaching the right and left foramen of Monroe measuring approximately 1.5 x 1.1 x 0.8 cm and 1.6 x 1.5 x 1.1 cm, respectively, representing subependymal giant cell astrocytomas Figures -5. The mA well-defined tiny, ovoid hyperintense lesion measuring 1.3 x 0.7 cm seen in the subcortical region of the left frontal lobe on FLAIR imaging and shows ‘restricted’ diffusion on DWI/ADC imaging in keeping with subcortical tuber. A similar but smaller lesion-measuring 0.6 x 0.4 cm is also seen in the cortex of the left parietal lobe and the right parietal lobes respectively all representing subcortical tubers. No obvious enhancement seen post contrast administration  is a rare autosomal dominant inherited neurocutaneous syndrome that consists of hamartomatous lesions in the brain and kidneys, to mention just a few. This genetic disorder has no predilection for sex or ethnic group. The estimated prevalence ranges from one in 6,000 to one in 12,000 and approximately two-thirds of the cases are sporadic; this may explain why the patient did not have a family history of TS .TS typically shows three clinical features, the Vogt triad which consists of mental retardation, epilepsy, and facial angiofibroma; however, approximately half of TS patients have normal intelligence and a quarter do not have seizures. Hence, it is not surprising that our patient had normal intelligence at this stage of the disease process and thus may have fallen into the proportion which has normal intelligence ,9,12. MuMajor neurological manifestations of TS include seizures, autism, and behavioral and psychiatric disorders. Seizure is present in about 80-90% of patients which begin during the first year of life; varying from subtle focal seizures, infantile spasms, to generalized seizures. Our patient had seizures that seemed resolved but the typical brain lesions were evident as mentioned earlier, he however did not manifest any autistic or psychiatric disorder during our interaction with him at the time of imaging .Cutaneous lesions in TS are hypomelanotic macule (90%), facial angiofibroma (75%), and Shagreen patch 20-30%) [0% [3]. TPatient was referred to the dermatologist and the pediatric neurologist for symptomatic treatment and counselling of the family but was lost to follow-up.TS is a neurocutaneous syndrome and it is a rare genetic disorder. In addition to the clinical history of seizures and cutaneous lesions, imaging plays an important role in diagnosis. The moment this is suspected the individual’s parents should be counselled and enrolled in multi-disciplinary treatment programs. It is true there is no cure but symptomatic treatment is available. Support groups should be formed in the country and individuals encouraged to join.


Endometrial stromal cell sarcomas (ESS) are a unique subtype of uterine malignancy. Recurrent low grade endometrial stromal sarcomas (LESS) is identified in half of the patients. Here, we discuss a case of a 76-year-old Asian female with a past medical history of adenomyosis and hypertension who presented to the outpatient clinic with a chief complaint of painless hematuria for one day. Computed tomography scan of abdomen and pelvis with contrast showed a new right-sided mixed cystic and solid pelvic mass measuring up to 6 cm, obstructing and invading the distal right ureter, which was concerning for malignancy. Positron emission tomography (PET scan) demonstrated a right pelvic mass with increased radiotracer activity consistent with malignancy. She underwent laparotomy with excision of the right-sided pelvic mass with an abdominal washout and at the same time, also underwent cystoscopy with right ureteral stent placement. Tissue pathology was consistent with spindle cell neoplasm with staining and histologic features consistent with a recurrent stromal cell sarcoma. Uterine sarcomas tend to have an aggressive nature but there are key features about ESS that distinguish it from other uterine sarcomas. ESS has a more indolent clinical course and can reoccur years after initial diagnosis. They usually relapse locally, although relapses in extra-uterine sites have also been reported. Treatment of ESS depends on the grade and stage at the time of diagnosis. The main line of treatment for ESS consists of a total abdominal hysterectomy (TAH) and salpingo-oophorectomy (BSO). The significance of this case demonstrates that, although remission can be obtained after the initial diagnosis, recurrence can happen. Even when patients seem to be disease-free, clinicians should follow them closely; early diagnosis is important as treatment for this type of entity has a high survival rate. Uterine sarcomas are an uncommon type of malignant mesenchymal tumor. They only account for 1% of all gynecological malignancies and 4-9% of all malignant uterine neoplasms . The incA 76-year-old Asian female patient with a past medical history of hypertension and adenomyosis presented to the outpatient clinic with a chief complaint of painless hematuria for one day, which was associated with generalized weakness for a few weeks prior to presentation. She denied weight loss, nausea, diarrhea, or abdominal pain. The remainder of the review of symptoms was negative. On physical exam, she was afebrile, with a respiratory rate of 15 per minute, heart rate of 80 beats per minute, blood pressure of 130/90 millimeter of mercury, and saturating 99% on room air. Physical examination revealed a mobile mass in the right lower quadrant. She was subsequently referred to the emergency department. The laboratory results on admission are revealed in Table CT scans of abdomen/pelvis with IV contrast showed new right-sided mixed cystic and solid pelvic mass measuring up to 6 cm, which obstructed and invaded the distal right ureter, concerning for malignancy Figures -2. CT chest with IV contrast showed multiple pulmonary nodules less than 5 mm. PET/CT revealed increased radiotracer activity in the right pelvic mass consistent with malignancy. Tumor markers including CA-125, CEA, and CA 27-29 were negative. Colonoscopy, mammogram as, well as a recent pap smear, were all negative for malignancy. Based on the diagnostic workup, the patient was thought to have a relapse of sarcoma. She underwent laparotomy with excision of the right-sided pelvic mass along with an abdominal washout. At the same time, she also underwent cystoscopy with right ureteral stent placement.Tissue pathology was consistent with spindle cell neoplasm and histologic features were consistent with a recurrent stromal cell sarcoma as shown in Figure Prior to the current presentation, the patient had been diagnosed with stage 1B low-grade endometrial stromal cell carcinoma (as per the FIGO [Federation of Gynecology and Obstetrcs] staging) when she was 50 years old. Back then, she presented with abnormal uterine bleeding and CT scans of her abdomen and pelvis showed an 11 cm uterine mass. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, without adjuvant therapy. She was under surveillance every six months for the first two years, then annually after for the next 10 years post-surgery. Tissue pathology biopsy findings were similar to the findings found two decades ago, indicating the recurrence of endometrial stromal cell sarcoma. Repeat CT abdomen and pelvis after the surgery showed a diminished right-sided pelvic mass. She was classified as endometrial stromal cell cancer with local recurrence. She did not receive adjuvant therapy. She is currently under surveillance every six months and has been doing well in the last two years. Uterine sarcomas can be classified into four histological entities: carcinosarcomas (40% of cases), leiomyosarcoma (40% of cases), endometrial stromal sarcomas (10-15% of cases) and undifferentiated or “other” sarcomas (5-10% of cases) . The focVarious risk factors may contribute to developing ESS, such as increasing age, polycystic ovarian disease, diabetes, obesity, adenomyosis, endometriosis, family history of endometrial cancer, tamoxifen use, estrogen therapy, history of pelvic radiation and history of breast or ovarian cancer -10. Our More than half of the patients are symptomatic at the time of diagnosis, resulting in early diagnosis at an early stage ,11. The The five-year survival rate for ESS is between 80%-100% ,12. ESS Recurrent ESSAround 40-50% of patients diagnosed with ESS develop recurrent disease -7. It isManagementTreatment of ESS depends on the grade and stage at the time of diagnosis. The standard of treatment of ESS for eligible surgical candidates is composed of a total abdominal hysterectomy (TAH) plus salpingo-oophorectomy (BSO) -2. If a Adjuvant therapies include external beam radiation therapy (EBRT), hormonal therapy, and chemotherapy. Adjuvant EBRT has excellent local control and has delayed recurrences especially in stage II-IV, but has not been shown to improve overall survival ,12-13. MTreatment for recurrent ESS consists of the same modalities as in initial presentation but adapted to local recurrence, isolated metastasis, and disseminated disease. Another important characteristic in reappearance is to identify whether or not the patient had previous radiation therapy . The rolOur patient underwent TAH and BSO for stage I LESS almost two decades ago in 1993. She neither received adjuvant EBRT or hormonal therapy, given the very early stage of the disease. She had a very long disease-free interval, as LESS is very slow-growing but was lost to follow-up. Due to the slow-growing nature of the disease, routine visits are an essential part of the patient's management.Uterine sarcomas are a heterogeneous and rare type of cancer that needs to be more extensively studied. Among uterine sarcomas, ESS deserves a special approach, as it can have a large pathological variation. The new nomenclature has helped with the meticulous classification of ESS as there are three clinicopathological entities. This classification has aided in determining prognosis and management but further research is needed in this area, as this patient population is scarce. There is also still a lot of ambiguity on how to manage recurrent ESS; in many cases, reoccurrence can be seen decades after a disease-free period. More randomized clinical trials are needed in order to study whether lifelong surveillance is needed or if there should be specific screening modalities.