On the PET images, a hypermetabolic region was found in the lesion. The average standardized uptake value of FDG was 2.47, and the tumor-to-normal-tissue ratio was 1.25. The cat died 408 days following the commencement of treatment, and a grade 1 meningioma was confirmed by postmortem histopathology. Immunohistochemistry for Ki-67 and p53 was performed. The labeling indices of Ki-67 and p53 were 2.56 and 0%, respectively. This case shows that chemotherapy with hydroxyurea and prednisolone may be considered in the treatment of feline meningiomas. Furthermore, this is the first case describing the application of FDG-PET to visualize a naturally occurring meningioma in a cat.A 15.5-year-old, neutered, male, domestic shorthair cat was presented with neurologic dysfunctions. At presentation, an obtunded mental status and vestibular ataxia were identified. On neurologic examination, postural reactions were decreased-to-absent in all four limbs, and pupillary light reflexes showed bilaterally delayed results. Magnetic resonance imaging was performed, and a demarcated lesion was identified in the third ventricle. The cat was tentatively diagnosed with a brain tumor, which was suspected to be a meningioma. The cat was treated with hydroxyurea and prednisolone. Mental status was considered more alert, and ataxia improved following treatment. On the 106th day after the commencement of treatment, a  FDG uptake correlates proportionally with the level of glucose metabolism in tissues; thus, FDG-PET is generally used in oncology to identify tumors , Co., Ltd., China], post-contrast images were taken and the oval-shaped mass lesion appeared heterogeneously enhanced (Magnetic resonance imaging (MRI) examination of the brain was performed using a 0.3-Tesla unit . General anesthesia was induced with intravenous administration of propofol  and maintained by inhalation of 2.0% isoflurane  with a circle rebreathing circuit. T1-weighted (pre- and post-contrast), T2-weighted, and fluid-attenuated inversion recovery (FLAIR) images were obtained in the transverse, sagittal, and dorsal planes. An oval-shaped extra-axial mass (length × height × width: 2.0 × 1.7 × 1.4 cm) was identified in the third ventricle, compressing the rostral cerebellum, brainstem, and the occipital cortex . It was enhanced . A cerebThe cat was initially treated with oral prednisolone  as a palliative therapy to decrease the intracranial pressure by relieving the tumor-associated brain edema  and decrSUV = average tissue concentration of FDG (MBq/ml)/injected dose (MBq) per body weight (g)For more objective evaluation of the metabolic activity, the tumor-to-normal-tissue (T/N) ratio was generated by dividing the tumor SUV by the SUV of the normal tissue . On visual evaluation of the PET images, a hypermetabolic region was found in the tumor lesion . The meaAt necropsy, a well-demarcated, oval-shaped mass was found in the third ventricle . HistopaThis is the first reported case describing the application of FDG-PET to detect a naturally occurring meningioma in a cat. Immunohistochemistry for prognostic markers, such as Ki-67 (a proliferation marker) and p53 (index of cell cycle regulation), was performed to assess the tumor and to correlate the findings with FDG-PET results.FDG-PET has been used for the assessment of glucose metabolism in humans –10, 16. Although grading of meningiomas by histologic evaluation has clinical and prognostic implications, it is hard to predict the outcome of meningiomas. Therefore, to predict the prognosis of meningiomas, several studies have evaluated the use of immunohistochemical markers of meningiomas in humans –23. AmonThere are several treatment options for feline meningiomas, including palliative therapy, chemotherapy, surgery, radiotherapy, and combination therapies , 5, 6. TFor cats that receive limited surgical and radiation therapy, medical treatment, including administration of chemotherapeutic agents, could be considered as an alternative. The effects of chemotherapy for treating meningiomas have been described in humans and veterinary patients , 30–34. To the best of our knowledge, this is the first case report to describe FDG-PET results in a case of feline grade 1 meningioma. The mean SUV and the T/N ratio were 2.47 and 1.25, respectively, and the labeling indices of Ki-67 and p53 were 2.56 and 0%, respectively. In the future, these data may provide valuable diagnostic information to better understand feline meningiomas in veterinary medicine, and further studies are needed to establish diagnostic criteria for feline meningiomas.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Ethical review and approval was not required for the animal study because the study was a case report, thus no ethical approval was required. Written informed consent was obtained from the owners for the participation of their animals in this study.TY, YK, HK, D-IJ, M-PY, and B-TK contributed management of case. SK was in charge for the histopathological evaluation. WL helped with the PET/CT operation. TY wrote the first draft of the manuscript. TY, HK, SK, D-IJ, M-PY, and B-TK were participated in the revision of the manuscript. All authors read, commented on, and approved the final manuscript.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.


Peripheral nerve sheath tumors (PNSTs) are benign lesions arising from the connective tissue sheath surrounding the neurons and are labeled schwannoma, perineurioma, or neurofibroma according to their histopathological characteristics. Lesions with a mixture of two or more of the aforementioned tumors are known as hybrid peripheral nerve sheath tumors (HPNSTs). These hybrid tumors have been described as rare entities. In this report, we present a case of a solitary hybrid schwannoma/neurofibroma in an unusual location. Peripheral nerve sheath tumors (PNST) are benign lesions arising from the connective tissue sheath surrounding the neurons. Most of these tumors present as focal soft tissue swelling with symptoms attributable to mass effect to adjacent structures. Diagnostic classifications based on the histopathology of PNST have been published previously . The mosA 35-year-old male, a known case of type I autosomal dominant cerebellar ataxia, was referred to our otolaryngology clinic for a slowly progressing neck mass for three years. Upon further questioning, the patient had no associated symptoms or significant family history. Examination of the swelling yielded a palpable, non-tender mobile mass in the left supraclavicular region. The left upper limb had no sensory or motor deficits. The rest of the examination was insignificant. The patient showed no signs of stigmata of NF or schwannomatosis.The patient was sent for a neck MRI, which showed a left lower supraclavicular, well-circumscribed, heterogeneous hyperintense enhancing mass measuring 30 x 26 mm Figure . The lesCore biopsy of the mass was taken, and histopathology was well consistent with schwannoma. The lesion was excised surgically through an anterior supraclavicular approach. The brachial plexus was identified intraoperatively and preserved Figure . On grosHistopathologically, schwannoma nodules showed areas of Antoni A and Antoni B, which is different from the neurofibroma component. Multiple immunohistochemical stains were tested to confirm the diagnosis, including S100, which showed higher positivity in the schwannoma component compared to the neurofibroma. Neurofilament protein (NFP) showed entrapped axons in the neurofibroma component, while in the schwannoma components, axons were absent. Both CD34 and glial fibrillary acidic protein (GFAP) stains showed positivity in the neurofibroma component only  suggested mild hyperacute upper trunk brachial plexopathy. However, at the two-month follow-up visit, the patient was able to fully abduct his shoulder. At the six-month follow-up, the patient showed no evidence of tumor recurrence.PNSTs were classically divided into three categories: schwannoma, neurofibroma, and perineurioma . In receUnfortunately, solitary hybrid schwannoma/neurofibroma tumors have been rarely reported in the literature. Such cases were initially described by Feany et al. in a series of nine cases. Three out of the nine reported cases failed to show signs or features of NF, suggesting that hybrid tumors are not confined to NF alone . Only onLater on, multiple cases were reported in the literature in English by different authors representing solitary hybrid schwannoma/neurofibroma in different locations Table . All thoThe development of schwannian differentiation within a neurofibroma remains unclear. It has been suggested to be due to clonal genetic alteration in the microenvironment . NeverthThis report described a rare entity of PNST that might be diagnostically challenging or can even go underdiagnosed. The absence of NF or schwannomatosis stigmata makes the diagnosis even more difficult. However, advances in molecular testing have shown an increase in the number of reported cases. To date, the exact etiological factors remain unclear. In conclusion, schwannoma/neurofibroma tumors resemble benign peripheral nerve sheath pathology with no reported malignant transformation reported in the literature so far.


We report a 74-year-old male presented to an outpatient dermatology clinic in Manaus, Amazonas, with a one-year history of pruritic, keloidal lesions on his left lower extremity. Histopathology showed round structures in reticular dermis. Grocott methenamine silver stain revealed numerous round yeasts with thick double walls, occurring singly or in chains connected by tubular projections. The diagnosis was lobomycosis. Although the keloidal lesions presented by this patient are typical of lobomycosis, their linear distribution along the left lower limb is unusual. In 2005, a 74-year-old male presented with a one-year history of pruritic, cutaneous lesions on his left lower extremity. Physical examination revealed an erythematous plaque and cord-like nodular lesions on the left thigh and leg. Culture, histopathological and mycological examinations were performed at that time but the patient was subsequently lost to follow-up until 2017, when he returned with complaints of recurrent, secondary bacterial infections on the left lower extremity. On physical exam, ulcers with perilesional induration, erythema, and desquamation were noted on the left leg A. Additia)Lymphangitic cutaneous leishmaniasis;b)Nontuberculous mycobacteriosis;c)Lobomycosis;d)Sporothricosis.What is your diagnosis?Cutaneous biopsy was performed on the ulcer border A. HistopDiagnosis: Lobomycosis.Lacazia loboi, to Paracoccidioides braziliensis, the mycosis had also been described as keloidal blastomycosis.Lacazia loboi has never been isolated in culture from humans or animals. Since the initial description of lobomycosis in patients from the Brazilian Amazon Region, other cases have been reported in tropical and subtropical regions of Latin American countries.Lobomycosis, also known as Jorge Lobo's disease and lacaziosis, is a subcutaneous, chronic, granulomatous mycosis initially described by Jorge Lobo, in 1931. There are no systemic manifestations in lobomycosis.Tursiops truncatus) caught in Bay of Biscay, Spain.An important fact related to this mycosis was the discovery, in the Florida coast in 1970, of a dolphin with a clinical and histopathological disease similar to human lobomycosis.The disease is clinically characterized by the presence of nodular, verrucous or keloidal lesions, which are found alone or in plaques, localized or disseminated, with a generally long evolution. The most common clinical presentation is keloidal, characterized by firm, shiny, pinkish-brown to brown nodules.Another clinical aspect that drew attention in this patient was the linear arrangement of lesions along the leg and thigh. It is admitted that the spread of the disease occurs by contiguity, and through lymphatic route; however, an aspect similar to that observed in the present case is not common.None declared.Flaviano da Silva Oliveira: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Nadya Picanço Lopes: Obtaining, analysis, and interpretation of the data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Carolina Talhari: Approval of the final version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript; obtaining, analysis, and interpretation of the data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.Antonio Schettini: Approval of the final version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.None declared.


To investigate the clinical imaging manifestations, diagnosis and treatment of intraperitoneal extraosseous osteosarcoma.A 52-year-old male patient with intraperitoneal extraosseous osteosarcoma was retrospectively analyzed. He suffered from left lower abdominal pain accompanied by mass for 6 months. On abdominal CT scan, multiple patchy and banded calcification were found. The largest is about six centimeters in diameter and underwent mass resection. Postoperative pathology revealed retroperitoneal osteosarcoma. The reported intraperitoneal extraosseous osteosarcoma was analyzed and the related literature was reviewed. Two years after operation, the patients had recurrence of the tumors and invaded sigmoid colon, peritoneum and bladder. Palliative operation was performed to remove the tumors in the bladder and transverse colostomy was performed. The patients were followed up by telephone and died 2 months after the second operation.Intraperitoneal extraosseous osteosarcoma has a low incidence and has no specific imaging features. Surgical resection is the main treatment and the prognosis is poor. Extraosseous osteosarcoma, also known as soft tissue osteosarcoma, refers to osteosarcoma occurring in soft tissue rather than bone. Wilson  first deTherefore, it is necessary to summarize these cases. A case of peritoneal soft tissue osteosarcoma confirmed by pathology in our hospital was analyzed retrospectively and the related literature was reviewed. Objective: To investigate the clinical manifestation, diagnosis, treatment and prognosis of celiac osteosarcoma.A 52-year-old male was recurrent crampy left lower abdominal pain with mass. Symptoms had been present over 6 months. The mass of left lower abdomen was progressively enlarged. Physical examination: the left lower abdomen can touch the mass, about 5*6 cm in size, hard, no tenderness, clear boundary, slightly poor mobility, and no blood vessel pulsation. Abdominal CT: Multiple lesions and calcification in the lower abdomen. It is more likely to be considered as mesenteric cavernous hemangioma Fig. a, b. IntExtraosseous osteosarcoma (EOS), also known as soft tissue osteosarcoma, is a rare malignant tumor that accounts for about 1% of all soft tissue sarcomas . PreferrThe etiology of EOS remains unclear, but related risk factors include previous exposure to radiation, such as X-rays and radioactive thorium dioxide. Or at least 4 years after the development of the site that had previously received high-dose radiation therapy was induced to occur . Some EOTypical clinical manifestation of Intraperitoneal extraosseous osteosarcoma is a progressively enlarged soft tissue mass. About one-third of patients suffer from occult onset and pain. Often, when patients go to treatment, the tumors grow very large . The patThe diagnosis of EOS must be combined with clinical manifestations, imaging and pathological examination. It should have the following points: (1) appearing in soft tissue and not adhering to bone or periosteum; 2) having a unified sarcoma pattern ; (3) producing bone-like and/or cartilage matrix [ having aIt has been reported that extraosseous osteosarcoma is easily misdiagnosed as ossifying myositis, and later pathologically proved to be osteosarcoma . The patRadical or extensive resection, preoperative radiotherapy and adjuvant chemotherapy are the treatment options for extraosseous osteosarcoma. Expanding the scope of operation can only reduce the local recurrence rate, but can not prolong the survival time . Active Regardless of its origin and location, the prognosis of EOS is poor, and there is no good treatment plan. Some scholars reported that tumor size less than 5 cm was an important factor affecting the prognosis of EOS. Bane reported that only 1 of 7 patients with tumors smaller than 5 cm died, but 14 of 16 patients with tumors larger than 5 cm died . The tumTo review the relevant literature on intraperitoneal extraosseous osteosarcoma. The key words were “extraskeletal osteosarcoma”, “extraosseous osteosarcoma” and “soft tissue osteosarcoma”. “Intraperitoneal extraosseous osteosarcoma” The database of Pubmed. The literature is summarized in Table Table In conclusion, extraosseous osteosarcoma has a high degree of malignancy and poor prognosis. Intra-abdominal extraosseous osteosarcoma is rare. Abdominal pain and abdominal mass are common clinical manifestations, but the early symptoms of the disease are often not obvious, and when found, the tumors are often very large. The imaging manifestation lacks specificity. It can be shown as one or more irregular high and low mixed density shadows with multiple patchy and banded calcification. The diagnosis of primary bone tumors in the skeletal system of the whole body should be excluded. The final diagnosis requires diagnostic laparotomy and pathological examination. Surgical excision is the most important treatment method, and chemotherapy and radiotherapy also have a certain effect. The size of tumors is one of the factors affecting prognosis.


Rhabdomyosarcoma (RMS) is a malignant neoplasm that originates from undifferentiated myogenic progenitor cells. It is predominantly a pediatric disease, and its occurrence in adults is exceedingly rare. Adult primary RMS of gynecologic origin is an uncommon phenomenon, and the cervix is the most frequently involved site. The incidence of adult primary uterine RMS is extremely scarce. Herein, we present the case of primary uterine RMS in a 54-year-old Saudi postmenopausal woman who presented to clinic attention with a six-month history of abdominal pain and vaginal bleeding. Rhabdomyosarcoma (RMS) is a malignant neoplasm that originates from undifferentiated myogenic progenitor cells . It is lOwing to the rarity of uterine RMS, diagnosis is often challenging and largely delayed . Herein,A 54-year-old Saudi postmenopausal woman presented to the clinic with a six-month history of abdominal pain and vaginal bleeding. The abdominal pain was mainly localized to the lower abdomen. The pain was dull in nature, continuous, non-radiating and moderately intense (6 out of 10 in terms of severity). The complaints were associated with shortness of breath, palpitations, loss of appetite and weight loss. The patient denied symptoms of urinary retention/incontinence, constipation or bleeding per rectum. Past medical history was significant for diabetes mellitus. Past surgical history and family history were unremarkable. Socially, she was a widowed housewife and non-smoker. With regard to the obstetric and gynecologic history, menarche started at 12 years of age. The menstrual cycles were regular. No use of oral contraceptive pills or hormonal replacement therapy for the past 10 years. Menopause occurred seven years ago. The last gynecological checkup was eight years ago, and Pap smear was negative. The patient had two uncomplicated pregnancies with two babies delivered vaginally at full term.Laboratory testing revealed a blood hemoglobin level of 9.2 g/L  and tumor markers were negative. On general examination, a mass protruding through the endocervical canal with active bleeding was seen.CT scan showed a large uterine soft tissue mass extending to the upper vagina and abutting the rectum and urinary bladder Figure . There wA biopsy from the protruding cervical mass was obtained for histopathological analysis. The specimen consisted of multiple pieces and fragments of soft red-tan tissue measuring in aggregates 10 cm. Microscopic examination of the tissue showed sheets of malignant cells with hemorrhage and necrosis. The neoplastic blue cells were discohesive and had spindle-shaped morphology, frequent mitoses and bizarre nuclei Figure .Immunohistochemical (IHC) staining showed diffuse positivity of the neoplastic cells to myogenin, MyoD1 and desmin Figure . ConversThe case was discussed in a multidisciplinary tumor board meeting. In consideration of the advanced stage disease presentation, the consensus was to consider palliative pelvic radiotherapy  to control the active bleeding. The patient would be reassessed after three months. RMS is predominantly a pediatric disease, and its occurrence in adults is exceedingly rare ,4,5. AduClinically, vaginal bleeding is the most frequent presenting symptom in patients with uterine RMS . This fiIt is crucially vital to correctly differentiate between the three histopathological types of RMS as they hold substantial variances in biological behavior and prognosis . EpidemiDue to the rarity of uterine RMS especially in adults, other common neoplasms should be ruled out. These neoplasms comprise leiomyosarcoma, high-grade endometrial stromal sarcoma, adenosarcoma and carcinosarcoma . The posThe prognosis of adult RMS generally and uterine RMS specifically is extremely unfortunate, with the vast majority of patients presenting with extensive disease at time of clinical diagnosis ,8. Our pPrognostic data about survival outcomes in adult patients with uterine RMS are very limited. This is largely ascribed to the small number of published cases about adult patients with uterine RMS . HoweverUterine RMS in adults is a biologically aggressive malignancy with dismal prognosis despite the multimodal therapeutic strategies. Although rare, however, uterine RMS should be considered in the differential diagnosis of postmenopausal women presenting with vaginal bleeding. Histopathological examination in addition to immunohistochemistry and cytogenetic studies can aid in stabling the definitive diagnosis. Aggressive multimodality therapy yields better clinical outcomes.


Hemangioendothelioma is a rare tumor arising from the vascular endothelium of soft tissue, skin, bone, and viscera. The disease has an indolent course, with the potential for recurrence, and is often associated with multi-organ involvement. We present a rare case of subcutaneous tumor in the thigh, without systemic involvement in a middle-aged woman. The tumor was completely excised after ligation of the feeding vessels, and the histopathologic diagnosis was consistent with hemangioendothelioma. Regular follow-up is suggested due to the potential for recurrence. Hemangioendothelioma is a rare vascular tumor arising from the vascular endothelium of soft tissue, skin, bone, and viscera. It is considered a neoplasm of intermediate malignant potential. Soft tissue hemangioendotheliomas affect the extremities in two-thirds of cases, followed by head and neck region, trunk, mediastinum, and other sites. The lesions can be multicentric, and more than 50% of the cases develop around or from a large vein.A 38-year-old woman presented with a swelling on the back of her right thigh, which gradually increased in size for six months. It was first noticed 15 years ago with a smooth skin surface but now presenting with a few tortuosities over the swelling. It was associated with a dull aching pain with no diurnal variations, no history of any trauma or ulcerations. On examination, a 15 × 15 cm swelling was seen on the inner and posterior aspects of the thigh with an irregular surface. Dilated tortuous vessels were seen on the surface with no visible pulsations. The skin over swelling was normal. The swelling was well defined and firm in consistency, with no obvious thrill. The swelling was superficial to the muscles, and the skin was pinchable. There was no regional lymphadenopathy. Proximal and distal pulses were palpable. She underwent a CT angiogram that revealed a brightly enhancing vascular tumor occupying the posteromedial aspect of the right upper thigh in the deep subcutaneous plane with the muscles displaced away from the skin Figure . TherefoHemangioendothelioma is an uncommon, well-differentiated endothelial vascular neoplasm of low-grade malignancy belonging to the intermediate variant of the family of vascular tumors where its behavior lies between entirely benign hemangiomas and highly malignant angiosarcomas . It is cHemangioepithelioma of the thigh region is a rare vascular tumor, which has good prognosis if detected early and managed surgically. Larger and deeply located tumors with high mitotic activity are associated with metastasis and lower survival rates.


The utility of intracystic administration of indocyanine green for near-infrared fluorescent cholangiography in acute calculous cholecystitis initially treated with percutaneous transhepatic gallbladder drainage (PTGBD) was described in this report.Two cases who underwent near-infrared fluorescent cholangiography guided interval laparoscopic cholecystectomy two weeks post-PTGBD were studied retrospectively. Both patients were diagnosed with moderate acute calculous cholecystitis based on diagnostic criteria of the Tokyo guidelines. Two routes of indocyanine green administration were utilized during surgery, first through direct intracystic administration through PTGBD tube (5 ml of 12.5 mg ICG) to achieve critical view of safety and then intravenous administration (1 ml of 2.5 mg ICG) to visualize cystic artery.Both patients had critical view of safety visualized clearly with ICG with the operation time of 84 and 125 min in cases 1 and 2, respectively without any intra or postoperative complications.In comparison with intravenous ICG administration, trans-PTGBD ICG route can provide better signal-to-noise ratio by avoiding hepatic fluorescence and thus increasing the bile duct to liver contrast. However, ICG may enter the lymphatic system through necrotic and inflammatory gallbladder mucosa, of which lymph spillage during gallbladder dissection can obscure the fluorescent view. Even though LC is regarded as more safe and time-saving procedure compared to open cholecystectomy, it comes with increased incidence of bile duct injury and related morbidity because of misidentification of cystic duct due to its peculiar operative environment . To mitiCritical view of safety (CVS) is a ductal identification technique by ensuring that only two structures enter the gall bladder, cystic duct and cystic artery, and thus helps to avoid bile duct injuries during laparoscopic cholecystectomy . Near-inDuring NIRF indocyanine green (ICG) which is a FDA approved safe, easily available and stable fluorescent dye is injected intravenously (IV) where it binds to proteins and gets excreted into bile subsequently. Many studies  have admLiu et al.  recently2Two male patients, over 70 years old with the diagnosis of moderate acute cholecystitis according to Tokyo guideline, 2013 and undergone interval LC ,13 after2.1An 84-year old male patient with history of hypertension and type-II diabetes mellitus presented with right upper quadrant abdominal pain associated with intermittent fever for 3 days to emergency department after having fatty food. On physical examination Murphy’s sign was positive with no other abnormalities. Patient’s blood report showed abnormal hepatobiliary profile with elevated leucocyte count. Abdominal CT confirmed the diagnosis of moderate acute cholecystitis with cholelithiasis and cystic duct stone. PTGBD was performed to manage acute cholecystitis in urgent settings in accordance with the management criteria of Tokyo Guidelines 18 (TG18) based on patient’s probable surgical risks and complications . Patient2.2A 73-year old male patient with history of hypertension, type-II diabetes mellitus and benign prostatic hyperplasia was diagnosed with moderate acute cholecystitis with gall bladder stone. Abnormal renal index and hepatobiliary profile was noted on blood reports. T-tube cholangiography was suggestive of gall stones and ruled out presence of CBD stone. Considering the multi-comorbid conditions, patient was discharged with percutaneous transhepatic gall bladder drain in-situ to manage acute cholecystitis  and was 2.3In both cases, the surgery was performed with standard three port approach by same team of surgeons having 8 years of surgical experience. ICG  was resuspended in 10 ml of sterile water for injection to yield a 2.5-mg/ml stock solution. Of this stock solution 5 ml, corresponding to the dose of 12.5 mg, was administered intracystically as a bolus via two-week fistularized PTGBD right after all trocars were inserted. Laparoscopic images were acquired using the Image 1 High Definition fluorescence laparoscope .During surgery, dense fibrotic changes and scarring was observed in the Calot’s triangle. In case 2, there was dense desmoplastic omental adhesion around the gallbladder. Adhesiolysis was done to expose the gallbladder. The cystic duct and common bile duct was clearly identified under the guidance of NIRF cholangiography. Angulated cystobiliary junctions were identified in both cases , Fig. 3.An additional fluorescent enhancement other than biliary system was observed in pericystic region, which was identified negative for bile leakage under white light view . ICG conThe total operation time for cases 1 and 2 were 84 and 125 min, respectively. Both surgeries were completed without any intra or post-operative complications. The follow-up was uneventful.3The study showed trans-PTGBD ICG injection would reduce the noise-to-signal ratio by reducing liver fluorescence and thus increasing the contrast with higher biliary fluorescence signal, but it may not decrease operation time as it does not change the inflammatory and fibrotic status. For LC, the total intraoperative time is not a reliable parameter to assess the utility of NIRF technique as the total time can be influenced by the pericystic complications like severe inflammation, adhesions, and fibrotic tissue. Comparing with case 1, case 2 presented the pericystic tissue that was more fibrotic. All factors indicated a more severe inflammation and fibrosis, which explains the extended operation time in case 2. The mean operation time for LC with NIRF via IV injection was reported 75–90 min in the previous studies . In termThe time interval and the dosage of ICG for IV administration is yet to optimize, but it goes without saying that intravenous administration tends to have high noise-to-signal ratio because of prolonged hepatic fluorescence. While direct intracystic ICG injection might offer better solution to lower this noise-to-signal ratio by avoiding direct hepatic fluorescence, it might lead to major contamination of the surgical field as reported by Liu et al. . Five ouThough there was an additional fluorescent enhancement in pericystic region in case 2, there was no evident bile-content material under white light to suggest bile leakage. Lymph spillage could have occurred during gallbladder dissection. ICG may enter the lymphatic system through the necrotic gallbladder mucosa into the submucosal lymphatic drainage and the associated adhesive tissue. Despite the minor contamination, it did not interfere the identification of extrahepatic biliary structures in this study. Yet, serious contamination would obscure the surgical view.NIRF provides an easier and safer option to visualize extra-hepatic biliary tree intraoperatively as compared to intraoperative cholangiography as it is radiation-free and non-invasive technique with real-time visualization . However4In conclusion, intracystic injection of ICG reduces noise-to-signal ratio in comparison to IV injection by only illuminating the extra-hepatic biliary system. It could not reduce operation time, but could increase surgeon’s satisfaction with NIRF cholangiography. ICG spillage through lymphatic system may occur during gallbladder dissection in significant pericystic inflammatory adhesion cases which further obscures the florescent view. However, the ICG lymphatic fluorescent noise did not interfere with extrabiliary identification.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This study was approved by the institutional review board IRB of Show Chwan Memorial Hospital, Taiwan approval no. 1070507. The requirement of informed consent was waived for the study.Written informed consent was obtained from the patients for publication of this case report and the accompanying images. All identifying details have been omitted. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Man-Ling Jao, Hon Phin Wong: Data Curation, Investigation, Writing-Original draft.Yen-Yu Wang and Kai-Che Liu: Conceptualization, Supervision, Project Administration.Sayali Bachhav: Writing-Original draft, Writing-Review and Editing.All authors have contributed equally in the final manuscript approval and otherwise.Name of the registry: ResearchRegistry.com.Unique Identifying Number (UIN): researchregistry5213.Dr. Hon Phin Wong.Dr. Kai-Che Liu.Not commissioned, externally peer-reviewed.All authors have no conflicts of interests or financial ties to disclose.


Actinomycosis is a chronic granulomatous infection caused by opportunistic bacteria, Actinomyces. These bacteria lack virulence and cause disease when there is a breach in the integrity of the mucosa. Diagnosis of Actinomycosis is challenging and less than 10% of abdominopelvic cases are diagnosed preoperatively. The treatment involves prolonged course of antibiotics with or without removal of tissue. In this case report we will present a case of hepatobiliary actinomycosis which was managed by a combination of both surgical and medical treatment. Actinomyces are gram positive, filamentous, anaerobic to microaerophilic bacteria endogenous to the oral cavity, gastrointestinal and genitourinary tracts . Actinom9 (4-10 x 109) and C-reactive protein (CRP) 32 mg/L (0-5 mg/L). All other laboratory parameters were within normal limits. Clinical impression of acute cholecystitis was made and ultrasound was done.A 47-year-old female, presented to the emergency department with right upper quadrant pain, vomiting and fever for two days. She was previously known to have gallstones and was awaiting cholecystectomy for recurrent biliary colic. On examination, she was found to be tender in right upper quadrant with minimal rebound tenderness. Her liver function tests on admission showed total bilirubin 12.4 umol/L (2.0-21 umol/L), alanine aminotransferase (ALT) 25 IU/L (5-33 IU/L), gamma-glutamyl transpeptidase (GGT) 44 IU/L (3-40 IU/L), alkaline phosphatase 78 IU/L (30-130 IU/L), WBC 7.7 x 10Ultrasound revealed a thick-walled gallbladder, gallstones, dilated common bile duct (CBD) with intra and extrahepatic duct dilation; no stone was identified in the CBD Figure , 1B.Following this report a magnetic resonance imaging (MRI) was performed which confirmed a dilated common bile duct but no stones were identified in the common bile duct Figure . The patLaparoscopic approach was undertaken and the omentum was found to be wrapped around the gallbladder, on mobilization of the omentum, a contained perforation of the gallbladder fundus was identified. Severe fibrosis was noted at the Hartmann’s pouch making it difficult to identify the cystic duct and artery, a dilated CBD was also noted intraoperatively. Due to difficult dissection, gallbladder was opened at the level of the Hartmann’s pouch, stones were removed and a subtotal cholecystectomy was done. A drain was placed in the gallbladder fossa. Apart from the histopathology of the gallbladder the peritoneal fluid  and bile aspirate were sent for gram stain and culture.The patient had an uneventful postoperative course and the drain was removed on third postoperative day. However, the bile culture grew Actinomyces naeslundii and as per microbiologist’s suggestion the patient was started on Benzylpenicillin 2.4 gm IV four times a day for two weeks followed by three months of amoxicillin. The peritoneal fluid culture and the tissue culture from the abscess cavity showed no growth and the histopathology reported active chronic cholecystitis.Actinomyces species encompasses more than 30 bacteria of which Actinomyces israelii is the most commonly identified in the clinical diagnosis of actinomycosis. Actinomyces are non-spore forming gram positive rods and except Actinomyces meyeri, which is short and non-branching, they all form branching filamentous rods . Due to Primary diagnosis of actinomycosis is difficult and computed tomography (CT) in abdominal actinomycosis may show thickened bowel, pelvic or peritoneal mass with extensive infiltration . BacteriHistopathology may reveal sulfur granules; these are basophilic masses with eosinophilc terminals on hematoxylin and eosin staining but it's present in about 75% of cases . CombineA similar case was reported in 2005 of a 50-year-old Sudanese male, who presented with clinical features of acute cholecystitis and was initially managed conservatively and brought back for a delayed cholecystectomy after six weeks. Although we operated on our patient on the same admission the intraoperative findings in both cases were of dense adhesions and fibrosis. Both the patients recovered well postoperatively with prolonged course of antibiotics .In our case of hepatobiliary actinomycosis the proposed mechanism is the retrograde spread from duodenum into the common bile duct, liver is involved in 5% of these patients. To the best of our knowledge so far only 30 cases have been reported of gallbladder involvement and two cases of isolated CBD involvement , 8, 14.Our case discussed hepatobiliary actinomycosis which is extremely rare. The article highlights the difficulty in diagnosis and challenges in surgical approach. Clinicians should be aware of the intraoperative findings so that appropriate cultures are ordered and tissue is carefully examined. Currently all reported cases of gallbladder actinomycosis are diagnosed after surgical resection and the role of endoscopic retrograde cholangiopancreatography (ERCP) is not well investigated in diagnosis. Theoretically, if actinomycosis is diagnosed through culture of bile sample (obtained through ERCP), and if patient's clinical condition allows, it may be treated with prolonged course of antibiotics only.


Ureterocele is a cystic dilatation of submucosal distal ureter. It presents a higher incidence in infants and young children but is rare in adults. The urethral prolapse of ureterocele is extremely rare, and its clinical presentation includes vulvar mass, hematuria, and urinary tract dysfunction. We present a case of ureterocele prolapse in a 45-year-old woman who has a 3-day-evolution vulvar mass and intense urethral bleeding. The patient underwent armed cystoscopy and ureteroscopy, ureterocele resection, and biopsy. She evolved with good postoperative condition and was then discharged. Ureterocele is a cystic dilatation of submucosal distal ureter. This condition presents an incidence about 1/5000 to 1/12000  There arA 45-year-old patient, a menopausal woman, sought medical attention complaining of a “mass” in the genital region . She repThe first ever reported case of prolapsed ureterocele was first described in 1982 in a 45-year-old female patient with a 2-month evolution of hesitancy, nocturia, and suprapubic discomfort, in addition to a swelling in her vulvar region. [The most accepted theory of the origin of ureterocele is an embryogenesis failure in the canalization of the ureteral bud , which wAs many reports showed, including ours, the symptoms have a quick evolution, from days to months –4, 7–9, Another differential diagnosis is pelvic organ prolapses (POP), which is a “herniated vagina” containing one pelvic organ  . Althoug


Intracholecystic papillary neoplasms (ICPNs) of the gallbladder are rare, preinvasive lesions characterized by an intracholecystic papillary growth that may be associated with invasive adenocarcinoma. The natural history of ICPN is unknown. Here, we report a case of ICPN, highlighting its natural course.A 79-year-old woman presented to the emergency department with perforated cholecystitis. After percutaneous transhepatic gallbladder drainage, due to the presence of surgical risk factors, we opted to perform gallstone removal through percutaneous transhepatic cholangioscopy instead of cholecystectomy. ICPN, which was accidentally detected after the removal of the gallbladder stones, was also endoscopically removed. After 4 years, the patient came back to the hospital with a large gallbladder mass. After cholecystectomy, pathological examination revealed ICPN with invasive adenocarcinoma.The current case showed endoscopic findings of ICPN and its natural progression, particularly its clinicopathological features and outcomes. Intracholecystic papillary neoplasms (ICPNs) of the gallbladder are suspected to be similar to intraductal papillary neoplasms of the bile duct (IPNBs) and intraductal papillary mucinous neoplasms (IPMNs) of the pancreas . ICPNs aA 79-year-old woman with a recent history of acute myocardial infarction presented with abdominal pain, fever, and altered mental status. The vital signs included the following: blood pressure, 80/60 mmHg; heart rate, 118 beats/min; and body temperature, 39.2 °C. A laboratory analysis showed leukocytosis  and elevated levels of C-reactive protein , total bilirubin , aspartate aminotransferase , alanine aminotransferase , alkaline phosphatase , and gamma-glutamyl transpeptidase . Carcinoembryonic antigen and carbohydrate antigen 19–9 were within the normal ranges. Contrast-enhanced computed tomography (CT) showed an approximately 1-cm-sized gallbladder stone, marked thickening of the gallbladder wall, and focal transmural defects with extensive pericholecystic inflammation and fluid collection. Percutaneous transhepatic gallbladder drainage was immediately performed. She was a high-risk patient and not a good candidate for cholecystectomy because of the dual antiplatelet treatment. Moreover, she was strongly averse to undergoing surgery. Therefore, we performed percutaneous transhepatic choledochoscopy (PTCS) for gallbladder stone removal. After stone removal, we found an approximately 1-cm-sized papillary-growing polypoid mass (Fig. Approximately 4 years later, the patient came back to the hospital after a mass was detected in the gallbladder on abdominal ultrasonography at another hospital Fig. a. MicrosICPN is a preinvasive neoplasm of the gallbladder, first mentioned by the World Health Organization in 2010 . Adsay eThe prognosis of ICPN is better than that of other invasive cancers of the gallbladder and also depends on the degree of invasion within ICPN , 6, 8. TAdsay et al. emphasized the importance of long-term follow-up because 3 patients among their 55 patients with noninvasive ICPN died > 5 years after their diagnosis . These pA few studies and reports have been published on the progression of ICPN. The present case demonstrated the natural progression of ICPN. The ICPN found during the removal of the gallbladder stone was thus not completely removed through PTCS. After 4 years, the remaining lesions had progressed and found to have grown to approximately 3 cm. CT findings were indistinguishable to those of a gallbladder cancer. Cholecystectomy was performed, and the specimen was pathologically confirmed to be ICPN with an associated invasive adenocarcinoma. In a recent case report by Oba et al., a gallbladder adenocarcinoma was found to be localized to the mucosa in association with ICPN through pathological and immunohistochemical analyses . In addiTo the best of our knowledge, this is the first case report on the natural disease progression of ICPN to invasive ICPN or adenocarcinoma, both visually and pathologically.In conclusion, we reported a rare case of the natural progression of ICPN to invasive adenocarcinoma that was successfully treated with laparoscopic cholecystectomy.


A 77-year-old woman with a rare oral intraductal papilloma arising from the minor salivary gland located on the floor of the mouth and causing the mucus retention is reported. Microscopically, the lesion was characterized by unicystic cavity exhibiting the lumen partially filled by papillary projections of the ductal epithelium with varying degree of oncocytic metaplasia. Based on the histopathological analysis, the differential diagnosis of oral intraductal papillomas and other ductal neoplasms of salivary origin are discussed. The incidence of oral tumors arising from the salivary ductal glands, such as intraductal papillomas, is difficult to determine because different terminology has been used for the denomination of the same lesion . SpecifiWe reported a rare intraductal papilloma that developed in the sublingual region involving a minor salivary duct gland and the differential diagnosis of this lesion with other ductal neoplasms of salivary origin are discussed.A 77-year-old woman with a two months history of swelling and pain in the floor of the mouth was referred to the dentist. The patient was edentulous, and she has associated the lesion to the trauma of the complete dentures. The intraoral examination revealed a unique soft nodule, tender to palpation, covered with clinically normal mucosa, well-circumscribed, sessile, located at the floor of the mouth, in the anterior left region of the mandible, measuring 1.1 × 0.9 × 0.7 cm. Upon extraoral examination, there were no palpable lymph nodes. Her medical history was noncontributory. The clinical hypothesis was of inflammatory fibrous hyperplasia or mucus retention cyst. An excisional biopsy was performed, and the surgical specimen was well defined, with no attachment to surrounding tissues.The histopathological analysis revealed a well-circumscribed unique cystic cavity arising from a minor salivary duct gland characterized by papillary projections of the cuboidal/columnar mucous and oncocytic cells to the cystically dilated ductal space and with no nuclear atypia or mitotic figures. The cystic lumen was partially filled by many branching papillary elements, consisting of thin strands of fibrovascular cores, surfaced by columnar cells and by a mucous fluid. The lesion is surrounded by a thick, fibrous tissue wall Figures . Mucous Although rare, oral intraductal papillomas are benign solitary tumors arising from the excretory duct characterized by intracystic papillary growth and duct-like structures . ClinicaMicroscopically, intraductal papillomas, as described in The incidence of tumors that arise from the salivary ductal glands is difficult to determine because different terminology has been used for the denomination of the same lesion, and there have been less than 50 cases of oral intraductal papilloma in minor salivary glands . In a reIn contrast with intraductal papilloma, cystadenoma and cystadenocarcinoma show a multicystic well-circumscribed lesion lined by papillary epithelium with variable size , 6. HoweAdditionally, sialadenoma papilliferum is characterized by a combination of exophytic projection of the surface squamous epithelium and inward papillary proliferation of duct epithelial cells , 2, 6, 7The distinction between intraductal and inverted papillomas residues in the epidermoid cell component, in which intraductal papilloma is a well-circumscribed unicystic lesion and inverted ductal papilloma expands to the surrounding connective tissue , 3, 6. AConcluding, our case reported reinforces that, although rare, the oral intraductal papilloma arising from the minor salivary gland may be an etiologic factor of mucus retention cyst in the mouth and the histopathological analysis is essential to establish the precise diagnosis.


Uterine Tumors Resembling Ovarian Sex Cord Tumors) are rare neoplasms of unknown etiology usually occurring in middle-aged women. Less than 100 cases of UTROSCT have been reported so far. Although the typical behavior of UTROSCT is benign, metastatic and recurrent cases can occur. Here we describe an extremely rare case of vaginal vault recurrence of UTROSCT occurring 5 years after total hysterectomy with bilateral salpingo-oophorectomy. Though rare, UTROSCT should always be taken into account in the differential diagnosis of uterine masses initially considered leiomyomas.UTROSCTs ( Uterine Tumors Resembling Ovarian Sex Cord Tumors (UTROSCTs) are rare neoplasms of unknown etiology . They usIn January 2013, a 54-year-old pluriparous woman was admitted to the Department of Obstetrics and Gynecology of Tor Vergata University Hospital (Rome) for recurrent postmenopausal abnormal uterine bleeding. At pelvic examination the uterine volume appeared increased by three times the standard volume.Pelvic transvaginal ultrasound showed an intracavitary mass (80x73x74 mm) with heterogeneous echogenicity in which multiple anechoic areas with central and peripheral vascularization at power Doppler (RI 0.49) were present. The initial diagnosis was uterine leiomyoma. Other intramural leiomyomas, measuring 31x20x31 mm, 18x8 mm, and 9x6 mm, respectively, were identified. Ovaries appeared normal  [The tubes and ovaries were histologically normal. At regular annual checks the patient remained asymptomatic with normal pelvic examination and ultrasound findings until December 2017 when a transvaginal ultrasound described the presence of a new solid lesion at level of the vaginal vault. The lesion was 45x19x20mm, highly vascularized (color score 4) and had a characteristic arboriform vascular pattern. It was adherent to the surrounding tissues but not to the bladder and bowel wall. These findings were confirmed by a CT scan of the abdomen and pelvis. A laparoscopy was performed with removal of the mass and partial infracolic omentectomy; multiple peritoneal biopsies were also taken . Gross eAt microscopic examination, the lesion showed elements similar to the sex cords cells, with trabecular and alveolar architecture, and tubular elements. The mitotic index was equal to 3 mitoses for 10 HPF assessed by means of Ki67 index, and proliferation index was 30%. Immunohistochemical profile showed the following: CD 56 +, CD 99 +/-, ER +, WT1 +, alpha actin -, panCK -, EMA -, CD10 -, S100 -, inhibin -, CroA -, calretinin-. The neoplasm was completely removed with free margins. It was compatible with the diagnosis of uterine tumor with elements similar to the sex cords type II according to Blaustein's 2011 . The morphological and immunohistochemical characteristics were similar to those of the previous uterine neoplasm. No adjuvant therapy was administered according to the oncologic counselling. To date, the patient is asymptomatic, and pelvic examination and ultrasound are normal.To date, less than 100 cases of UTROSCT have been reported . Althougα-Inhibin, calretinin, CD56, melan A, CD99, WT1, and MART-1; (b) epithelial markers: pancytokeratin, AE1/3, and epithelial membrane antigen; (c) myoid markers: α-smooth muscle actin, desmin, h-caldesmon, and histone-8 deacetylase; (d) neuroendocrine markers: estrogen receptors, progesterone receptors, androgen-receptors, and chromogranin; (e) miscellaneous markers: CD10, S100, CD117, and vimentin [UTROSCT is a rare and intriguing tumor. This neoplasm resembles an ovarian sex cord tumor. Even though several hypotheses have been raised to explain the histogenesis of UTROSCT—including its origin from sex cord cells, mesenchymal stem cells, and endometrial stromal tumors in which an excessive growth of sex cord cells occurs —its pathImmunoexpression for calretinin and at least for one of the other sex cord markers above reported is believed to be required to establish a diagnosis of UTROSCT . HystereTo our knowledge, the present case is the tenth one in which VVR of UTROSCT has been described. The possibility of VVR should be considered in the long-term follow-up of patients with UTROSCT, even if they are completely asymptomatic.


Multiple polypoid colonic metastases are very rare which mainly originated from gastric carcinoma or melanoma. For rectal cancers, liver, lung and peritoneum are the most common metastatic sites. Here we present an unusual case with rectal adenocarcinoma and metachronous multiple colonic polypoid metastases.A 53-year-old man who underwent radical resection for rectal cancer 2 years ago was admitted to our department for an elevation of CEA level of 18.4 ng/ml. Colonoscopy revealed ten ivory rubbery colonic polypoid lesions (about 5 mm in diameters) in the large bowel which were confirmed as signet ring cell carcinomas (SRCC) by biopsy, but full-body contrast enhanced CT and PET-CT showed no other suspicious lesion. Seven weeks later, a laparoscopic total colectomy was performed and more than 50 polypoid lesions were observed throughout the mucosal surface of the large intestine which were confirmed as metastatic SRCC by postoperative pathological examination. All the 34 paracolic lymph nodes retrieved were involved. After 4 months, diffuse abdominopelvic and multiple bone metastases were identified by CT and the patient died of the disease 1 month later.Here we present an unusual case of multiple colonic polypoid metastases of rectal adenocarcinoma. For SRCC that is prone to have disseminated micrometastases, colonic ‘polyps’ may be the early noticeable sign of undetectable and extensive tumor spread. Instead of surgical resection of ‘the confined disease in colon’, systemic treatment maybe a more appropriate choice. Multiple polypoid colonic metastases from other distant gastrointestinal carcinomas are extremely rare, only a few cases have been reported in the literatures –7. AmongThe most common sites of metastases from rectal cancer are the liver, lung, and peritoneum. Here, we report an unusual rectal cancer case with metachronous multiple colonic polypoid metastases.A 53-year-old man with progressive abdominal pain and distention was admitted to our tertiary care center on October 15, 2013. Colonoscopy revealed a rigid circumferential neoplasm in the rectum about 8–9 cm from the anal verge, with an increased CEA level of 10.4 ng/ml. In addition, two sessile polys (2–3 mm) in descending colon were also found and removed by forceps during colonoscopy, which were pathologically confirmed as adenomas. MRI showed a circumferential thickening of the bowel wall , suggesting the diagnosis of malignant tumor (cT3N0Mx). After three times of fruitless biopsies, which invariably revealing “inflammation”, a transrectal incisional biopsy under the general anesthesia was performed and poorly differentiated adenocarcinoma was diagnosed. The patient received the neoadjuvant chemoradiotherapy (long-term radiation of 50 Gy/25f with concomitant capecitabine) and followed by the radical abdominoperineal resection surgery. The postoperative pathology showed poorly-differentiated adenocarcinoma with signet ring cell features (staged ypT3N1b). Thereafter, the patient received six cycles of adjuvant single-agent chemotherapy (capecitabine), owing to his refusal of the recommended intensified regimens.During regular follow-up, the patient was diagnosed with thrombocythemia and began to take hydroxyurea 1 g twice a day. Two years after surgery, the CEA level increased significantly from 2.9 to 18.4 (ng/mL). Colonoscopy revealed about ten polypoid lesions (about 5 mm in diameter), and the biopsies proved to be SRCC (Fig. ALK, EPHB2, ERBB4, GRIN2A, PTPRD, TP53 were detected in tumor tissue.In additional investigation by targeted next generation sequencing using a 1021-gene panel, somatic mutations of Informed consent documents were provided by patients’ surrogates.−/CK20+, which indicated the gastrointestinal origin [Polypoid colonic metastases are extremely uncommon, which has been previously reported less than 10 cases [l origin , 13. ThePatients with SRCC often have distinct clinical characteristics and poor outcomes . EvidencAs the colonic polypoid metastases implied the wide spread of the disease, most of the previous cases were treated with a non-operative approach using systemic chemotherapy , 5, 6 orIn 2015, Hugen et al.  found thIn summary, the presence of multiple polypoid colonic metastases may represent a very rare condition of extensively systemic spread of SRCC. Even without evidence of involvement of other organs, we think there is no role for colectomy in this condition. Systemic treatment with intensified chemotherapy and new targeted therapies may bring a glimmer of hope for patients with such refractory cancer.


Abdominal lipoblastomas are uncommon soft tissue tumors in children and rarely arise from the mesentery. Due to intraabdominal location and slow growth, these masses can go unnoticed for long periods of time and often found on surgical exploration. We present a case of a 12-year-old male with years of abdominal distension accompanied by new onset early satiety that was found to have an intra-abdominal mass. He underwent an exploratory laparotomy revealing a large 33 x 27 x 15 cm rubbery mesenteric mass displacing the entire intra-abdominal contents, connected by a single vascular pedicle and encasing a loop of small intestine. The mass was resected and the patient did well without signs of recurrence. Histology confirmed the presence of mature adipocytes but on further cytogenetic analysis, a translocation between chromosomes 2 and 8 at the 12q arm was detected, which is often associated with lipoblastomas. This case represents the one of the largest mesenteric lipoblastomas that matured extensively to lipoma-like histology at the time of surgical resection. Lipoblastomas are an uncommon soft tissue tumor of infancy and early childhood. These tumors are composed of fetal lipoblasts that continue to proliferate in the post-natal period and can clinically mimic the more common lipomas seen in older patients , 2. MostA 12-year-old male with a history of a distended abdomen presented to the emergency department (ED) after outpatient imaging studies were significant for an abdominal mass. He initially presented to his gastroenterologist with a 2-week history of intermittent epigastric pain that, worsened after each meal. He also developed early satiety and his parents reported increased distention. Review of systems was otherwise negative. Of note, the patient had a protuberant abdomen starting at 3 years of age. Two ultrasounds were completed at that time and both were reportedly negative for any findings; the images were not available for review. Over the years, his abdomen gradually became more distended.He underwent an abdominal X-ray, which was significant for an abdominal mass. He was then sent for a CT of the abdomen and pelvis, which again noted an abdominal mass 27 x 33 x 15 cm in size that displaced the majority of his abdominal contents posteriorly and that appeared to be mesenteric in origin . He was Hematology/oncology was consulted, and a CT neck and chest were obtained to look for potential metastatic disease, both of which were negative. The patient was admitted and underwent surgical resection of the mass the following day. On exploration, the mass was tan-yellow in color, firm with a rubbery consistency, involved a segment of small bowel, and was connected via a single vascular pedicle . The vasPathological examination revealed that the mass arose in the mesentery of the small bowel, measuring 38 x 23 x 12 cm and weighing 5 kg. On thorough sectioning, the mass was well-circumscribed and composed entirely of lobulated adipose tissue without any fibrous septa. The small bowel was 30 cm in length with unremarkable mucosal and serosal surfaces.PLAG1, which is the characteristic abnormality in lipoblastoma. This finding is consistent with lipoblastoma with complete maturation, thereby resembling a lipoma on histology.Morphologically, the lesion was composed entirely of mature lobulated adipose tissue, with delicate fibrous bands surrounding the lobules, without any immature component . The lesAdipose tissue tumors are uncommon in the first two decades of life, with lipoma as the most common mesenchymal tumor overall. Lipoblastomas are comprised of immature adipocytes, rare, mostly benign, and over 80% present before 3 years of age , 6. TheyO'Donnell et al. proposed renaming lipoblastomas as “infantile lipoma” since the term “blastoma” is generally reserved for tumors that metastasize . In theiPLAG1 oncogene, which is prevalent in 70% of lipoblastoma tumors  on chromosome 8 and collagen 1 alpha 2 (COL1A2) on chromosome 7, with additional genes possible as well (A distinctive feature of this case is not only the giant size of the tumor, but that cytogenetics uniquely identified this tumor's pathogenesis extensive maturation. Lipomatous tumors can have normal karyotypes; however, there have been a number of tumor specific chromosomal translocations and associated fusion genes that have been identified in adipocyte tumors. For example, there exists chromosomal rearrangements at regions that include 12q14–15, 6p21–23, 13q2–22 , 18. Re-tnatally . Through as well . While t as well , 21. TheTumor-defining genetic abnormalities such as translocations and the resultant genes affected can be particularly beneficial in cases where tumor histopathology may appear similar, but genetic tumor identity carries vastly different treatment implications. For the adolescent patient group with a large lipomatous tumor like the one described here, this distinction may be crucially important. Perhaps a critical example is in distinguishing between a benign lipoma and a malignant well-differentiated liposarcoma as the incidence of these malignant lipomatous tumors become more common in the second decade of life and both contain mature adipose cells. While both these tumors share a cytogenetic abnormality at 12q13-15 chromosome region, they carry vastly different prognoses, as a well-differentiated liposarcoma as malignant and metastatic potential (This case represents the one of the largest known mesenteric lipoblastoma with extensive maturation on histology to be resected in a child. While mature adipocytes were present on histology, cytogenetic analysis revealed a novel karyotype that more closely resembled a lipoblastoma. Additional studies may help further understanding of the role of karyotypes in distinguishing between lipomas and lipoblastomas that undergo extensive maturation by the age of clinical resection.The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author/s.Written informed consent was obtained from the minor's legal guardian for the publication of any potentially identifiable images or data included in this article.AS, Y-HL, and ES participated in the care of the patient. AS and MC collected, analyzed, and interpreted the data and drafted the manuscript. FA collected and interpreted the data and critically revised the manuscript for important intellectual content. ES and Y-HL interpreted the data and critically revised the manuscript for important intellectual content. Y-HL was the lead physician in the care of this patient and supported the study. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.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.


Large bowel obstruction (LBO) is a potential surgical emergency, commonly caused by colorectal carcinoma, diverticular stricture, and volvulus. LBO secondary to chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) is a rare occurrence. We report an 81-year-old man with a history of CLL/SLL who presented to the emergency department with episodes of abdominal cramps and discomfort, diarrhea, vomiting, subjective flushes, and sweats. After a thorough evaluation, the patient was found to have a malignancy-mediated mechanical LBO at the hepatic flexure due to colonic compression by extensive pericolic lymphadenopathy. After resuscitation and medical optimization, an urgent laparotomy with oncologic right hemicolectomy was performed. Analysis of resected specimens, including lymph nodes, revealed atypical CD23- CLL/SLL cells. Postoperatively, aside from temporary ileus, the patient recovered well and was discharged home. Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a common malignancy of bone marrow origin in US adults, with a recent report projecting 21,040 new cases in 2020 [Gastrointestinal (GI) involvement in CLL/SLL is uncommonly reported, ranging from 5.7% to 13% -6. The tAn 81-year-old, tobacco-smoking Caucasian man with a history of CLL/SLL diagnosed 13 years ago, coronary artery bypass, and multiple abdominal wall hernia repairs presented to the emergency department (ED) with several hours of progressive abdominal discomfort, distension, diarrhea, sweats, and subjective flushes. He also had some belching and vomiting, but no hematemesis or hematochezia. While the patient had been experiencing subjective flushes since starting on ibrutinib (selective tyrosine kinase inhibitor), a potential side effect, for CLL/SLL one year ago, the flushes experienced on presentation were “very intense.” His colonoscopy three years ago revealed two benign polyps, which were removed, but no other abnormalities. On physical exam, the patient had dry mucous membranes but was normothermic with stable vital signs, except an elevated blood pressure of 150/92 mmHg. The abdominal exam showed a well-healed midline scar, distension, tympany to percussion, with a reducible incisional hernia on palpation. No tenderness to palpation or peritoneal signs were noted.On admission, laboratory studies were significant for moderate leukocytosis at 19.2 K/μL  with elevated neutrophil count at 12.2 K/μL (NR 1.8-7.7 K/μL). Complete metabolic profile was within normal limits, aside from mild hypomagnesemia. Abdominal radiography showed small bowel and right colon dilation. CT scan demonstrated right colon thickening that was concerning for colitis versus mass, and small bowel dilation with possible fecalization, raising concern for disease in the terminal ileum/cecal area  with the resolution of his abdominal symptoms, and continues to do well. He was restarted on ibrutinib for his CLL/SLL upon discharge.The final pathology confirmed the diagnosis. Gross pathology demonstrated normal terminal ileum, non-specific mucosal ulceration of the right colon, and extensive pericolic lymphadenopathy, with lymph nodes ranging from 0.3 to 2.4 cm in size. Microscopically, colonic ulcer demonstrated normal non-neoplastic colonic mucosa with some granulation tissue at the base of the ulcer with focal surface exudate  of bowel obstructions occur in the small bowel, the remaining (25%) are caused by LBO, which still constitutes 2%-4% of all admissions requiring surgical intervention ,11. The Our case demonstrates a serious complication of longstanding CLL/SLL, presenting as an LBO secondary to pericolic lymphadenopathy. Large intestinal involvement in CLL/SLL is rare and is often reported as an extranodal infiltration of the mucosa/submucosa rather than involvement of lymph nodes . There iAs LBO is not commonly reported in CLL/SLL, guidance for managing this condition specifically requires using principles related to the management of an LBO. Anatomic colon resection with or without anastomosis (colostomy) remains the standard approach in patients presenting with abdominal pain secondary to mechanical LBO ,17. In oIt is important to confirm that CLL/SLL is the cause of a malignancy, especially if it involves the lymph nodes. Analysis of lymph node effacement and identification of cell markers and any translocations are imperative for the classification of CLL/SLL versus other lymphoma subtypes . Mantle Finally, classifying new symptoms in patients with a history of CLL/SLL necessitates ruling out Richter syndrome, as GI involvement in CLL/SLL is generally reported after transformation to a diffuse large B-cell lymphoma (DLBCL) . RichterAlthough rare, CLL/SLL should be considered in the differential diagnosis when evaluating a patient with LBO, especially if the patient has a history of CLL/SLL. Initial laboratory tests, including complete blood count, complete metabolic panel, and radiographic imaging, can provide guidance for the initial workup and severity of the obstruction. Once the patient is stabilized and causes for emergent operation are ruled out, a colonoscopy may be warranted to visualize large bowel pathology. Anatomic colon resection is an important and standard procedure for patients presenting with LBO. In the setting of CLL/SLL, a thorough pathologic evaluation of the resected specimens and lymph nodes is crucial for further management. A multidisciplinary team approach, in which surgeons and medical oncology teams are involved, provides the best evidence-based practice to achieve the best outcome for the patient. This approach ensures selection of the optimal treatment method for the LBO, and adequate follow-up on medication type and dosing for continued treatment of CLL/SLL.


Fibroma of tendon sheath (FTS) is a rare benign soft tissue tumor that often occurs in the upper extremities. It manifests as a slow-growing mass, often without tenderness or spontaneous pain. FTS occurs most commonly in people aged 20–40 years and is extremely rare in young children. Because FTS presents with atypical physical and imaging findings, it might be misdiagnosed as another soft tissue tumor such as a ganglion cyst or tenosynovial giant cell tumor (TSGCT). Although marginal resection is usually performed, a high rate of local recurrence is reported.A boy aged 3 years and 1 month visited our outpatient clinic with a complaint of a mass of the left hand. An elastic hard mass approximately 20 mm in diameter could be palpated on the volar side of his left little finger. This mass was initially diagnosed as a ganglion cyst at another hospital. Ultrasonography revealed a well-circumscribed hypoechoic mass with internal heterogeneity on the flexor tendon. On magnetic resonance imaging (MRI), the mass showed iso signal intensity to muscle on T1-weighted images, and homogeneously low signal intensity to muscle on T2-weighted images. The mass was peripherally enhanced after contrast administration. FTS was initially suspected as the diagnosis on the basis of these imaging features. Because of the limited range of motion of his little finger, surgery was performed when he was 4 years old. Histopathological findings indicated the mass was well-circumscribed and contained scattered spindle cells embedded in a prominent collagenous matrix. The spindle cells contained elongated and cytologically bland nuclei with a fine chromatin pattern. Nuclear pleomorphism and multinucleated giant cells were not observed. On the basis of these findings, we made a diagnosis of FTS. One year after surgery, no signs of local recurrence were observed.We experienced an extremely rare case of FTS in the hand of a 3-year-old child. We especially recommend ultrasonography for hand tumors of young children to diagnose or eliminate ganglion cysts. MRI helped differentially diagnose FTS from TSGCT. Although marginal resection can be performed as a treatment, great care should be taken postoperatively because FTS has a high possibility of local recurrence. Fibroma of tendon sheath (FTS) is a rare benign soft tissue tumor that often occurs in the upper extremities. In 1923, Buxton classified benign soft tissue tumors of the tendon sheath into the following four categories: lipoma, fibroma, chondroma, and ganglion . FTS occA boy aged 3 years and 1 month visited our outpatient clinic with a complaint of a mass of the left hand. There were no problems with his delivery, medical history, or family history. At the age of 2 years and 7 months, his parents noticed a protuberance on the volar side of his left hand. There was no apparent episode of trauma. The lesion was diagnosed as a ganglion cyst at a nearby hospital and he was followed-up. However, the mass continued to grow, and further examination was recommended at a health screening when he was 3 years old.On physical examination, an elastic hard mass approximately 20 mm in diameter was palpated on the volar side of the left little finger from the distal palmar crease to the proximal interphalangeal crease Fig. a-b. TherBecause of the restricted range of motion and the increased difficulty of using his left hand in daily life, we decided to perform surgical resection after obtaining informed consent from his parents. The surgery was performed under general anesthesia when he was 4 years old. After a zigzag skin incision, a yellowish-white mass was found below the skin. There was no obvious adhesion to the surrounding tissues including the skin, flexor tendon, and neurovascular bundles Fig. a. The maMicroscopically, the excised mass was well-circumscribed and contained scattered spindle cells embedded in a prominent collagenous matrix Fig. c. A highFTS is a rare benign, slow-growing soft tissue tumor with a high rate of local recurrence following surgical resection . ApproxiThere have been five reports of cytogenetic analysis to determine the causes of FTS. Dal Cin et al. investigated whether FTS represented a reactive fibrosing process or a type of neoplasm . They foAmong the four reports of FTS in young children, one presented a case of FTS that occurred in the patella tendon of a 6-year-old boy , and theThe differential diagnosis includes ganglion cyst, infantile digital fibromatosis, and TSGCT. First, ganglion cysts can be easily diagnosed by ultrasonography. Therefore, we recommend ultrasonography as the primary image analysis when a subcutaneous soft tissue mass is suspected clinically, especially for young children. Second, infantile digital fibromatosis is also a rare soft tissue tumor and the lesion is often painful and covered by shiny red skin . In our Regarding the treatment of FTS, marginal resection is typically performed as a surgical procedure. While some authors reported that the indications for the surgical treatment of patients with FTS included symptoms such as pain or a limited range of motion , other aHistopathologically, FTS is composed of spindle-shaped cells similar to fibroblasts in a dense collagenous stroma. Cytological atypia is generally not seen. It was reported that the spindle-shaped cells are myofibroblasts and that fibrous tissues have various levels of hyalinization . FTS is In 1979, Chung and Enzinger reported that the local recurrence rate in 40 patients was 24% at a mean follow-up of 4.3 years after surgical excision , 27. In


Adrenal myelolipoma (MLS) is a rare, benign and non-functional neoplasm, composed of adipose tissue and myeloid. We report a rare case of adrenal myelolipoma of a 20-year-old female revealed with chronic abdominal pain. Computed tomography (CT) scan of the abdomen guided diagnosis and surgical resection was performed given symptomatic and bulky mass. Histological examination confirmed the diagnosis. At 18 months after the surgery, the patient had no evidence of recurrence. The diagnosis of MLS is radiological. Therapeutic abstention is the rule for a small, asymptomatic tumor. The surgical removal is indicated when it is bulky (exceeds 7cm), symptomatic or hormonal activity. Adrenal myelolipoma (MLS) is a rare, benign, non-functional tumor. Composed of mature adipose tissue and hematopoietic elements, the MLS are often a fortuitous discovery and detected during imaging procedures. Usually respected, surgical removal is indicated when tumor is bulky, compressive or at risk of haemorrhage. We report a case of adrenal myelolipoma and review of the literature.2. An ultrasonogram (US) revealed adrenal masses. Computed tomography (CT) scan showed an 8.35 × 5.73cm right adrenal mass, composed of fat tissue, which has a -112 HU value  guideline, Zeiger lolipoma . The clilolipoma . It is vlolipoma . Ultrasololipoma . On CT slolipoma . MRI alllolipoma .Imaging studies are accurate in diagnosing AML in up to 90% of the cases . If CT sAdrenal myelolipomas are uncommon benign tumors, most often asymptomatic and discovered incidentally in imaging diagnostics. Computed tomography can yield the diagnosis. Smaller, asymptomatic myelolipomas can be observed expectantly. The bulky (greater than 7cm), symptomatic, metabolically active tumor scan recommend surgical resection. Mini-invasive techniques performed by experienced laparoscopic surgeons are an effective and feasible way for their removal.The authors declare no competing interests.


Incarcerated inguinal hernia is a common diagnosis in patients presenting a painful and nonreducible groin mass. Although the diagnosis is usually made by physical examination, the content of the hernia sac and the extent of the surgical operation may vary and can require multimodal imaging integration ; the usual finding is a segment of small bowel and, less commonly, large bowel. We present an extremely rare case of a sigmoid cancer incarcerated in a left inguinal hernia and infiltrating the spermatic cord. The patient underwent whole-body computed tomography (CT) with contrast agent injection for staging, followed by a left hemicolectomy paralleled by a unilateral orchiectomy. Inguinal hernia is a common problem in adults, with a 4% prevalence for adults >45 years of age . The conAs for inguinal carcinoma, Lejars  classifiIntrasaccular tumors are primary tumors of abdominal organs  contained within the inguinal sac ; left coThe combination of colorectal cancer and inguinal hernia is uncommon, with an estimated incidence of 0.5% in the excised sac . Althoug6/µL (nr: 4.7 × 106/µL to 6.1 × 106/µL), hematocrit 32% (nr: 42%–52%), platelets 334 × 103/µL (nr: 130 × 103/µL to 400 × 103/µL), neutrophils 71% (nr: 40%–68%), lymphocytes 19% (nr: 20%–45%). The tumor markers tests showed the following values: alpha-fetoprotein 2.3 U/mL (nr: 0–7 U/mL), CA125 7.5 U/mL (nr: 0–30 U/mL), CA19.9 8.9 U/mL (nr: <40 U/mL), CEA 5 ng/mL (nr: 0–2.5 or 0–3 ng/mL), troponin t high sensitivity <0.000 ng/mL (nr: <0.02 ng/mL). After laboratory tests, patient underwent whole body computed tomography (CT) and colonoscopy; whole body CT was performed on a General Electric LightSpeed 16 Slice scanner, using a standard clinical CT protocol with the following parameters: axial mode acquisition, standard filter convolution kernel, slice thickness 2.5 mm, current 365 mA, voltage 120 kV and 1.37 pitch. At first, a whole body noncontrast scan from head to feet was performed, followed by iodinated contrast agent injected into peripheral intravenous line; scan was synchronized to the injection using the prep smart technique, which consisted of placing a Region of Interest (ROI) on the descending aorta and then the injection of contrast medium automatically starting when 126 Hounsfield units were reached. Finally, a postcontrast whole body scan was achieved.Informed consent was obtained from the patient, and the local ethics committee  approved the study (project identification code: 7_19). The patient had a history of arterial hypertension, chronic obstructive pulmonary disease and a previous pulmonary embolism. He presented nonspecific abdominal pains without hernias or visible masses. For several weeks, fecal occult blood had been reported together with episodes of rectorragia, alvus alteration and episodes of diarrhea. Laboratory tests showed several abnormal values: azotaemia 70 mg/dL : 10–55 mg/dL), creatinine 1.6 mg/dL (nr: 0.8–1.3 mg/dL), red blood cells 4.6 × 10Whole-body CT showed a voluminous left inguinal hernia occupied by a dolichosigma loop showing thickened walls and with an intense enhancement after contrast injection . Other fIn top row, from left to right, axial CT acquisition pre- and postcontrast injection, respectively, depict a left inguinal hernia occupied by the sigmoid tract, showing a concentric wall thickening with inhomogeneous enhancement that narrows the bowel lumen, and appearing suggestive for intrasaccular neoplasm. In bottom row, coronal and sagittal multiplanar reconstructions show the carcinoma relationship with neighboring structures. Colonoscopy showed a neoplastic disease 30 cm from the anus that determined a concentric stenosis of the intestinal lumen, for a length of about 8–10 cm. The lesion underwent multiple biopsies for tissue characterization and tumor grading. After diagnostic exams, patient underwent surgery with neuraxial anesthesia. A supraumbilical incision was performed in order to access the peritoneal cavity, where exploration showed no signs of disease repetition. Tumor in the hernial area was reached through the cavity. The testicle was intimately adhered to the organ, but there was no sign of tumor infiltration, so an inguinocrural incision was performed and the sac was isolated and then opened. Finally, after the opening of the hernial neck, the testicle and the cord attached to the sigmoid loop were also reduced into the abdominal cavity. Hemicolectomy was performed on the colic portion affected by the neoplastic mass, including the orchiectomy and an extensive mesenterectomy with conservation of nerves, ureters and vessels.Patient had no postoperative complications, recovering his normal intestinal function in the third day postsurgery. Histological analysis was performed on the surgical specimen, showing an ulcerated-vegetative-infiltrating area of three-fourths of the bowel; the sample also included 7 cm × 3 cm of testicle with a spermatic cord 10 cm long. The result showed a mildly differentiated adenocarcinoma infiltrating the mucosa, submucosa, smooth muscle and subserosa, while the testicle and spermatic cord were free from neoplasia. Six pericolic lymph nodes were also excised, and a reactive lymphoreticular hyperplasia was found. The patient showed colorectal cancer stage G2 PT3 TN0, according to TNM international staging system.® Gemini Automatic stainer (Thermo Electron Corporation), and immunohistochemistry. Rabbit monoclonal primary antibody anti-cytokeratin 7 (CK7)  and rabbit monoclonal primary antibody anti-cytokeratin 20 (CK20)  were used with OptiView DAB IHC Detection Kit on a Ventana BenchMark ULTRA automatic instrument . The histological analysis and CK7, CK20 expressions were evaluated by a pathologist using a direct light microscope in bright field at 20× and 40× magnification. Sample analysis showed areas exhibiting histological features of adenocarcinoma, with moderately differentiated morphology, with glandular structures present in more than 50% of total tissue and submucosal invasion through the muscularis mucosa. After the surgical excision, the bioptic tissue was immersed in a solution of 10% neutral-buffered formalin for 24 h to preserve the cellular structure. Then, the tissue was dehydrated and embedded into paraffin blocks. Tissue sections of 4 µm were used for hematoxylin and eosin staining, with Shandon VaristainIn our case, the immunohistochemistry showed a CK7-negative/CK20-positive expression pattern .A case of moderately differentiated sigmoid intrasaccular tumor was reported in an 88-year-old man that underwent physical examination, colonoscopy and whole-body CT exams.The literature reports 38 cases of colon cancer incarcerated in hernia ; they meThe causes of high incidence are due to the relevant frequency of colorectal cancer in the population and to the equally high engagement frequency of this bowel in the hernial sac, owing to its mobile anatomy. Hypotheses that circulatory distress and the consequent inflammation of the herniated bowel were responsible for the onset of the intrasaccular tumor were formulated in the past; currently, a direct association between these two common pathologies is considered implausible . No signMost cases of inguinal hernia are usually confirmed by a physical examination, which then leads to surgery. An ultrasound can sometimes be useful for diagnosis; however, in complicated cases, as in our particular case, an ultrasound and a physical examination have a limited role in detecting its etiology, extent and environment. Main differential diagnosis was the strangulation of an irreducible inguinoscrotal hernia, mainly for intrasaccular perforated malignant tumors that can mimic clinical presentation and have a poor prognosis .In our case, physical examination revealed a nonreducible inguinal groin mass, although the clinician was not able to characterize saccular content and mainly suspected oncological disease. Following, a colonoscopy was performed for the referred rectorrhagia, and a whole-body CT was performed for the unspecific oncological markers’ increase and surgical planning. A sigmoid moderately differentiated adenocarcinoma was detected within the inguinal hernial sac that circumferentially reduced colonic lumen and showed strict relationship with left spermatic cord. No signs of wall perforation, nodal involvement or metastases were detected by whole-body CT exam. Histological analyses revealed a CK7-/CK20+ phenotype, recognized as highly specific and sensitive for colorectal adenocarcinomas . Indeed,Regarding treatment management, for people over 85 years old with stage II colon cancer, no supportive evidence has been found for benefit from adjuvant chemotherapy, while for younger patients, higher survival rates (>16%) were reported ,18,19.There is also no evidence to support a certain approach in elective surgery for the inguinal carcinomas of the colon. The choice of the abdominal versus inguinal approach will depend on the patient’s anatomy, the surgical findings and the surgeon’s experience .In many cases, surgery was performed in an emergency environment or carcinomas were found as incidental findings, resulting in suboptimal treatment. An extra abdominal incision was often necessary in order to perform resection, increasing the risks of complications and mortality ,21,22,23In conclusion, the rarity of the association of inguinal hernia complicated with a tumor of the intestine must never prescind from an accurate clinical examination of the patient  and from the search for possible symptoms relative to an equally frequent pathology such as colorectal cancer. Imaging should be carefully performed in the diagnostic workflow of this kind of patient, considering the tricky findings and the important effects on the optimal treatment planning.


Pneumoperitoneum, or the accumulation of free air in the peritoneal cavity, is commonly associated with visceral perforation, mandating emergent surgical intervention. Non-surgical pneumoperitoneum, where visceral perforation is not the cause, does not commonly require surgical management. Chronic pneumoperitoneum secondary to small bowel diverticulosis is rare. Of all gastrointestinal diverticular diseases, jejunoileal diverticulosis is the rarest form.We describe a case of chronic pneumoperitoneum in an 83-year-old male presenting with intermittent abdominal distension and constipation over five years resulting in many presentations to his rural hospital. There were never any associated signs of sepsis such as fever or tachycardia. A computed tomography scan revealed large volume pneumoperitoneum without evidence of perforated viscera or free fluid.An elective diagnostic laparoscopy revealed extensive small bowel diverticular disease. One of the diverticuli exhibited pneumotosis intestinalis where bubbles of gas were noted within the diverticulum wall and mesentery in the local vicinity. Given the extent of the small bowel diverticular disease, the patient’s advanced age, and relative lack of symptoms, bowel resection was not undertaken and the patient was managed conservatively.This article illustrates a case of chronic pneumoperitoneum due to small bowel diverticulosis. It highlights the differential diagnoses for chronic pneumoperitoneum, increases awareness of this rare and challenging condition, and portrays the utility of conservative management avoiding major surgery and its potential complications. Pneumoperitoneum, or the accumulation of free air in the peritoneal cavity, is associated with visceral perforation in 85% to 95% of cases and frequently requires emergent surgical intervention. Non-surgical pneumoperitoneum accounts for 5% to 15% of cases, where free visceral perforation is not the cause, and does not commonly require surgical management . ChronicAn 83-year-old male was referred to a tertiary hospital outpatient clinic for opinion and management of his recurrent abdominal distension and constipation over a five-year period. He had multiple similar presentations to his local hospital with no overt clinical signs of sepsis such as fever, pain, or tachycardia to warrant surgical intervention. His past medical history included hypertension, gastro-oesophageal reflux disease, hypothyroidism, dyslipidaemia, and previous inguinal hernia repair. He underwent colonoscopy and gastroscopy which were both normal. On examination, he was haemodynamically stable and in no distress. His abdomen was markedly distended but soft and not tender to palpation. Blood biochemistry revealed normal inflammatory markers. A computed tomography scan revealed significant pneumoperitoneum without evidence of visceral perforation, inflammation, pneumatosis intestinalis or free fluid Figure .An elective diagnostic laparoscopy to further evaluate the cause of free air was undertaken. There was an audible escape of gas on entering the abdomen and extensive small bowel diverticular disease noted. One of the jejunal diverticuli exhibited pneumotosis intestinalis, where bubbles of gas were noted within the diverticulum wall and the mesentery in the vicinity Figure . ImmersiSmall bowel diverticulosis is rare, occurring approximately in 1%-2% of the population, with 80% of diverticula occurring in the jejunum, 15% in the ileum, and 5% in both . ChronicIn the majority of cases, pneumoperitoneum is secondary to an acute visceral perforation requiring emergent surgical intervention. Chronic pneumoperitoneum, however, is less common and may be managed conservatively in selected cases if peritonitis, fever, and leucocytosis are absent ,6. The mThe pathophysiology of this type of pneumoperitoneum is not well understood. Dunn and Nelson postulated that the distended diverticular mucosa may function as a semipermeable membrane allowing transmural gas equilibration . AccordiChronic pneumoperitoneum secondary to small bowel diverticulosis is a rare finding and the precise diagnosis may be missed, delayed, or overtreated due to lack of clinical awareness of the disease process. Once diagnosed, it can be successfully treated conservatively by observation and supportive measures alone, avoiding unnecessary laparotomy and potential bowel resection. However, where there is a potential for onset of acute complications, surgical management should be considered.