We report a case of rare and aggressive gallbladder neuroendocrine carcinoma (GB-NEC), diagnosed with the help of endoscopic ultrasound (EUS). A 65-year-old asymptomatic male, with a past medical history of hypertension, underwent abdominal ultrasound for the screening of an abdominal aortic aneurysm. He was found to have a mixed echogenicity area near the stomach, an incidental finding on abdominal ultrasound. The patient had an upper gastrointestinal (GI) endoscopy exam, which revealed an antral mass that was biopsied. The tissue specimen showed an epithelioid mesenchymal tumor of unclassified type and, eventually, the patient underwent partial gastrectomy. Surgical pathology reported a low-grade sub-serosal gastrointestinal stromal tumor (GIST) of the resected tissue specimen. He was later discharged and advised to follow up with abdominal computed tomography (CT) every year. Two years later, his abdominal CT revealed a new 3.7 cm x 2.0 cm mass in the posterior gallbladder fundus. Subsequently, the patient underwent laparoscopic cholecystectomy and the excisional biopsy reported a T3NXM1 neuroendocrine small cell carcinoma. Then, he received six cycles of systemic chemotherapy with carboplatin and etoposide, showing excellent response initially. However, a repeat CT abdomen/pelvis with contrast, on his eighth-month follow-up, demonstrated the interval development of an infiltrative mass in the pancreatic head. The gastroenterology team was then consulted, who performed sphincterotomy with temporary stent placement and celiac plexus neurolysis. Also, a transduodenal fine-needle aspiration (FNA) of the pancreatic mass was performed, which revealed metastatic small cell carcinoma. Based on these findings, the patient received an additional three cycles of carboplatin/etoposide chemotherapy, along with one cycle of immunotherapy. However, the patient had a poor response to chemotherapy, and he eventually chose hospice care. Neuroendocrine tumors (NETs) comprise a group of rare, heterogeneous malignancies that present with varying histories and biological behaviors. Most of the times, these tumors emanate from the neuroendocrine cells present in the gastrointestinal (GI) and respiratory tracts but may originate from anywhere in the body. The neuroendocrine cells usually produce neuromodulators, neurotransmitters, and neuropeptide hormones.Small cell carcinoma is a distinct but very unusual neoplasm of the gallbladder. The prevalence of gallbladder NEC is 1% to 5% of all gastrointestinal carcinoids. Here, we report a case of a neuroendocrine tumor of the gallbladder diagnosed by endoscopic ultrasound (EUS).A 65-year-old asymptomatic male, with a past medical history of hypertension, hyperlipidemia, and anxiety, presented to the primary care physician, for the screening of abdominal aortic aneurysm. Incidentally, the patient’s abdominal ultrasound revealed a mixed echogenic area near the stomach. It was later confirmed to be a 4.5-cm solid mass Figure  between The immediate onsite evaluation suspected a neuroendocrine tumor vs. a lymphoma, however, the transduodenal fine-needle aspiration (FNA) pathology reported an epithelioid mesenchymal tumor of unclassified type, negative for CD117 and DOG1, markers of GIST and other tumor types. Consequently, the GI tumor board recommended surgical resection, given the ambiguous biopsy results, unclear tissue origin, and the patient’s great performance status and lack of comorbidities. The patient underwent partial gastrectomy and the surgical pathology reported a low-grade sub-serosal gastrointestinal stromal tumor, with clear gastric muscularis, submucosal, and mucosal margins of resection. The tumor was positive for DOG1 and desmin and weakly positive for CD117 and smooth muscle actin. MIB1 showed approximately 1%-2% of the cells with nuclear immunoreactivity, indicating a low proliferative rate. Of note, the following markers were negative: AE1, CAM5.2, PAX8, CD34, S100, MelanA, HMB45, inhibin, EMA, myogenin, synaptophysin, and chromogranin. Postsurgical adjuvant chemotherapy was not indicated due to the low risk of recurrence, based on the modified National Institutes of Health (NIH) risk stratification criteria. The patient was then advised to follow up with an abdominal CT every year.Despite an initially negative surveillance one year later, a repeat CT after two years revealed a new 3.7 cm x 2.0 cm mass in the posterior gallbladder fundus, an 11-mm perihepatic node, and a 3.7-mm low-density lesion in the right hepatic lobe. Meanwhile, the patient developed new-onset nocturnal abdominal pain. Concerned for a possible GIST recurrence versus a new malignancy, an abdominal MRI was performed, which revealed a soft tissue mass along the gallbladder fundus/body, enlarging the pathologic portal caval, peripancreatic, and pericholecystic lymph nodes  ratio and coarse nuclear chromatin. Unfortunately, extensive necrosis prevented the determination of a definite diagnosis. Since imaging studies were suggestive of aggressive pathology, the patient agreed to proceed with a laparoscopic cholecystectomy and wedge resection of a segment four liver lesion, in order to obtain an excisional biopsy. Pathology reported a T3NXM1 neuroendocrine small cell carcinoma, strongly positive for synaptophysin and CD56, with clear resection margins.Based on this information, the oncologist started the patient on systemic chemotherapy utilizing carboplatin and etoposide. The patient finished six cycles of chemotherapy with an excellent response. A follow-up PET/CT scan at three months and six months Figure  revealedHowever, a repeat CT abdomen/pelvis, with contrast, at the eight-month follow-up demonstrated interval development of an infiltrative mass in the pancreatic head, peripancreatic lymphadenopathy, a hypodense lesion in the pancreatic tail Figure , and newIn addition, nine months postoperatively, the patient was admitted via the emergency department for acute abdominal pain, secondary to metastatic biliary obstruction. Blood work revealed an acutely elevated liver enzyme panel consistent with cholestasis. A EUS/endoscopic retrograde cholangiopancreatography (ERCP) Figure  was perfSphincterotomy and celiac plexus neurolysis were performed, and a temporary stent was placed. Pancreatic mass transduodenal FNA revealed a metastatic small cell carcinoma.Despite aggressive management, the patient manifested with worsening epigastric pain and obstructive jaundice. He finished an additional three cycles of carboplatin/etoposide chemotherapy, together with one cycle of immunotherapy but showed a poor response, as evidenced by abdominal CT and PET/CT Figure . EventuaNeuroendocrine small cell carcinomas are very unusual endocrine tumors arising in the gastrointestinal tract and comprising less than 2% of all the primary gastrointestinal tumors . PrimaryGallbladder neuroendocrine carcinomas (GB-NECs) have a higher incidence in women with age at presentation ranging from 35 to 80 years. According to most researchers, older females are at high risk of developing GB-NEC. A study by Ahn et al. revealed that only a few functional GB-NECs will have specific presentations . MoreoveRadiological imaging, such as CT, MRI, ultrasound (US), and tumor biomarkers, may not help in differentiating GB-NECs from other gallbladder tumors. Therefore, a biopsy should be obtained for immunohistochemical and pathological examinations. Currently, chromogranin A (CgA), synaptophysin (Syn), and neuro-specific enolase (NSE) are the most commonly used immunological biomarkers for NECs. Neuroendocrine carcinomas are very malignant tumors that progress rapidly, resulting in early liver invasion and lymphatic metastasis. Most GB-NETs are identified incidentally during a routine histological examination of gall bladder samples after surgical excision and are often accompanied by cholelithiasis and cholecystitis. Literature suggests that the origin of NETs is supported by the presence of metaplasia in the gall bladder due to chronic irritation, caused by cholecystitis. This hypothesis is supported by the histology and epithelial origin of the tumor. Since the normal gallbladder does not typically contain neuroendocrine cells, these tumors are very rarely found.The gold standard treatment for GB-NET involves surgery for the total removal of the gallbladder. Various surgical procedures can be used, ranging from simple cholecystectomy to extensive radical resection  . While sIn a study by MSKCC researchers, involving 13 patients with GB-NEC, the median patient survival time was 9.8 months, which was not significantly different from the median survival time of patients (n=435) with gallbladder carcinomas (10.3 months) [Literature regarding the prognosis of GB-NEC is relatively limited. Some studies revealed that elevated Ki-67, a high mitotic index, and invasion into adjacent structures predict poor outcome and prognosis. Despite major surgical removal, a majority of the patients can still develop recurrent metastatic disease -10. MoskMost patients with GB-NEC are diagnosed at late stages, as most NETs are highly invasive and have a high risk of lymphatic metastasis, which decreases the rate of radical resection. Platinum-based chemotherapy is the first-line chemotherapeutic agent. A study by Elahi et al.  reportedNew targeted therapies are being developed for NETs since traditional chemotherapy became ineffective. Recent advancements include the involvement of tyrosine kinase inhibitors in advanced gastro-entero-pancreatic tumors -17. NETsIn summary, GB-NECs are rare gallbladder tumors, with a low rate of incidence and a non-specific clinical presentation. Therefore, pathological and immunohistochemical examinations are needed to make a definite diagnosis. GB-NECs are highly malignant tumors and can present with lymphatic metastases and local invasion during the early stages. The prognosis of GB-NEC is usually poor as compared to a gallbladder adenocarcinoma. Therapy with a combination of surgical resection, radiotherapy, and chemotherapy can potentially increase patient survival. However, no universally accepted guidelines of treatment are available because of its low incidence and few relevant studies. Further studies with a larger sample size are needed to explore efficient treatment strategies.


We report this large neck mass, located behind the sternocleidomastoid (SCM) within the posterior cervical space and anterior to the prevertebral fascia. The mass is displacing the carotid sheath and its neurovascular contents medially. It extends almost the whole length of the SCM muscle all the way down to the lung apex.  A 30-year-old female patient presented to our clinic with a left anterior neck mass for a few months with dysphagia. The lipoma was excised completely along with level II to IV lymphadenectomy. A very small volume chyle leak was noted intraoperatively. The drain was removed 2 weeks later only to recur in one month. A new drain was placed by interventional radiology, and the drainage resolved completely.  The patient with mild dysphagia had a lipoma large enough to push vital structures away from their normal anatomical position. Due to the difficult location and the size of the lipoma, a meticulous formal lateral neck dissection was required. A 3D imaging like CT or MRI would be helpful to preoperatively plan the dissection. Substernocleidomastoid neck lipoma in our case is a rare benign tumor that was challenging to excise. Neck lipomas are rare, slow-growing, benign tumors that can be asymptomatic or cause various neck symptoms and signs that include pain, dysphagia, and hoarseness. Most frequently, the presentation is of an asymptomatic, pain-free, slowly growing mass involving subcutaneous tissue . Many asA 30-year-old female patient presented to our clinic with a left neck mass that she noticed a few months prior to clinical evaluation. She had a full range of motion in her neck and rarely complained of pain but did notice a lot of difficulty swallowing. The patient reported the mass has been increasing in size. She denied any fever, chills, nausea, vomiting, redness, or drainage around the mass. The rest of her history was unremarkable to the case. On physical exam, the patient was noted to have a BMI of 43.67 and all vital signs were within normal limits. The physical exam showed a left neck mass with poorly defined borders, nontender, and without inflammatory changes. The patient previously had an ultrasound of the left neck which demonstrated a circumscribed solid echogenic mass measuring 6.7 cm × 1.8 cm × 4.8 cm which corresponded to the palpable abnormality superior to the clavicle. The mass was identified as a lipoma .A left lateral transverse incision and dissection showed no subcutaneous mass. Intraoperative Doppler showed extreme medial displacement of the carotid sheath vessels. Then, a formal lateral neck dissection released the medial investing fascia of the sternocleidomastoid muscle enabling its further lateral retraction . The masStaphylococcus aureus. She was discharged 3 days later with a 5-day course of Bactrim. The drain was removed one week after discharge.The drain was removed after 2 weeks of follow-up when the drainage stopped only to present later with swelling and erythema surrounding the JP drain site. A CT of the neck showed a fluid collection at the area of the JP drain site measuring 3.7 × 3.1 cm. She underwent IR drainage of the fluid and returned 10 cc of chyle fluid. It drained the same volume amount daily. Fluid culture came back positive for MSSA—methicillin-sensitive Lipomas are slow-growing, benign tumors composed of adipose tissue that can occur anywhere in the body. Approximately 13% are located in the head and neck regions. They are commonly located in the posterior neck in the subcutaneous tissue layer, external to the superficial cervical fascia . This caWe reviewed the literature of lipomas, specifically on those in the deep anterior neck area. An intramuscular SCM lipoma was noted in the anterior neck area . A deep Formal left level II-IV lymphadenectomy was added in the procedure as it was contiguous with the mass and very well exposed in the dissection. Lymph nodes were sent for formal histopathological evaluation with the mass in the event it turned out to be malignant. When confronted with a complex and complicated lipomatous mass, liposarcoma and Madelung's disease should be included in the differential diagnosis for it can be hard to differentiate clinically. This further stresses the need for histopathologic analysis , 17.The thoracic duct is a major structure on the left side close to the apex of the lung as it exits into the vein junction of internal jugular and subclavian veins. Careful and meticulous dissection is of extreme importance to prevent a chyle leak. Should it happen to be injured, the surgeon should attempt to determine a low or high output level and be able to manage the complication intraoperatively. Cyanoacrylate glue and fibrin glue have been reported to be of value in sealing the leak with good outcomes . Others Our patient presented with dysphagia with no other neurological signs or complaints of pain. The lack of symptoms reported from the patient suggested that the lipoma would be superficially located and not located substernocleidomastoid. Our patient required an extensive lateral neck and carotid sheath dissection without 3D imaging available to visualize structural abnormalities. Our dissection illustrates the need to appreciate neck anatomy in order to avoid damage to the brachial plexus, the accessory nerve, lymph nodes, and the carotid space . Our case illustrated the need for a full preoperative workup even on lipomas that appeared clinically benign and demonstrated a good operative dissection plan with a favorable postoperative outcome even without 3D imaging to guide neck dissection.This case report of a substernocleidomastoid neck lipoma is an isolated one. It is a rare benign tumor that required a formal lateral neck dissection. A preoperative CT scan with IV contrast or an MRI cannot be underemphasized as an aid in delineating the mass with its contiguous vital anatomical structures. We recommend that surgical management of this kind of lipoma, though benign, should be reserved for experienced surgeons well-versed in formal deep neck dissection and capable of managing surgical complications.


Primary angiosarcoma of the pleura is an extremely rare tumour arising from arterial or venous pulmonary vessels of various size. It is characterized by an aggressive course and a poor prognosis. The early diagnosis is challenging due to diverse clinical and radiological manifestations. We report a case of a 70 year old male with primary right pleural epitheloid angiosarcoma. The patient had a history of a two week's progressive dyspnea. CT-scan showed a prominent thikening of the right pleura associated with pleural effusion and atelectasis. CT-scan guided by biopsy was performed and histological examination showed a tumor proliferation consisting of sheets of polygonal and epitheloid cells showing rudimentary vascular differentiation. Immunohistochemically, tumor cells were strongly positive for CD31 and Factor VIII-related antigen, negative for CD34, weakly and focally positive for EMA and Cytokeratine. The overall pathological and immunohistochemical features of the pleural specimens supported the diagnosis of epitheloid angiosarcma. The patient died after a week of discharge by pulsless ventricular tachycardia arrest. In addition, we also present a brief litterature review on pleural angiosarcoma. Our experience with this case suggests that comprehensive and sufficient sample collection and meticulous histological examination aided with immunohistochemical stains, particulary the endothelial markers, are required for accurate diagnosis of this rare malignancy. Angiosarcoma is a very uncommon neoplasm derived from endothelial cells. It represents 1% to 2% of all soft tissue malignancies. The most frequent locations are skin and soft tissues. Primary pleural angiosarcoma is extremely rare; only 50 cases have been reported in the literature until 2010 . Herein,A 70 year old man smoker was admitted to the emergency unit of the military hospital, with a history of progressive dyspnea during two weeks, and with increase of the abdominal volume and diffuse oedema of the lower limb, giving a rise to a clinical diagnosis of heart failure. He had no fever and no weight loss. His past medical history included HTA without treatment, and without diabetes or tuberculosis. On clinical examination, vesicular breath sound was diminished in right hemithorax, blood pressure was 15/10. An ECG showed sinus rhythm and left ventricle hypertrophia. An echocardiogram revealed normal function of both ventricles. Chest radiographs showed large pleural effusion . At righThe cytological study of pleural effusion did not reveal any definit results. A fibroscopy was performed and multiple biopsies were taken from the parietal pleura. On macroscopic examination, the received sample of pleural tissue matched with a red brown tissue of 0.4x0.3x0.2cm. The sample received was fixed with 10% buffered-formalin and stained with the hematoxilen and eosine(HE) after paraffin-embedded sections. Imunohistochemical stains have been performed on serial paraffin sections of 5u mounted on precoated slides and followed by deparrafinization using the following antibodies: TTF1, calretinin, CKAE1/AE3, Ck5/6, CD3, CD20, CD31, CD 34, FVIII-related antigens, EMA, MPO, MELAN A, HMB45, HMBE1. Histologically, it was a neoplastic proliferation consisting of large atypical epitheloid cells with abundant amphophilic cytoplasm. A marked nuclear polymorphism was observed and the nuclei showed a single prominent nucleoli and vesicular chromatine. The mitotic index was 10 per 10HPF. Intratumoral lymphocyte infiltrate was rather scanty . This moMalignant vascular tumors correspond to rare sarcomas which can affect any part of the body , 4-6. ThThe final diagnosis of the pleural angiosarcoma requires a histological and immunohistochemical study of the pleural samples. Histologically, the morphology of the pleural angiosarcoma can be spindle-shaped, which corresponds to the classical variant, or can be of epitheloide type , 3. ClasThe epithelial markers , are always strongly expressed in the mesothelioma and the adenocarcinoma, whereas they are seldom expressed in the pleural angiosarcoma, and more particularly in the epitheloid variant . Howeveret al. [The CD31 would be of close, the most sensitive and the most specific vascular marker, which rarely react with non-vascular tumors , 3, 18. et al. , reporteet al. , 18. Theet al. , 20. Suret al. , 19, 20.In conclusion, pleural angiosarcoma is a very rare aggressive malignancy with fast fatal outcome, regardless of the various therapeutic methods. The diagnosis requires a meticulous morphological analysis, supplemented imperatively by an immunohistochemical study, including mandatory the use of vascular markers.The authors declare no competing interests.


Malignant melanoma predominantly develops in middle-aged and older adults, most commonly occurring on the skin and rarely on internal organs. Malignant melanoma originating in the liver is extremely rare. Imaging findings of primary hepatic melanoma (PHM) are scarce in relevant literature.The patient was a 69-year-old woman from Zhejiang, China, who was admitted to the hospital because of upper abdominal pain that persisted for >10 days.Computed tomography (CT) findings indicated the presence of a circular low-density shadow of approximately 7.5 × 8.0 cm in the hepatic hilar region. Magnetic resonance imaging (MRI) indicated a heterogeneous solid cystic mass in the hepatic hilar region. The mass exhibited heterogeneous low-signal intensity on a T1-weighted image (T1WI) and slightly higher signal intensity on a T2-weighted image (T2WI). The tumor appeared as multiple irregular strips with high-signal intensity on T1WI and low-signal intensity on T2WI. The diffusion-weighted image revealed increased signal intensity. The tumor continued to be enhanced after enhancement. Clinical data suggested that the tumor was a malignant liver tumor.The patient underwent a CT guide puncture hepatic biopsy. The tumor was located in the hepatic hilar region adjacent to the large blood vessels and invaded the portal vein. Because a resection was highly risky, conservative treatment was conducted.Postoperative pathology and clinical examination confirmed that the tumor was malignant PHM. The patient has been followed up for 6 months. The patient underwent CT reexamination 2 months after conservative treatment, the results of which revealed that the tumor progressed. Multiple lesions were identified; moreover, the tumor size had increased and the tumor had invaded the portal vein and intrahepatic bile duct. The patient was reexamined by CT in another hospital 6 months after conservative treatment. The results revealed peritoneal, omental metastases and multi bone metastases.To our best knowledge, this is the first reported case of a PHM with complete imaging data, including preoperative CT and MRI examinations and a follow-up CT examination. From compiling the CT and MRI findings of this patient and those of relevant studies, this study can serve as a reference for the preoperative diagnosis and differential diagnosis of PHM. The risk of recurrence and metastasis of malignant melanoma is high, and the prognosis is usually poor. Metastatic spread–7 of abdominal melanoma to the liver is common, and primary melanoma is extremely rare. Primary hepatic melanoma (PHM) cannot be easily identified through clinical observation and imaging technology because of its unspecific features; thus, PHM may be diagnosed as other types of hepatic malignant tumors. This study provides a report of a patient with PHM that was confirmed through clinical observation and pathological diagnosis. Patient computed tomography (CT) and magnetic resonance imaging (MRI) characteristics were analyzed, and relevant studies were reviewed to improve the understanding of PHM and provide an example that may serve as a reference for clinical treatment.Malignant melanoma refers to a malignant tumor that has developed from melanoma cells. Studies in pathology and molecular diagnostics have revealed that malignant melanoma is a relatively rare malignant tumor with highly aggressive biological behavior. Moreover, a malignant melanoma is not a single entity; rather, it is a group of different neoplasms with variable etiopathogenesis, biological behavior, and prognosis.29 cells/L, neutrophils = 69.5%, erythrocyte count = 3.37 × 1012 cells/L, hemoglobin = 97 g/L, total protein = 68.4 g/L, albumin = 36.5 g/L, alkaline phosphatase = 139 U/L, gamma-glutamyl transferase = 49 U/L. Leukocyte, neutrophil, and high-sensitivity C-reactive protein levels were all within the normal range. The patient had no history of hepatitis B.The patient was a 69-year-old woman who was admitted to the hospital because of upper abdominal pain that persisted for >10 days. The pain was characterized as primary distension pain without obvious cause. The patient received a B ultrasound examination at a local hospital, and the results revealed that the patient had multiple space-occupying lesions on the liver. She was treated in the Division of Gastroenterology at the author's affiliated hospital. A physical examination revealed no apparent jaundice; superficial lymph nodes, such as those on the neck, supraclavicular lymph nodes, and axillary lymph nodes were not swollen. Breath sounds were normal, and no coarse rhonchi and moist rales were noted. The patient's heart rate was 83 bpm, and heart sounds were normal. The abdomen was slightly bulging; the spleen was not palpable below the costal margin. Tenderness was reported in the right epigastrium, bowel sounds were 4 times per minute, and no shifting dullness sound or lower-limb edema were noted. A laboratory examination indicated that tumor indices CA199, CEA, AFP, and CA125 were in the normal range. A routine blood count yielded the following results: leukocyte count = 5.2 × 102. Dynamic MR images were acquired through the fat-suppressed 3-dimensional gradient-echo sequence.The patient underwent CT and MRI examinations during hospitalization. CT was performed using a 64-MDCT scanner . The parameters for both plain and enhanced CT examination were: tube voltage, 120∼130 kV; tube current 210 mAs used as the quality reference for an online dose modulation system  for the definition scanners; slice thickness 1.5 mm. MRI was performed using a 3.0 Tesla (T) Siemens scanner  with a phased-array body coil. MRI sequences included T1-weighted, axial and coronal T2-weighted image; diffusion-weighted image (DWI) findings were obtained using the following parameters: echo planar imaging technique b values: 0, 400, 1000 s/mmThe image characteristics were as follows: CT revealed a circular low-density shadow of approximately 7.5 × 8.0 cm in the hepatic hilar region Fig. . The intIn September 2018, a biopsy was performed on the patient under local anesthesia, and the pathology of the liver biopsy sample suggested that the tumor was malignant. Furthermore, immunohistochemistry proved that the tumor was malignant melanoma Fig. . The resThe tumor was located in the hepatic hilar region adjacent to the large blood vessels and bile duct, and the tumor invaded the portal vein. Because a resection was highly risky, conservative treatment was conducted. During hospitalization, the patient underwent symptomatic treatment, including anti-infection treatment, anemia correction, hypoproteinemia treatment, liver protection, stomach protection, and nutritional support.The patient has been followed up for 6 months. In November 2018, 2 months after conservative treatment, the patient underwent another CT examination. The results of the CT scan revealed that the tumor size had substantially increased Fig. . A newly3 The diagnosis of PHM primarily depends on clinical observation, imaging examination, and laboratory examination. The principal clinical symptoms are abdominal pain, abdominal mass, and weight loss. However, these clinical manifestations are not specific. This study summarizes the clinical features and imaging findings of this patient to serve as a reference for the preoperative diagnosis and differential diagnosis of PHM.PHM is rare and has been insufficiently reported. The diagnosis of PHM is currently required to include the following three indicators: histopathologically confirmed diagnosis of PHM, exclusion of other types of primary malignant melanoma, and no unexplained skin tumors or surgeries to destroy or excise tumors without a histologic examination.Imaging examination is essential for diagnosing melanoma. CT is the most commonly used method for diagnosing liver tumor lesions and is crucial for the localization and characterization of hepatic tumors. The soft-tissue resolution of MRI and its multiazimuth imaging are useful for evaluating intratumoral cystic changes and hemorrhagic necrosis. Multiphase dynamic imaging can be used to comprehensively investigate tumor enhancement patterns and characteristics.–12  all affect the diagnosis of abdominal melanoma and increase the difficulty of diagnosing abdominal melanoma using MRI imaging. Regarding the patient in the present study, DWI revealed a restricted diffusion change, and the tumor continued to exhibit uneven enhancement with internal necrosis. The tumor compressed the intrahepatic bile duct, caused dilatation, and invaded the right branch of the portal vein, which suggested that the tumor was invasive and that the patient had a poor prognosis. After 2 months, a CT scan indicated that the tumor had progressed, multiple new masses had appeared, the size of the mass had increased, and that the tumor had invaded the hepatic portal blood vessels and bile ducts. This study proposes the following features of PHM to assist diagnosis: single or multiple cystic-solid space-occupying lesions in the liver, expansive growth, possible capsule, easy bleeding, necrosis, and cystic lesion; after enhancement, the tumor may display flower-ring-shaped enhancement and no enhancement of the tumor in the central cystic necrosis area; the tumor manifests in various forms through MRI, that is, if the tumor exhibits high-signal intensity on T1WI and low-signal intensity on T2WI, then it may contain melanin. Moreover, such imaging results are the most characteristic of PHM.In summary, this study presents a rare case study of PHM. The CT and MRI findings of PHM have rarely been reported in other studies. This study compiled a case study and literature review to define the imaging performance of PHM, which can serve as a reference for the preoperative diagnosis and differential diagnosis of PHM.Conceptualization: Guoqun Mao.Data curation: Weiqun Ao, Jian Wang.Investigation: Xiaoyu Han.Resources: Guangzhao Yang, Xiaoyu Han.Supervision: Guoqun Mao.Validation: Yougen Cheng.Visualization: Yuzhu Jia.Writing – original draft: Weiqun Ao.Writing – review & editing: Yougen Cheng.


T1, hyperintense on T2 that enhanced heterogeneously with contrast. The T2 signal is higher than pilocytic astrocytoma, which indicates the presence of myxoid matrix. These findings on MRI scan have a direct correlation with a specific pathological finding—monomorphic proliferation of piloid cells in a mucopolysaccharide-rich matrix. These characteristics associated with the absence of Rosenthal fibres or eosinophilic granules indicated the diagnosis of PMA. To our knowledge, this is the first case report of PMA affecting the corpus callosum in an adolescent.A 17-year-old male patient with history of intraventricular haemorrhage in 2007 underwent a brain MRI scan in 2013 owing to headache. Brain MRI scan showed an expansive lesion adjacent to the left lateral ventricle infiltrating the anterior portion of the corpus callosum. After surgery, pathology confirmed a pilomyxoid astrocytoma (PMA), an aggressive subtype of astrocytoma that occurs predominantly in the hypothalamic-chiasmatic region. On imaging, PMA presents as a tumour isointense on  The goal of this new classification was the same of the older ones—grading the brain neoplasms. Based on six pathological criteria, these experts had the difficult task of classifying the tumours predicting theirs biological behaviour. The pathological criteria defined were the number of mitosis, presence of necrosis, vascular endothelial proliferation, nuclear polymorphism, cellular density and presence of genetic markers.2The largest category between the primary neoplasms is the neuroepithelial tissue tumours, which encompass the astrocytomas. Anaplastic astrocytoma and glioblastoma are the most aggressive ones, classified as grades III and IV, respectively. The diffusely infiltrating astrocytomas are designated as grade II. One of the most benign-behaviours astrocytomas are the pilocytic one (grade I). However, there is a more aggressive subtype of pilocytic astrocytoma (PA), named pilomyxoid, classified as grade II.The pilomyxoid astrocytoma (PMA) occurs predominantly in the hypothalamic-chiasmatic region. To our knowledge, there is no previous case report that described a PMA affecting the corpus callosum (CC). Here, we describe the clinicopathological and radiological features of this patient with new observations.An 11-year-old male, previously healthy, was brought to the emergency room with occipital headache and vomiting in 2007. He performed a brain CT scan, which showed a hyperdense area into the lateral left ventricle. A brain MRI scan performed in the same period confirmed a haemorrhagic lesion without abnormal enhancement adjacent to the CC. No vascular malformation was revealed by the conventional angiography. As the cause of the haemorrhage was not diagnosed, follow-up studies revealed that haematoma reduced in size and the clinical status of the patient improved, conservative management was chosen.The neurosurgery team followed the patient until 2013, when owing to new intense headaches episodes, a new MRI scan was requested. The exam showed an expansive lesion in the left lateral ventricle infiltrating the anterior portion of the corpus callosum. The patient was submitted to a craniotomy followed by resection of the lesion. The details of the brain MRI scan and the histopathological findings are described in the foolowing section.T1 and hyperintense on T2/fluid-attenuated inversion-recovery. It enhanced heterogeneously after gadolinium injection, presented a haemorrhagic component with blooming artefact that was hypointense on T2 gradient echo sequence and infiltrated the anterior horn of the left lateral ventricle predominantly  are suprasellar, with the geometric center in hypothalamus. However, owing to its expansive characteristic, the PMA generally invades the adjacent structures, such as deep gray nuclei, temporal lobes and closer white matter. The others 40% are located outside of the diencephalon, usually in the temporal lobe. Less commonly, it may occur in the midbrain, cerebellum, fourth ventricle and spinal cord.In our case, the PMA diagnosis was established in a 17-year-old patient, with a history of previous haemorrhagic vascular event.The diagnosis was initially obscured by the extent of intraventricular haemorrhage. It was initially considered a vascular lesion or arteriovenous malformation as the most likely cause of the haemorrhage5 which rarely occur in the PA.14 The tumour had a heterogeneous gadolinium enhancement, a pattern that is usually not found in PA as most of these tumours present a solid-cystic lesion, with a large cystic component.15 However, a heterogeneous enhancement usually suggest a glial tumour of a higher grade than lower grade gliomas.15Almost 25% of the cases of PMA bleed,16The final diagnostic was based on pathological findings. The main characteristics were the matrix predominantly myxoid and the proliferative index beyond that expected for PA. The absence of Rosenthal fibers and eosinophilic granular bodies, common in PA, ratified our hypothesis.17 Some imaging features such as haemorrhagic component, mainly solid mass, leptomeningeal dissemination and a higher T2 signal intensity inside the lesion suggest PMA  was obtained from the patient(s) for publication of this case report, including accompanying images.


Bezoars represent a rare cause of small bowel obstruction (SBO). Nonoperative management of bezoars includes use of endoscopy with mechanical or chemical dissolution methods. When obstruction persists, surgical intervention becomes necessary. Here, we present the case of an Asian woman with a SBO secondary to a phytobezoar masquerading as a malignancy. She presented with two days of acute-on-chronic abdominal pain that started after eating seaweed. Initial computed tomography (CT) scan showed a SBO with a jejunal transition point and ill-defined liver lesions, worrisome for a malignant obstruction with liver metastases. Further imaging, however, showed the resolution of these artifacts. Subsequent laparotomy revealed a small bowel loop with copious obstructing seaweed. A distal stricture was palpated, and the involved segment was resected. Intraoperative liver ultrasound was negative, and final pathology revealed benign small intestine with a mild stricture. Given the rarity of bezoar-related obstructions, the diagnosis is often delayed particularly when confounding factors exist such as our patient's concomitant hepatic findings. Contrast-enhanced CT has a high sensitivity but a lower specificity in identifying bezoars. A high index of suspicion is therefore necessary especially when managing higher risk patients. Small bowel obstructions (SBOs) are common surgical encounters. There are a large variety of causes with >50% caused by adhesions. Bezoars are masses of ingested undigested materials that accumulate in the gastrointestinal lumen , 2. TheyA 51-year-old Asian lady with no surgical history presented to the emergency room with two days of emesis and abdominal pain. She had been experiencing intermittent abdominal pain for a year, but her symptoms acutely worsened after eating a seaweed salad. Initial computed tomography (CT) scan showed a SBO with transition point in the jejunum  and multObstructive bezoars can be managed in several different ways. Nonoperative methods include the use of endoscopy with mechanical or chemical dissolution. When surgical intervention is needed, both laparoscopic and open approaches have shown similar outcomes . Our pat


A definitive diagnosis of extensive suture line exostoses affecting the nasofrontal, nasolacrimal, nasomaxillary, frontolacrimal, lacrimozygomatic and lacrimomaxillary suture lines in a 7-year-old Thoroughbred mare with chronic bilateral epiphora and facial deformation was achieved using standing computed tomography (CT) examinations. Positive contrast dacryocystorhinography using CT revealed partial bilateral obstruction of the nasolacrimal ducts. Minimally displaced depression fractures of the right nasal bone, the right maxillary bone and right frontal bone were also demonstrated. The cosmetic appearance of the periosteal reaction associated with the suture line exostosis and epiphora significantly improved within 3 months of diagnosis and treatment. The equine skull is composed of many flat bones bound together by collagen fibres and overlying periosteum Dixon . CraniofInflammation and suture line exostosis of the equine craniofacial suture lines result in regional swellings and is a common cause of firm facial swellings in the horse Carslake . Suture This case report describes the clinical, radiographic and computed tomographic findings of suture line exostoses of the nasofrontal, nasolacrimal, frontolacrimal, lacromaxillary and lacrimozygomatic craniofacial suture lines in a skeletally mature Thoroughbred mare who suffered severe facial trauma. The use of computed tomography (CT) with dacryocystorhinography has not previously been reported in a standing horse.Ethical clearance was not needed or required for the study.A 7-year-old Thoroughbred mare was presented to the Onderstepoort Veterinary Academic Hospital (OVAH) for the evaluation of a severely painful facial swelling of approximately 6 weeks’ duration. The owners reported that she had suffered severe violent blunt trauma directly to the facial region that resulted in extensive facial swelling over the following 48-hour period. Intermittent treatment with non-steroidal anti-inflammatory medicines and stable confinement in the 6 weeks prior to referral had failed to resolve the facial swelling, and bilateral epiphora had developed. Additionally, bilateral conjunctivitis developed 5 days prior to presentation at the OVAH.Clinical examination at presentation showed normal clinical parameters and mentation. Bilateral epiphora with a purulent discharge from the medial canthi and three discrete firm prominent swellings situated between the eyes in the areas of the frontal, nasal and lacrimal bones  were obsRadiographic and CT examinations with retrograde dacryocystorhinography, under a standing sedation protocol, were performed. An intravenous catheter was aseptically placed in the left jugular vein , and the mare was sedated using intravenous detomidine hydrochloride  and intravenous butorphanol tartrate . Radiographic evaluation of the head was performed using a ceiling-mounted computed radiography unit . Latero-lateral and the oblique (RtDLeVO and LeDRtVO) radiographic projections  and c reBilateral retrograde dacryocystorhinography was performed using 15 mL of Iohexol , with a 15-cm 6-FR Foley catheter (Foley catheter) inserted into the nasal puncta. Motion artefact was present in all the scans because of the standing sedation method employed but did not significantly affect the diagnostic quality of the images. The examination revealed mild soft tissue swelling associated with underlying marked bilateral irregular periosteal proliferation of the caudal aspects of the nasal bones, lacrimal bone, rostral aspect of the frontal bone and the nasofrontal-, nasolacrimal- frontolacrimal-, lacrimozygomatic and lacrimomaxillary suture areas  and e. TMinimally displaced depression fractures of the right nasal bone, the right maxillary bone and right frontal bone were demonstrated, despite the presence of motion artefact. Surgical intervention was not deemed necessary based on the mild displacement, good stability of the fracture and callus formation.At the completion of the CT examination and with confirmation of the patency of both nasolacrimal ducts, retrograde flushing of both ducts was performed successfully, although significant pressure had to be applied to the right nasolacrimal duct. The mare was discharged with instructions of stable confinement for 6 weeks, and a therapeutic regimen of ocular chloramphenicol  twice daily for 5 days and oral meloxicam  once daily for 14 days.A re-examination 6 weeks post-presentation and 12 weeks after the initial traumatic episode revealed that the mare had normal clinical parameters and mentation. A firm area of swelling was evident extending between the medial canthi of both eyes. Palpation of this swelling revealed a moderate pain response, but this was markedly reduced compared to 6 weeks previously. There was no evidence of epiphora or conjunctivitis, and the owners reported the mare to be showing significantly less resentment to general palpation of the facial region.A second radiographic evaluation was performed under a standing sedation protocol, which revealed no significant differences compared to the initial radiographs.The owners were requested to maintain the mare in stable confinement and to commence hand walking and trot work on the lunge over the next 6 weeks. A telephone update at this point confirmed that the mare had made excellent progress, and small paddock turnout was commenced.Eight months after the initial injury, the mare had returned to her normal routine, although a firm swelling was still present at the nasofrontal suture line area. The lacrimal and maxillary bones appeared normal . The marLocal facial trauma has been suggested as the likely aetiology of the inflammatory response seen in suture line exostosis Carslake . This aeAlthough, like the mare in this case, some affected horses have a definite history of a single episode of head trauma, present with acute-onset epistaxis or have a history of recent facial bone surgery, the majority of cases of suture line exostosis do not. Two studies reporting a series of suture exostosis cases revealed 0/16 cases (Gibbs & Lane Clinical signs of suture line exostosis of the nasolacrimal, maxillolacrimal and frontolacrimal suture lines commonly include bilateral diffuse swellings situated rostrally to the medial canthus of the eye with or without accompanying epiphora Carslake . These sRadiographic evaluation is the most common method of diagnosing suture exostosis (Butler et al. In this case, the resolution afforded by CT with the use of dacryocystorhinography confirmed partial obstruction of both nasolacrimal ducts and allowed the severity and location of the nasolacrimal duct obstructions to be determined.Dacryocystorhinography has been frequently performed under standing sedation Carslake , and theDacryocystorhinography is a moderately technically demanding procedure and can be irritating for the horse because of the pressure within the duct Carslake . It has After accurate identification, craniofacial suture line exostoses are normally treated successfully with stable confinement and anti-inflammatory treatment (Bonilla et al. The significant improvement in this case after 8 months has been previously recorded in studies assessing the long-term outcome of these cases Carslake . NasofroReassessment and surgical excision or stabilisation has been recommended in cases with persistent epiphora, large lesions unresponsive to conservative therapy, or in cases where the cosmetic appearance and epiphora are unacceptable to the owners (Bonilla et al. It is the opinion of the authors that CT examination with positive contrast dacryocystorhinography is a very useful technique for the diagnosis of suture line exostosis and evaluation of the patency of the nasolacrimal ducts when the nasofrontal or lacrimomaxillary suture lines are affected and epiphora is present. There is minimal risk to the horse as both diagnostic techniques can be performed in the standing, sedated horse. However, a sliding gantry design CT is required for standing equine CT to be performed. Further studies utilising CT will be of benefit to assess the complexities and relationships of suture line exostosis, as well as to define the relationship between fractures and exostosis.


Omental infarction is an uncommon cause of acute abdomen but one that clinically mimics more serious and common causes of acute abdomen like appendicitis and cholecystitis. Historically, it was diagnosed only intraoperatively during surgery for presumed appendicitis or other causes of acute abdomen. But with the increase in the use of imaging, especially abdominal computed tomography (CT) scan in the work-up for acute abdomen, more cases of omental infarction are being diagnosed preoperatively. This has also led to the observation that omental infarction is a self-limiting condition which can be managed conservatively. Currently, conservative management and surgery are the only treatment options for omental infarction with no consensus as to the best treatment modality. Having a patient with both acute appendicitis and omental infarction simultaneously is extremely rare with only two reported cases in the literature thus far. Here, we present a 10-year-old obese female who presented to our hospital with acute abdomen and was found to have acute appendicitis and omental infarction. The patient underwent laparoscopic appendectomy and resection of the infarcted omentum and had uneventful recovery and was discharged on the second postoperative day. In this report, we present a review of current literature on omental infarction and highlight the importance of imaging especially abdominal CT scan in the nonoperative diagnosis and treatment of omental infarction. Acute appendicitis is a very common cause of acute abdomen with children and adolescents having the highest incidence . OmentalA 10-year-old overweight Hispanic female (BMI > 28) complaining of abdominal pain for 2 days was brought to our emergency department (ED) by her mother. The pain reportedly started in the periumbilical area and later localized to the right lower quadrant. She also reported left lower quadrant pain, anorexia, and nausea but denied vomiting. She had no fever. Upon arrival to the emergency department, her vital signs were within normal limits for her age, but physical exam revealed generalized lower abdominal tenderness with rebound and guarding.Her laboratory investigation was positive for elevated white cell count of 12.10 per microliter of blood with a left shift. The rest of her laboratory results were within normal limits. Abdominal and pelvic CT scan were done which showed hyperemic appendix and hazy anterior mesentery and a small amount of free fluid Figures 1.Based on the history, physical exam, and CT scan findings, a diagnosis of acute appendicitis was made and the patient was taken to the operating room for laparoscopic appendectomy. Intraoperatively, a tortuous retrocecal appendix with free fluid was found, and appendectomy was performed without any complications. After performing the appendectomy, the omentum was noted to be adherent to the anterior abdominal wall and on careful examination, it was noted to be hemorrhagic and necrotic as shown in Figures Histopathological exam of the appendix revealed focal superficial acute mucositis and recent hemorrhage suggesting early acute appendicitis. Examination of the omental mass showed fragments of adipose tissue with hemorrhage, fat necrosis, and granulation tissue formation consistent with omental infarction Figures –11.Omental infarction is a rare cause of acute abdomen with reported incidence being less than 4 per 1000 cases of appendicitis . It usuaDespite being rare, more cases of omental infarction are being reported in recent literature due to the increasing availability and use of imaging modalities especially CT scan in the work-up for acute abdomen , 7 leadiRadiological features of omental infarction are not straightforward as seen in our case and also as reported by Itenberg et al. . The twoTwo treatment options exist for omental infarction: conservative/medical management and surgical intervention, which is usually done laparoscopically. Currently, there is no consensus on the best treatment modality, but with increasing preoperative diagnosis, conservative treatment has gained popularity since omental infarction is seen as a self-limiting condition . This apThe proponents of surgical approach argue that surgery  expedite the resolution of symptoms and shorten hospital stay in addition to preventing the complications associated with conservative treatment . HoweverIn the rare case of omental infarction occurring simultaneously with another more serious acute abdominal pathology like appendicitis as in our patient, surgical intervention is the treatment approach of choice. Both two cases reported in literature thus far , 5 and oLaparoscopy not only aids in the treatment of omental infarction but also can be diagnostic such as in our case where it was missed preoperatively with the radiological imaging. Had we done an open appendectomy with McBurney's incision, there is every possibility that the patient would have continued to have postoperative symptoms leading to prolonged hospital stay as well as requiring further diagnostics and intervention to manage the same. Hence, laparoscopy is clearly superior in diagnosis, management, and resultant shorter hospital stay with resolution of symptoms. Based on our experience, we recommend placement of ports as per surgeon comfort and usually can be managed without placement of additional ports than already required for the appendectomy. However, this has to do with the skill and comfort level of the surgeon; if additional ports are required for the safe resection of the infarcted omentum, they should be placed based on the location of infarcted omentum and intraoperative surgeon judgement.Imaging, especially abdominal CT scan, is central to the nonoperative diagnosis of omental infarction and as such; it is imperative that both radiologists and physicians become familiar with its interpretation and have a high index of suspicion of omental infarction after ruling out more serious causes of acute abdomen. When the diagnosis is made preoperative, we recommend a trial of conservative management and only doing surgical intervention when conservative management fails or in the rare case of a complication.For the patient with both acute appendicitis and omental infarction, we recommend laparoscopic appendectomy and resection of the infarcted omentum and only doing open resection when the expertise and/or resources for laparoscopy is lacking.


Alpha-fetoprotein-producing gastric cancer (AFP-GC) is a relatively rare disease, with a dismal prognosis.We report the case of a patient with long-term survival after surgery for the recurrence of AFP-GC. A 71-year-old man was diagnosed with gastric cancer and underwent distal gastrectomy with D2 lymphadenectomy (pT3N2M0). Pathological examination of the resected specimen revealed AFP-GC. Fifteen years after the gastrectomy, the patient experienced anorexia and was admitted with a mass located at the mesentery of the small intestine. Following a diagnosis of gastrointestinal stromal tumor of the mesentery, a tumor resection with partial small intestine was performed. The final histopathological diagnosis was AFP-GC’s recurrence in the small-bowel mesentery. Two months later, multiple liver metastases were identified, and serum AFP level was found to be extremely high . Chemotherapy with S-1+CDDP (SP) was initiated for liver metastasis. However, owing to anorexia and fatigue, SP therapy was discontinued following the patient’s request at the end of two courses. A CT scan at 1 month after the discontinuation of chemotherapy did not reveal liver metastasis, and serum AFP level decreased to the normal range. He is alive at present with no re-recurrence and no elevation of serum AFP level at 7 years after the second surgery without any chemotherapy.Even if recurrence of AFP-GC is diagnosed, radical resection and chemotherapy are effective, as noted in the present case. Alpha-fetoprotein-producing gastric cancer (AFP-GC) is a relatively rare disease, accounting for 1.3–15% cases of gastric cancer . AFP-GC Herein, we present a case of a patient with long-term survival after successful treatment with radical surgery for the solitary metastasis of the mesentery and chemotherapy for the multiple liver metastases of AFP-GC at 22 years after the first gastrectomy.A 71-year-old man was admitted to our hospital with complaints of persistent anorexia. Fifteen years ago, he had undergone distal gastrectomy with D2 lymphadenectomy, followed by Billroth-II type reconstruction for gastric cancer. Pathological examination of the gastric tumor revealed an AFP-GC, and the pathological stage was pT3 (SS) N2 M0, stage IIB (Japanese classification of gastric carcinoma: 3rd English edition) [Two months after the second surgery, CE-CT scan revealed multiple liver metastases Fig.  and seruPrevious studies have reported a poor prognosis for AFP-GC with lymphatic and venous invasion, along with high rates of liver metastasis as compared with non-AFP-GC , 8, 9. IOur case highlights three key learning points: first, the long-term  dormancy following the initial gastrectomy until the identification of the solitary metastasis to the mesentery; second, the multiple liver metastases, which went unobserved for 15 years, were evident only 2 months after the second surgery; and last, the disappearance of liver metastases for 5 years following only two courses of chemotherapy with S-1+CDDP.Gastric cancer usually recurs within the first 2 years of gastrectomy. Late recurrences are rare, with approximately < 1% cases recurring after 10 years . PrognosIn an earlier study, Adachi et al. analyzed 270 AFP-GC cases. The authors reported that the 5-year survival rate and median survival period in all patients were 22% and 14 months, respectively. However, they found that patients with curative gastrectomy comprised 42% of the study cohort and median survival period was 29 months . Our patIn Japan, SP therapy for unresectable and recurrent gastric cancers has been recognized as the standard therapy . At the Even if recurrence of AFP-GC is diagnosed, there are cases in which radical resection and chemotherapy are effective, as noted in the present case. Additional accumulation of AFP-GC cases is necessary to identify and select such cases.


Low-grade appendiceal mucinous neoplasm (LAMN) is a rare malignancy with symptoms varying depending on the clinical manifestations. The most worrisome complication of this particular neoplasm is seeding of mucin into the adjacent peritoneum leading to pseudomyxoma peritonei (PMP). There is a lack of standardized treatment approach; however, an appendectomy-only approach is currently being used for the resection of non-metastatic disease. We present an unusual case of a 67-year-old male found to have LAMN status post elective appendectomy, six months after being treated for an appendiceal abscess. Low-grade appendiceal mucinous neoplasm (LAMN) is a rare malignancy accounting for 1% of gastrointestinal neoplasms and is found in less than 0.3% of appendectomy specimens . LAMNs aGross examination of LAMN may be unremarkable or may appear as a mucin-filled, cystically dilated tissue. The appendix wall may appear thin, fibrotic, hyalinized, or calcified with a smooth or granular appearance . SimilarLAMNs are associated with diverticula, herniations, dissections, and rupture . The mosA 67-year-old Caucasian male with a past medical history of gastroesophageal reflux disease presented to the hospital for an elective appendectomy. Of note, he was admitted six months prior for acute appendicitis with perforation and abscess formation. At that time, computerized tomography (CT) scan of the abdomen/pelvis revealed a perforated appendix with a 7-cm abscess in the right lower quadrant Figure .The patient was medically managed with 10 days of ertapenem and percutaneous drainage. Follow-up CT scan of the abdomen/pelvis eight weeks post-drainage showed an intra-appendiceal mass, representing chronic inflammatory changes versus tumor Figure .The patient underwent evaluation of possible underlying tumor with complete blood count, basic metabolic panel, and carcinoembryonic antigen (CEA) which were all unremarkable. Colonoscopy was performed, which did not show any abnormality at the appendiceal orifice. Unfortunately, the patient was lost to follow-up prior to his elective appendectomy despite recommendations for surgery at that time. The patient was reevaluated after lost to follow-up and decided to undergo laparoscopic appendectomy. Laparoscopic appendectomy revealed an intact appendix with a visualized bulbous tip and no evidence of metastatic disease. Gross examination of the specimen revealed a vermiform appendix measuring 6.5 x 1.3 cm. Sectioning of the specimen showed a 1.3 x 0.6-cm mucinous area surrounding the distal aspect of the appendix. Specimen pathology revealed LAMN with rare diverticula into the appendiceal wall and an extensive 1.3-cm area of periappendiceal acellular mucinous deposits. Extensive mucinous pools were identified in the periappendiceal tissue without evidence of perforation , rupture, and PMP -2.Often, this malignancy is misdiagnosed as acute appendicitis, retroperitoneal tumors in the right iliac fossa, or an adnexal mass . ImagingControversy remains on the best surgical approach (laparoscopic vs open), adjuvant therapy, follow-up duration, and imaging technique. The goal of management of LAMN includes the prevention of rupture, seeding, and development of PMP . The praPMP is a complication of mucinous LAMN that can develop from peritoneal seeding in 20% of patients with a mucinous adenoma. It can be diagnosed using various modalities such as ultrasonography, CT scan, and magnetic resonance imaging depicting the presence of gelatinous mucinous nodules in the peritoneal cavity . HoweverSurveillance of patients with LAMN incorporates radiographic imaging every six months post appendectomy for two years for adequate monitoring of tumor recurrence and complications associated with PMP . AccuratOverall, further studies are needed for a more definitive method of diagnosis, treatment, and monitoring of LAMN. Diagnosis to date varies by imaging modality, the tumor markers utilized, and classification of disease. There remains a lack of standardization for post-treatment surveillance lengths and methods. This case presents the importance of developing a high index of suspicion regarding the development of appendiceal malignancies and choosing the appropriate surgical or medical treatment modality to prevent recurrence, seeding, and later development of PMP.


Central giant cell granuloma (CGCG) is a benign non-neoplastic, proliferative intraosseous lesion of the jaw with an unknown etiology often diagnosed during the first two decades of life. The true nature of this lesion is controversial and remains elusive. Here, we report a case of central giant cell granuloma, diagnosed using cone-beam computed tomography (CBCT). A 21-year-old female presented to the clinic complaining of a painless swelling involving the right side of the mandible that had started one year previously. A CBCT scan revealed a well-defined, multilocular radiolucent lesion on the right side of the mandible extending from the molar region to the ramus with wispy septations. Wispy septations and undulating borders are some of the characteristic radiographic features of a central giant cell granuloma. The patient underwent an excisional biopsy. The biopsy revealed multinucleated giant cells in a fibrous stroma confirming our radiographic diagnosis of a central giant cell lesion. The World Health Organization (WHO) classifies central giant cell granuloma (CGCG) as an intraosseous lesion consisting of fibrous cellular tissue that contains multiple foci of hemorrhage, aggregations of multinucleated giant cells, and occasionally trabeculae of woven bone with an incidence rate of 1.1 per million population per year . The CGCIn most cases, the lesion presents clinically as a painless, slow-growing swelling of the jaw. Pain and sensory disturbances are rare. Intraoral examination usually reveals swelling with a bluish-brown hue that can be observed in some cases. The displacement of teeth occurs frequently and can lead to a malocclusion . RadioloCone-beam computed tomography (CBCT) has gained immense popularity in maxillofacial imaging because of its high resolution and low radiation dose and is extensively used as a diagnostic imaging modality -9. Here,A 21-year-old female presented to the Case Western Reserve University School of Dental Medicine Clinic in Cleveland, Ohio. Her chief complaint was a slowly growing painless swelling involving the right side of the mandible that had started one year previously. Her past medical history revealed no previous surgeries or diseases. Her vital signs were recorded as 120/80 mmHg blood pressure, a pulse of 103 beats per minute (bpm), 15 respirations per minute, height - 5.1 ft, weight - 165 lb, and a calculated body mass index (BMI) of 23.71. No other medical conditions were identified, and the patient did not report taking any medications. Clinical examination revealed an intraoral swelling involving the posterior part of the body of the mandible and extending to the ramus on the right side. On palpation, the lesion was hard in consistency, except for select areas which exhibited a softer texture.The patient was referred to a private dental imaging center for a CBCT scan to evaluate the extent of the lesion. A board-certified oral and maxillofacial radiologist performed the radiographic interpretation of the CBCT scan. The scan revealed a well-defined radiolucent lesion ranging from the interdental bone in between the second and third right molars and extending to the ramus of the mandible posteriorly in the anteroposterior direction. The lesion extended from the alveolar crest to the inferior border of the mandible in the superior-inferior direction Figure .Osteolytic changes of the alveolar crest margin distal to the third molar were noted and displaced the roots of the third molar more distally. The sagittal cut showed that the lesion had a multilocular appearance with an incomplete internal septal structure, demonstrating wispy-like septations. The inferior border of the mandible showed some resorption with undulating borders Figure . The lesExtending more medially, the borders of the lesion showed fine wispy-like septations with undulating borders Figure . CoronalAn incisional biopsy was performed, and the histopathological report for the lesion revealed a giant cell reparative granuloma formed of proliferating spindle cells, multinucleated giant cells, extravasated red blood cells (RBCs), and mononuclear cells. No specific inflammatory granuloma or significant nuclear anaplasia and mitosis or other evidence of malignancy were noticed. This information, along with clinical and radiological features, was suggestive for CGCG and hyperparathyroidism . Laboratory investigations showed that the parathyroid hormone, alkaline phosphates, and calcium levels were all within normal limits. This excluded hyperparathyroidism as a possible diagnosis. The patient underwent surgical resection of the lesion. The surgery and recovery were uneventful.   This case report describes the unusual location of a central giant cell granuloma (CGCG). In this case; the patient was 21 years old at the time of the first examination and the lesion was noted in the posterior aspect. A CGCG of the jaw is more commonly found in the anterior mandible than in the maxilla and found in females more often than in males. These lesions occur before the age of 30 .CGCG has a variable clinical behavior. It may show an aggressive rapidly growing expansive lesion or be small, asymptomatic, and slow-growing . ClinicaConventional two-dimensional radiography is generally the first imaging modality performed in clinical practice. However, it provides limited information regarding the cortical integrity, size, and extension of the lesion, and thus imaging providing more in-depth detail, such as three dimensional (3D) imaging, is preferred , 12. CorCGCG is a benign, non-neoplastic proliferative intraosseous lesion of the jaw with an unknown etiology, which is diagnosed during the first two decades of life. CBCT offers more information about lesion extension and cortical wall integrity and aids in diagnosis.


Leiomyomas are benign smooth muscle tumors that have low malignant potential (0.1%) and can arise in nearly any area of the body. Genitourinary involvement is very rare and represents only 0.05% of all bladder tumors . The most common presenting symptoms of bladder leiomyomas are obstructive voiding (49%), irritative voiding (38%), and hematuria (11%) . Treatment involves complete excision, in this case transurethral resection (TUR), and generally results in complete cure with no recurrences noted in the 250 cases reported in the literature for open resection and 18% recurrence rates after TUR which were successfully treated with a repeat TUR in all cases. Herein, we report a case of leiomyoma of the bladder which was refractory to four visually complete transurethral resections and ultimately required radical cystoprostatectomy with ileal conduit urinary diversion. Bladder leiomyomas are very rare, representing only 0.05% of all bladder tumors. Worldwide this equates to a 250 cases total ever reported , 2. EquaA 64-year-old male with a past medical history of coronary artery disease, cardiac stent, COPD, HTN, and dyslipidemia presented as a referral for left testicular teratoma and primary bladder leiomyoma. Prior to presenting to our facility, he underwent left radical orchiectomy, and hernia repair due to enlarging left testicle, had a transurethral resection of bladder tumor (TURBT) due to hematuria, and underwent PSA screening. Pathology determined the testicular mass to be a pT1 teratoma without lymphovascular invasion, PSA was found to be elevated , and the 40 g of bladder tumor resected during the TURBT was found to be a leiomyoma of the bladder showing no sarcomatoid differentiation. A CT scan was performed which was notable for bilateral pelvic adenopathy with lymph nodes greater than 2 cm and an interaortocaval lymph node of approximately 1.2 cm. Additionally, outside CT scan with IV contrast of abdomen pelvis showed large 6 cm heterogeneous soft tissue mass within the posterior left aspect of the bladder . The masFollowing independent pathology review of the outside facility testicular specimen and review of in-house specimens, the previous diagnosis of testicular teratoma was recharacterized as a Leydig cell tumor of the testis and the patient's lymph node biopsy revealed follicular lymphoma. Discussion at multidisciplinary tumor board initially recommended bone marrow transplant, neoadjuvant chemotherapy, and extirpative surgery at a future date depending on the patient's response to chemotherapy. After bone marrow biopsy, his follicular lymphoma was staged as stage 4 with minimal bone marrow involvement. In advanced stage follicular lymphoma there is no survival benefit to early initiation of treatment, therefore serial PET CT scans 6 months apart were recommended by hematology/oncology to follow his lymphoma.The patient was managed conservatively with nephrostomy tube exchanges every 10–12 weeks and underwent cystoscopy with urodynamic studies after presenting with urinary retention and traumatic foley at approximately 1 year post resection. Cystoscopy revealed a large mass in the left lateral bladder wall extending down into the bladder neck and involving the prostate. He was started on Flomax and discharged without a foley catheter as he was able to void with a normal PVR at the time of the procedure. Due to significant regrowth of leimyoma on cystoscopy, he was encouraged to have repeat debulking of the tumor via transurethral approach as he declined cystoprostatectomy. The patient underwent repeat TURBT with bipolar resectoscope for recurrent left lateral bladder wall, bladder neck, and prostatic mass. The pathology again returned leiomyoma without sarcomatoid differentiation. A month after discharge the patient presented to an outside Emergency Room after developing gross hematuria. He was transferred for continuous bladder irrigation and refractory hematuria which required urgent TURBT to fulgurate bleeding vessels at the left lateral bladder neck and resect additional tumor regrowth.The patient followed up in clinic 1 month later, and after an in-depth discussion of his clinical course, he decided to undergo surgical extirpation of the bladder and prostate with creation of an ileal conduit urinary diversion. When reviewing the preoperative MRI there was loss of fat plane between the prostate and rectum, therefore colorectal surgery was consulted to assist in rectal dissection. He also underwent preoperative colonoscopy in order to rule out invasion into the rectum and screen the remainder of the colon. The patient underwent open radical cystoprostatectomy with ileal conduit urinary diversion and intraoperative angiogram of the involved bowel segment and omental flap interposition. He had intraoperative proctoscopy by colorectal surgery to ensure no rectal injury was present. He was discharged on postoperative day 4 after progressing without incident. The pathology report from his extirpative surgery revealed a 1.8 cm leiomyoma involving the submucosal bladder wall surrounding the left ureteral orifice. Incidental finding of High Grade Prostatic Intraepithelial Neoplasia was noted on the prostate specimen. The findings did not extend through the bladder wall into the perivesical or periprostatic adipose. Margins were negative. The patient was evaluated 8 weeks postoperatively and has had an uncomplicated postoperative course to date. He has been satisfied by his improved functional status and is to be followed with serial renal ultrasound in 6 months to ensure no obstruction at the uretero-ileal anastomoses.Leiomyoma of the bladder is a very rare, benign tumor; however, it can be locally invasive and incur significant morbidity if left untreated. Leiomyomas are classified into 3 groups based on location: intravesical, intramural and extravesical , 5. The


The application of minimally invasive surgery (MIS) to resect pediatric solid tumors offers the potential for reduced postoperative morbidity with smaller wounds, less pain, fewer surgical site infections, decreased blood loss, shorter hospital stays, and less disruption to treatment regimens. However, significant controversy surrounds the question of whether a high-fidelity oncologic resection of childhood cancers can be achieved through MIS. This review outlines the diverse applications of MIS to treat pediatric malignancies, up to and including definitive resection. This work further summarizes the current evidence supporting the efficacy of MIS to accomplish a definitive, oncologic resection as well as appropriate patient selection criteria for the minimally invasive approach. Adult colon cancer represents the first application of minimally invasive surgery (MIS) for definitive resection of malignant disease. The use of MIS for definitive resection of adult cancers has expanded rapidly over the past 15 years, and increasing types and numbers of intrabdominal malignancies are being treated with MIS, including the complexities of pancreatic adenocarcinoma . For anyHow does the minimally invasive approach affect the ability to achieve a complete or gross total resection, negative margin status, and adequate lymph node sampling for a given tumor type?How does MIS impact relapse-free and overall survival?What patient and tumor characteristics should be considered during patient selection?What are the technical considerations?Early uses of MIS in treating pediatric cancers were limited to biopsy, staging, evaluation of resectability, and management of therapeutic complications, such as infection . With tiWith the growing interest in using MIS to resect pediatric solid tumors, the question emerged whether a high-fidelity oncologic resection could be achieved in children. In other words, how does the minimally invasive approach affect the ability to achieve a complete or gross total resection, negative microscopic margins, and adequate lymph node sampling? And what is its impact on perioperative outcomes, relapse-free and overall survival? To date, no randomized controlled clinical trials have been conducted to compare MIS to open surgery for resecting pediatric solid tumors. Such studies are likely not feasible given the often massive tumors presenting in small children and disease heterogeneity . After ap = 0.249). Five-year OS was 1.00  after MIS and 0.80  after open resection (p = 0.124). Furthermore, high rates of GTR were achieved with MIS . Also, no significant difference in margin status was observed between tumors resected open or with MIS (p = 0.333). Finally, the median number of lymph nodes sampled with MIS was 1 (interquartile range (IQR) 0, 3) compared to 2  lymph nodes harvested with an open approach (p = 0.070) [n = 1330) to open resection (n = 141) of neuroblastoma and Wilms tumors. In that report, however, a higher rate of lymph node evaluation and a greater number of total lymph nodes sampled were documented when using an open approach [Our recent analysis is the first report that provides an in-depth critique of MIS to achieve gross total resection , negative microscopic margins, and adequate lymph node sampling as well as its impact on relapse-free (RFS) and overall survival (OS) . The lar= 0.070) . Though = 0.070) . No signapproach . ImportaPatient selection is of utmost importance when considering MIS for tumor resection in children. However, few authors have detailed specific selection criteria of the ideal patient amenable to a minimally invasive approach. Often, the decision is based on surgeon comfort with the approach to a given case rather than strict or objective criteria. One report suggested that neuroblastic tumors lacking image-defined risk factors  were feasible to a minimally invasive approach . One othp < 0.051) [The same benefits of MIS that apply when treating benign diseases theoretically can be realized in the malignant context as well, including decreased postoperative pain, lower incidence of postoperative intestinal ileus, reduced hospital stays, and earlier return to activity. Indeed, studies have shown that MIS for pediatric cancer is associated with decreased length of hospital stay, decreased blood loss, and decreased time to initiation of chemotherapy after laparoscopic biopsy ,12,22. O< 0.051) . Though embryonal tumors, other applications of MIS in treating pediatric cancers should also be noted. For example, video-assisted thoracoscopic surgery (VATS) for pulmonary metastasectomy in the setting of osteosarcoma has been recommended based on the finding that patients presenting with single pulmonary lesions on CT did not have additional nodules detected at the time of thoracotomy [single pulmonary metastatic deposit detected on high-resolution CT in those patients who may require multiple thoracic operations. More recently, uniportal VATS has been employed for excisional biopsy of peripheral lung nodules in pediatric cancer patients [Though this review focuses on the utility of MIS for definitive resection of pediatric racotomy . Thus, ipatients . A variepatients . A prospWhen lymph node dissection is indicated, a laparoscopic approach may be suitable in the appropriately selected patient. For example, laparoscopic retroperitoneal lymph node dissection has been described for high-risk (age greater than 10 years) pediatric patients with paratesticular rhabdomyosarcoma. Based on a small retrospective case series, the authors concluded that the approach is a safe diagnostic and therapeutic procedure .Finally, while ovarian masses are commonly resected minimally invasively, an open approach is preferred for ovarian malignancy to ensure proper Children’s Oncology Group (COG) staging of germ cell tumors, which involves visual inspection and physical palpation of ovaries, omentum, and peritoneum. Differentiating benign and malignant disease preoperatively is complex and lacks definitive criteria. Tumor characteristics favoring malignancy include size ≥8 cm, presence of thick septations >2–3 mm and nonhyperechoic solid nodular or papillary components, and tumor markers . The absence of tumor markers does not exclude malignancy, and the presence of tumor makers, particularly LDH and AFP, does not mandate malignancy. Thus, tumor markers must be assessed within the context of other clinical characteristics ,27.With increasing application of MIS in the malignant context, its technical and oncologic limitations should also be considered carefully. From a technical standpoint, often large tumors must be mobilized within small spaces, and tactile constraints and reduced visibility may limit the efficacy of a minimally invasive approach. Individual surgeon experience with MIS also contributes to the ability to effectively mobilize tumors with vascular encasement and other IDRF without compromising nearby structures or causing tumor spillage. Challenges unique to MIS include difficulty with vascular control when dissecting tumors away from large vessels and maintaining adequate pneumoperitoneum to visualize tissue planes when aspirating angiogenic bleeding.Specific concerns about how iatrogenic pneumoperitoneum or pneumothorax might affect tumor spread and additional concerns about the potential for port site recurrence have contributed to the controversy surrounding the use of MIS when treating solid malignancies in children. In one murine model of neuroblastoma, mice undergoing carbon dioxide pneumoperitoneum demonstrated a higher rate of hepatic metastases but not local peritoneal spread compared to mice undergoing laparotomy . Some evPort-site recurrence has been documented in MIS resection of adult cancers and represents another manner in which a less invasive approach may uniquely affect disease outcomes . Such ocIdentify appropriate patient and cancer type.Leverage neoadjuvant chemotherapy to shrink tumors to facilitate resection when appropriate .Position patient for success.Commit to the challenge of completing procedure with MIS.Memorize preoperative imaging and location of vascular and other vital structures (and display images during procedure for frequent reference).Complete or gross total (>98%) resection of neuroblastoma. *Complete resection of Wilms tumor without spill and adequate lymph node sampling.Must achieve the appropriate oncologic principles for the specific tumor type.Have laparoscopic suction in field for short bursts to aspirate angiogenic bleeding, especially if resecting a tumor after neoadjuvant therapy.Recommend ultrasonic scalpel when excising mass from kidney or liver to preserve margin analysis given less thermal spread. Bipolar vessel sealers are adequate as well if greater distance from specimen is permissible and when dividing larger vessels.Surgical clips or vascular staplers are good for dividing larger vessels.Monitor progress regarding time, blood loss, and oncologic integrity. Be prepared to open if absolutely necessary.Use a specimen bag to remove the tumor.Identify a port location having good cosmesis to deliver specimen in a bag.Lengthen this ideal port to the narrowest diameter of tumor and deliver in that dimension.* Note: The value of radical surgery for neuroblastoma is controversial. As little as 50% resection is sufficient in patients with low-risk disease. For intermediate-risk disease, the goal is to achieve the most complete resection possible with minimal morbidity. The COG high-risk protocol currently recommends gross total resection with removal of locoregional disease, despite conflicting evidence on the role of surgery in high-risk neuroblastoma [blastoma . RegardlExcessively large tumors.Vascular encasement.Limited tactile feedback, or haptics, with MIS instruments to appreciate large vessels, so must have good visualization of critical structures.Inappropriate patient selection:Not mentally committing to MIS approach. These procedures are challenging.Not positioning patient appropriately.Tissue planes are difficult after neoadjuvant therapy  and if angiogenic bleeding is excessive.Not recognizing feeding and draining vessels .Not sampling lymph nodes adequately.Not completing the appropriate oncologic operation for a given tumor type.Recommend using a specimen bag.Do not morcellate tumor to deliver specimen—it must remain intact.As MIS is increasingly applied to the resection of pediatric malignancies, the questions of appropriate patient selection and oncologic integrity with this approach remain controversial. Despite emerging evidence suggesting that MIS achieves oncologic equivalence to open resections in terms of RFS, OS, GTR, and margin status, no prospective randomized trial exists to confirm this notion because the need for careful patient selection precludes randomization. Currently, the characteristic tumor amenable to a minimally invasive resection appears most commonly to be a neuroblastic tumor without IDRF and with a tumor volume less than 100 mL. It is expected that the range of tumors considered to be amenable to MIS will broaden with increasing surgeon comfort using this approach, as is evident from the adult literature [


Actinomyces species are Gram positive anaerobic or microaerophilic bacteria that are part of the human flora in the oropharyngeal, gastrointestinal, and genitourinary tract. In the presence of a mucosal injury, they can become pathogenic and infect the underlying tissue without respect for tissue planes, leading to abscesses, fistulas, and sinus tracts. Through contiguous and hematogenous spread, virtually any organ can become infected. The presentation can be myriad and often mimics tumors, tuberculosis, or other more common infections and inflammatory conditions. While the cervicofacial region is the most common site of infection, involvement of the esophagus is unusual. Esophageal actinomycosis mostly occurs in patients with compromised immunity or prior esophageal injuries. Occurrence in immunocompetent individuals without risk factors is exceedingly rare. We report a case of esophageal actinomycosis complicated by an esophageal stricture in a patient with no apparent predisposing conditions. Actinomyces species are Gram positive anaerobic or microaerophilic filamentous bacteria belonging to the family Actinomycetaceae [ Actinomyces israelii. Actinomycosis involving the esophagus is extremely rare [cetaceae , 2. Thescetaceae –3. The mcetaceae . The mosely rare . Since tely rare , 5. The ely rare . Very raely rare –9. We re Actinomyces; rare fungal hyphal elements were additionally identified  Penicillin for a diagnosis of esophageal actinomycosis and oral Fluconazole for a presumed Candida coinfection given concurrent fungal elements. Her human immunodeficiency virus (HIV) status was negative and her fasting blood glucose was within the normal range. She was discharged on Fluconazole 200 mg daily for 2 weeks and IV Penicillin G 3 million units every 4 hours for 6 weeks followed by oral Penicillin to complete a total of 6 months of antibiotics. Her esophageal culture eventually grew normal oropharyngeal flora and rare Candida albicans. The patient returned to the hospital 6 weeks later due to an acute right upper extremity deep venous thrombosis (DVT) associated with her peripherally inserted central catheter (PICC). Her odynophagia had improved but she was still not able to advance her diet. Repeat EGD was performed, which showed resolution of her esophagitis, but a remaining stricture in the proximal esophagus  revealed erythematous and friable mucosa with ulcerations in the proximal esophagus . There w Figures . The cytsophagus . During Actinomyces are human commensal bacteria that only trigger an infection in the presence of an impaired mucosal defense, often due to surgery, trauma, foreign instrumentation, inflammation, or immunocompromising comorbidities [ Actinomyces as the sole culprit of an infection as most infections are revealed to be polymicrobial, involving additional pathogens such as Actinobacillus, Eikenella, Enterobacteriaceae, Fusobacterium, Streptococcus, or Candida [ Actinomyces at a target site [bidities , 10, 11. Candida , 13. It get site . Transloget site , 11. Due Candida coinfection might have facilitated it. The esophageal stricture formation was likely a result of the desmoplastic response typical in actinomycosis.Abdominal actinomycosis accounts for 25% of all actinomycosis, with ileocecal involvement being the most common followed by that of the left colon , 2, 11.  Actinomyces appear as sulfur granules with club-shaped ends, which signify clusters of bacteria in a proteinaceous matrix [ Nocardia also exhibits such an appearance, an AFB stain is usually employed to differentiate between the two [ Actinomyces remain highly sensitive to Penicillin; however, if Penicillin allergy is present, tetracycline and macrolides are alternative options [On histology,s matrix , 10. As  the two . Culture the two , 9. This the two . The tre the two , 15. Act options . In the  options . Surgery options , 7. Give


Internal hernias are defined as the protrusion of abdominal viscera through an aperture in the intraperitoneal recesses, they are considered as a rare cause of intestinal obstruction. The paraduodenal hernias are the most common type of congenital hernia especially the left-sided ones. We report a case of a 46 year-old man presenting a left paraduodenal hernia with acute small bowel obstruction, which was firstly (preoperatively) assigned to a tumoral cause. Internal hernias are defined by the protrusion of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity . They caA 46-year-old man was admitted to the emergency department with 3 days abdominal pain, colicky in nature, associated with vomiting and intestinal obstruction. On examination, the patient appeared in moderate pain, with mild tachycardia (85/mn), but normotensive and apyretic. Physical examination revealed a slight abdominal distension without any palpable mass. During digital rectal examination, the rectal ampulla was empty. Laboratory tests showed no noteworthy abnormalities except for leucocytosis of 16000 and a (pseudo) polycythemia (Hematocrit (HCT): the hematocrit = 54.1%. Hemoglobin (HGB) = 19.4g/dl. Plain abdominal X-ray in an erect position showed air-fluid levels of the small bowel loops in the upper abdomen . AbdominThe diagnosis of an acute bowel obstruction likely secondary to tumoral cause was made. Therefore, we decided to perform an emergency laparotomy which revealed that the proximal jejunum was prolapsed within a sac-like structure projected to the left of the midline . The rooInternal hernias are considered as an unusual cause of small-bowel obstruction, with a reported incidence of less than 2% . AlthougLeft paraduodenal hernias are congenital anomalies that arise during the rotation of the digestive tract, when the small bowel invaginates in an avascular segment of transverse descending mesocolon, localizing into a fossa (Landzert’s fossa) to the left of the fourth part of the duodenum, posterior to the inferior mesenteric vein and to left branches of the middle colic artery , 6, 8-10Small bowel loops  prolapse posteroinferiorly through the fossa into the left portion of the transverse mesocolon leading to its entrapment within this mesenteric sac , 13. WitAbdominal CT scan is the standard for the diagnosis of the left paraduodenal hernia. It may show different typical radiological aspects related to hernia: a “cluster” of small bowel loops, an encapsulated saclike mass at level of the ligament of Treitz, a depression of the duodenal-jejunal junction, a mass effect on the rear wall of the stomach, congestion and overcrowding of the mesenteric vessels with frequent right displacement of the main mesenteric trunk and anterior upwards displacement of the inferior mesenteric vein, which delimits the hernial defect and a depression of the transverse colon , 9, 15. Diagnostic laparoscopy for verification of diagnosis and simultaneous surgical intervention can be tried in cases that cannot be diagnosed with radiological method . SurgeryLeft paraduodenal hernia is an uncommon cause of small bowel obstruction, does not have distinctive clinical features therefore, it should be considered in a person with recurrent abdominal pain and intermittent bowel obstruction with no history of previous abdominal surgery. With a high lifetime risk of obstruction and high mortality rate, the diagnosis should occur preoperatively taking advantage of the important role of the modern imaging technique. The treatment is considered mandatory even in uncomplicated cases.The authors declare no conflict of interests.Mustapha Ben Moussa: study design, data collection, statistical analysis, data interpretation, manuscript preparation, literature search, and writing. The other authors: study design, data collection and interpretation. All authors have read and agreed to the final manuscript.