Monoclonal antibody targeting programmed cell death-1 (PD-1) is one of the most promising treatment therapies for human cancers. Canine PD-1 antibodies used in clinical trials have also shown efficacy in treating canine cancers. An 11-year-old male intact border collie presented to us for evaluation of left cervical mass. Computed tomography (CT) examination revealed an irregular pharyngeal mass invading the surrounding soft tissue. Histological and immunohistochemical results were consistent with a diagnosis of adenocarcinoma, most likely originating from the minor salivary gland. An anti-canine PD-1 monoclonal antibody was administered. Two months after the initial treatment, the tumor reached partial remission and maintained as such for 6 months. Finally, the patient was euthanized due to reasons unrelated to cancer, with a survival time of 316 days. To our knowledge, this is the first report of response to PD-1 blockade treatment in canine adenocarcinoma. Salivary gland neoplasms are primarily malignant epithelial tumors and rare in dogs. The incidence of salivary neoplasia in this population was calculated to be 15.3 per 100,000 dogs, which may be overestimated . SurgeryImmune checkpoint inhibitors (ICIs) have become attractive treatment options for a wide range of cancers in human. The first ICI, an antibody targeting the cytotoxic T lymphocyte antigen 4 (Ipilimumab), was approved by the Food and Drug Administration (FDA) to treat metastatic melanoma in 2011 . ProgramIn this case, the patient with oral adenocarcinoma was treated with the anti-canine PD-1 monoclonal antibody named MP001, produced by Biocytogen Pharmaceuticals (Beijing) Co., Ltd. MP001 is a fully caninized antibody and the immunoglobulin concentration is 10 mg/mL. To our knowledge, treatment with PD-1 blockade in canine oral adenocarcinoma has not been reported previously.An 11-year-old, male intact border collie was presented to the China Agricultural University veterinary teaching hospital with a left cervical mass. The mass has been present for two weeks with clinical symptoms such as ptyalism, dysphagia and occasionally tachypnea.On physical examination, 4/9 body condition score, normal mental state, adequate hydration, pink mucosa, normal capillary refill time and normal rectal temperature were detected. Except for the mass, there was no obvious enlargement of superficial lymph nodes (LNs). On palpation, the cervical mass was located deep on the left ventral side, solid and fixed. No obvious mass could be detected on oral examination without anesthesia.The mass was further identified by cervical ultrasound examination, showing mixed echogenic and cavitated appearance on the left neck with mild vascularity, measuring approximately 3.34 × 2.87 cm on the sagittal plane. The left medial retropharyngeal LN was unevenly hypoechoic and poorly demarcated from the mass. Soft tissue in the pharynx was hypoechoic of up to 1.0 cm thickness. In addition, CBC and serum biochemistry were within normal limits. No abnormalities were detected via two-view thoracic radiographs.Then the oral examination and computed tomography (CT) scan was performed under general anesthesia. The oral examination revealed a ring-thickened mass on the left soft palate . And CT 2.Fine needle aspiration (FNA) cytology from soft palate and incisional biopsy of the mass was performed. Cytology was suspicious of malignancy and the specific origin could not be distinguished. Sections of the mass were processed for histology, and embedded in paraffin. Sections (5 μm) were cut and stained with hematoxylin and eosin . HistoloAdditional sections were used for immunohistochemical (IHC) staining (using the Horseradish Peroxidase method), with antibodies against cytokeratin , vimentin , and melan-A . Neoplastic cells were intensely positive on cytokeratin IHC, and they were mostly negative on vimentin and melan-A IHC . Histoloth day after the first presentation. Based on information from other previous studies . Then before the fifth dose treatment, follow-up ultrasound suggested the mass reached partial remission  and the LN was significantly smaller (thickness of 0.43 cm) compared that to images from a month ago. Four months after the diagnosis, before the eighth dose, the gross appearance of the tumor was significantly reduced . Follow-In addition to dyspnea, gastrointestinal adverse events including vomiting and diarrhea only observed before the fifth treatment. And these adverse events are grade 1, according to VCOG-CTCAE v1.1 . No otheAt 6-month follow-up after CT re-examination, the patient remained in partial remission without metastasis. But the patient was euthanized later due to severe osteoarthritis of the hip. The survival time is 316 days and duration of response (DOR) is 252 days.The case was eventually diagnosed as oral adenocarcinoma. Based on anatomic location and IHC staining, we think this mass was originated from minor salivary gland of pharynx or soft palate. Adenocarcinoma of minor salivary gland is very rare in dogs, but should be included in the differential diagnosis list of oral tumors. The median age of dogs with salivary gland tumors is 10.5-year-old . A mediaThis case was stage III according to a WHO modified tumor node metastases (TNM) system . PartialAdverse events from immunotherapy are usually self-limiting. Compared with chemotherapy or molecular targeted therapy, ICI therapy has the advantage of causing fewer adverse events. The most common adverse events include fatigue, fever, anorexia, and gastrointestinal signs such as vomiting and diarrhea , which aSurprisingly, after the fourth dose, the mass reached partial remission. Therefore, we hypothesized that the enlargement of the mass after the second dose was pseudoprogression, which is kind of unconventional responses to anti PD-1 therapy. Pseudoprogression is defined as an initial increase in tumor growth followed by a decrease . It is nAntibodies that block PD-1 signaling can reverse PD-L1 mediated suppression of T-cell activation , 19. TheIn this case, we confirmed the expression of PD-L1 in tumor cells using IHC , indicatIn summary, a canine salivary gland carcinoma was effectively treated using canine PD-1 monoclonal antibody. Both survival time and DOR were longer than that in previous studies, confirming the great potential of ICI therapy. As the trial progresses, more information should be provided to veterinarians about ICI treatment, including but not limited to the applicable tumor type, possible side effects, and factors affecting ICI treatment.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The animal study was reviewed and approved by Ethic Committee of China Agricultural University Laboratory Animal Welfare and Animal Experiment (Issue No. Aw40103202-2-1). Written informed consent was obtained from the participant/patient(s) for the publication of this case report.SX wrote the manuscript. GL assisted in supervision of the clinical management of this case and contributed to conception of the case report. JX created the PD-1 antibodies for clinical trials. JF and NT supervised the clinical management of this case. SW and GL revised the manuscript. YS assisted in the histopathological staining of the PD-L1. All authors critically reviewed and approved the final version of the manuscript.


Spontaneous bladder rupture (SBR) is a rare condition and often missed diagnosis, especially after a non traumatic vaginal delivery. A 32-year-old para 3 woman, consulted for abdominal pain and anuria two days after instrumental vaginal delivery with forceps for foetal distress in second sate of labour. Blood tests were suggestive of an acute renal failure. An abdominocentesis revealed a clear fluid looking like ascites. The ultrasound and computed tomography (CT) scan showed a large abdominal effusion. An exploratory laparoscopy revealed a bladder perforation which was sutured after laparotomy. SRB is extremely rare after a non traumatic vaginal delivery. It is associated with significant morbidity and mortality. Symptoms are mostly non-specific. It is suspected when post partum abdominal pain is associated with an effusion and renal failure signs. If suspected, the uroscanner remains the gold standard for diagnostic. Laparotomy is the standard surgical approach in this condition. Abdominal pain with elevated serum creatinine should be suspicious of SBR in post-partum. Spontaneous rupture of the bladder (SRB) is a rupture that occurs in a healthy bladder without traumatic history ,2. Its uPatient information and clinical history: we present a case report of a woman who consulted a regional hospital for abdominal pain and anuria two days after vaginal forceps delivery. She was 32 years old and had no significant medical or surgical history. She had had two previous spontaneous uncomplicated vaginal deliveries. The index delivery was her third spontaneous instrumental vaginal delivery following an uneventful pregnancy.Clinical findings: the vaginal delivery was assisted by abdominal compression maneuver and then forceps for fetal distress in second stage of labour. No complication was recorded. The delivery was performed by an obstetrician in a peripheral regional hospital. Two days after, she reconsulted the same hospital for abdominal pain. The physical examination revealed generalized abdominal tenderness and distension associated with dullness at the flanks. Blood tests revealed features suggestive of acute renal failure (creatinine = 868 µmol/l/urea = 40 mmol/l)  and of urea (2.6-7.2 mmol/l)). Laboratory tests revealed also elevated white blood cells to 18,000 elements/mm3, elevated C-reactive protein (CRP) to 455 mg/l and elevated fibrinogen to 10 g/l ). An abdominocentesis revealed clear fluid looking like ascites. The patient had a session of dialysis and was then transferred to our university-hospital. On examination, at our facility, her overall clinical condition was good, with a normal blood pressure (118/78 mmHg) and tachycardia (pulse rate was 120 beats per minute).Diagnostic assessment: bacteriological investigation was done ). Empirical broad-spectrum antibiotic therapy was administered intravenously without waiting for the bacteriological results . The chest X-ray showed bilateral basal alveolar opacities. The ultrasound and CT scan showed a large abdominal effusion. Therefore, a laparoscopic exploration was decided.Therapeutic intervention: during this procedure, a bladder perforation was strongly suspected when air was observed in the urine bag after coelioscopic insufflation. Because of technical difficulties due to inflammatory adhesions, the laparoscopy was converted to laparotomy. About 1.5 liters of ascitic fluid was drained. Exploration revealed a 2 cm perforation of the bladder´s dome with jagged edges partially clogged by a grelic handle  [: 126 000The reported median onset of SRB was three days . UsuallyMany of the risk factors have been deduced from the reported cases: a history of a caesarean section, instrumental vaginal delivery and bladder distension and compression during engagement of the foetal head in labour. If the latter is prolonged, necrosis of the bladder dome may occur. Bladder distension and compression can also be caused by the absence of bladder catheterization during labor, the presence of a bladder diverticulum and prolonged second stage of labour especially in association with foetal macrosomia . HoweverConcerning the reported clinical manifestations of SRB, the most frequently described symptoms in order of frequency are: abdominal pain, abdominal distension, fever, oliguria, hematuria and vomiting . BiologiThe treatment of SRB is surgical repair and urinary rest . SurgicaDespite being a rare condition, post-partum SBR should be considered in cases of abdominal pain, effusion and features of renal failure following delivery. It is associated with high maternal mortality owing majorly to late diagnosis. Treatment should be prompt and appropriate.


In the case of trauma, the presence of free fluid in the abdominal cavity on the focused assessment with sonography for trauma scan usually indicates the possibility of hemoperitoneum caused by injury to the abdominal organs. However, on rare occasions, isolated injuries to gynecologic organs can also result in hemoperitoneum, especially among women of reproductive age. Thus, the rupture of a corpus luteal cyst may be one of the myriad causes of massive hemoperitoneum and carries a risk of misdiagnosis for patients with trauma.In this case report, we highlight the characteristic imaging findings of a case of apoplexy of the corpus luteum cyst that presented to the emergency department as a cause of massive hemoperitoneum after blunt abdominal trauma. Hemoperitoneum can occur in various emergency scenarios. In the case of trauma, the presence of free fluid in the abdominal cavity on the focused assessment with sonography for trauma (FAST) scan usually indicates the possibility of hemoperitoneum due to injury to the abdominal organs. In decreasing order of frequency, the most commonly injured abdominal organs following blunt abdominal trauma are the spleen, liver, kidney, small bowel, and mesentery ,2. On raTherefore, a radiologist should always be alert for common and rare causes of hemoperitoneum. We present a case of blunt abdominal trauma that led to the rupture of an incidental corpus luteal cyst as a culprit of the massive hemoperitoneum. We highlight the salient CT imaging features of a ruptured corpus luteal cyst to enable an efficient diagnosis.A 26-year-old female presented with trauma after an alleged fall from a height that directly impacted her lower abdomen. The primary survey revealed that her vitals were within the normal range, but mild tachycardia was recorded (102 beats/minute). Bruising was conspicuous over the lower abdomen. Per the institutional trauma protocol, the eFAST revealed the presence of free fluid in all four quadrants, including the epigastrium, hepatorenal, perisplenic, and pelvic regions. The patient’s pneumo-scan and urine pregnancy test (UPT) results were negative. Afterward, per our institutional protocol, she underwent a non-contrast CT (NCCT) scan of the head and cervical spine and a contrast-enhanced CT (CECT) scan of the torso with both arterial and venous phases.The CECT of the torso revealed the presence of high-attenuation free fluid (>30 HU) in all four quadrants around the perihepatic, perisplenic, epigastrium, and pelvic regions Figure , Panel aOutcome and follow-upThe patient underwent diagnostic laparoscopy (DL) in view of persistent tachycardia and the presence of gross hemoperitoneum. Intraoperatively, gross hemoperitoneum was observed around the right ovary as well in all four quadrants. Further, a large cyst was confirmed in the right ovary with an irregular crenated surface and a small rent, which was cauterized Figure , Panel eThe corpus luteal cyst is a functional vascular ovarian structure with tiny, fragile vessels in the wall that are prone to rupture, resulting in intracystic hemorrhage, intraperitoneal rupture, and massive hemoperitoneum . Its manThe etiology of the corpus luteal cyst varies from spontaneous rupture to lower abdominal trauma. Its recognized risk factors include anticoagulation therapy, strenuous physical activity, and iatrogenic factors such as uterine examination . As was Imaging is essential in diagnosis and characterization and helps in timely management. Ultrasonography (USG) is an easily accessible, non-invasive, real-time, and radiation-free method. Hence, this method is preferred for the initial evaluation and diagnosis of simple and complicated corpus luteal cysts effectively only in routine or follow-up cases, but in level 1 trauma centers where eFAST is performed as an adjunct to the primary survey to observe the presence of free fluid  in the peritoneal and pleural cavity and not to look actively for pelvic organ. Therefore the major findings of a complicated corpus luteal cyst on USG can be easily missed.MRI is the investigation of choice for better characterization of adnexal lesions in routine or follow-up cases but not in acute trauma settings, where CECT of the torso is the tool of choice to identify the source of hemoperitoneum after a positive FAST status. The most common cause of hemoperitoneum is solid organ injury, followed by bowel and mesenteric injuries and, on rare occasions, gynecologic injuries, as was observed in the present case.On CECT, the corpus luteal cyst appears as a hypodense adnexal cystic structure with a thick, enhancing wall . Direct The differential diagnosis in the case of hemoperitoneum includes ruptured ectopic pregnancy, which a negative pregnancy test and the serum β-HCG level can be used to rule out. Another differential diagnosis is the spontaneous rupture of a corpus luteum cyst, which is more common in the luteal phase of the menstrual cycle during pregnancy or after infertility treatment. The absence of pain in the abdomen before the trauma, a bruise over the lower abdomen on clinical examination, and fresh blood during surgery favor posttraumatic rupture over spontaneous rupture.The management strategy is either conservative or surgical, depending on the clinical and imaging presentation. Unstable vital signs, uncontrolled pain with massive bleeding, and active contrast extravasation on CECT are indications of immediate surgical intervention . In thisCauses of rupture of corpus luteum cysts vary from spontaneous to traumatic. Although traumatic rupture of an incidental corpus luteal cyst is rare, it should always be included in the differential diagnosis of women of childbearing age who present with a large hemoperitoneum after trauma without injury to a solid organ. The plausible mechanism could be a direct impact or deceleration injury in the lower abdomen. Because of the difference in anatomic embryology, the right ovary is more vulnerable than the left. Therefore, CECT of the abdomen is an important tool in the trauma setting for localizing the anatomic site of hemorrhage (sentinel clot sign) and effectively visualizing the direct or indirect signs of a complicated luteal cyst as described with varying sensitivity.


Gallstones are increasingly becoming a common diagnosis in hospitals across the continents, with predominance in women. Patients suspected of a gallstone disease require thorough evaluation including endoscopic ultrasound, magnetic resonance imaging, or magnetic resonance cholangiography. A delayed or missed diagnosis is associated with serious complications and poor prognosis.A 44-year-old female patient presented with fever, vomiting, hypochondria, and epigastric pain for 10 days. Clinical examination showed jaundice and tenderness at the right hypochondriac region. Blood analysis revealed elevated bilirubin, alkaline phosphatase, and white blood cells. The patient was sent for a computed tomography (CT) scan which showed a grossly enlarged liver about 17.2 cm in length and a hypo-attenuating mass in the gallbladder fossa that enhanced moderately and heterogeneously following intravenous contrast administration. Dilated intrahepatic biliary ducts were also appreciated. Explorative laparotomy was performed and revealed an enlarged, cirrhotic-appearing liver, a thickened gallbladder, and a whitish-yellow gallstone about 3 cm in the largest diameter situated at its neck. No isolated tumour was found.Although gallstone disease is very common, misdiagnosis still occurs especially in low and lower-middle-income countries. Inadequate evaluation and increased utilization of CT in emergency and surgical departments are the contributing factors for a missed diagnosis.A missed gallstone disease occurs due to various factors including inappropriate standard operating procedures, which set a CT scan as the first imaging test for all internal conditions. This case report presents the appropriate approach to achieving the diagnosis of a gallstone disease before surgical intervention. HighlightsMisdiagnosis of gallstone disease is common. This case presents a missed gallstone disease and discusses how to appropriately carry out a diagnostic workout to achieve the diagnosis.Biliary tumours can have signs and symptoms mimicking those of a gallstone disease. This report describes how to radiologically distinguish cholangiocarcinomas and gallstones to allow for correct planning of management.Evidence indicates an increased utilization of computed tomography in emergency and surgical departments. This report highlights the effects of over utilization of computed tomography in surgical departments as a contributing factor to missed diagnoses and unnecessary surgical operations which may worsen the patient’s prognosis.1 and are usually caused by local factors such as stasis, crystallization of cholesterol, and excessive secretion of mucin2, and systemic factors such as the interleukins-6, interleukins-7, interleukins-12, and interleukins-13, and other pro-inflammatory cytokines4. Molecular pathways involving the activity of HMG-hydroxyl-methyl-glutaryl coenzyme A (CoA) reductase, the transcription factor forkhead box protein 01 (FOX01), and the expression of ATP-binding cassette transporters G5 and G8 (ABCG5 and ABCG8) genes have also been described in the pathogenesis of gallstones6.Gallstone disease is increasingly becoming a common diagnosis. Two major types of gallstones have been described namely: cholesterol and pigment stones. Cholesterol gallstones account for more than 75% of all gallstone diagnoses in western countries7. When ultrasound findings are inconclusive, an MRI and endoscopic ultrasound are recommended8. The use of a computed tomography (CT) is less useful for the diagnosis of gallstones, hence, should be discouraged.Symptomatic gallstone disease may present with some typical features, however, confirmation of the diagnosis requires thorough evaluation. Abdominal ultrasonography is the imaging test of choice with a specificity of more than 95%9.This case report has been reported in line with the SCARE 2020 criteriaA 44-year-old obese, non-pregnant, African female patient presented to the surgical department with a 10-day history of fever, and sharp pain in the epigastric and right hypochondriac regions. The patient reported episodes of nausea, vomiting, and altered bowel movements. The patient was on antibiotics and analgesics for 10 days for cholecystitis without improvement. Her past surgical history was insignificant.oC. Abdominal examination revealed an enlarged tender liver.On clinical examination, the patient appeared sick, however, afebrile, jaundiced, and had a body mass index of 32. The blood pressure was 130/85 mmHg, pulse rate was 80 beats per min and body temperature was 37.13, elevated alkaline phosphatase 786 IU/l, and a bilirubin level of 2 mg/dl. The patient was put under 64-slice multidetector CT where serial axial sections were recorded, and a grossly enlarged liver measuring 17.2 cm in length was described  should warrant thorough and appropriate evaluation. Since most gallbladder stones are radiolucent, abdominal ultrasonography is considered the gold standard test for the diagnosis of gallstone disease7. Ultrasounds are inexpensive, easy to use, and available at most health facilities, even in low and lower-middle-income countries, and have sensitivity and specificity exceeding 95% and 96%, respectively. The European Association for the Study of Liver (EASL) Clinical Practice Guidelines on the prevention, diagnosis, and treatment of gallstones11 require the use of endoscopic ultrasound and, or MRI when ultrasound findings are inconclusive.This report presented the findings of a huge gallstone and thickened gallbladder wall which was missed after being confused with a Klatskin tumour under a CT scan. Small gallbladder stones are, in most cases (about 80%), asymptomatic. For the symptomatic proportion (about 20%), patients usually have bigger stones and present with typical radiating pain, biliary colic, and a history of using analgesiaet al.12 investigated the trends in CT utilization and found a 60% increase in CT use by the ED since 2010 in all age groups, except the children. The number of annual ED visits remained stable. In a similar study conducted elsewhere13, increased CT utilization was strongly associated with higher costs, longer hospital stays, and emergency operations. Since CT is often considered superior to ultrasound, patients who receive a CT scan first are less likely to undergo ultrasonography for further evaluation; and when a CT is less useful, as in the case of gallstone disease, a missed diagnosis is likely.Accumulating evidence suggests an increased utilization of CT in emergency departments (ED) and surgical departments in recent years; especially for privately insured patients. Bellolio 14. Unlike in gallstone disease, direct invasion of a tumour to the liver or adjacent vessels, intrahepatic segmental biliary dilatation, and an abrupt transition between dilated and non-dilated bile ducts, periductal thickening and endoluminal lesions are diagnostic features of a Klatskin tumour in radiography. A helical computed tomography can correctly detect and localize the tumour mass in over 90% of the cases15.Klatskin tumour (cholangiocarcinoma) is a rare, small, poorly differentiated tumour that arises from the epithelium of bile ducts, mostly at the bifurcation of the common hepatic duct. Symptomatic biliary tumours are, in most cases, associated with poor prognosis. Extensive workout with an multidetector CT, MRI, and, or MR cholangiography is therefore critical to define the size, location, vascular invasion, and optimal treatment strategy before surgery can be carried outIncreased utilization of CT in recent years in surgical departments is associated with increased emergency operations and the likelihood of missed diagnoses in cases where a CT is less useful; such as in the case of gallstone disease. Based on the findings in this report, we, therefore, recommend for optimization of standard operating procedures in diagnostic radiology in line with the current guidelines and protocols and emphasize a thorough diagnostic workout for patients suspected of a gallstone disease before surgery.The patient was aware of her symptoms and was concerned about irreversible liver damage, even after the histopathology results.None.Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.None.A.H.C. conceived the idea, designed the study, wrote the original manuscript, and revised the manuscript.None.Agapiti Hipoliti Chuwa.Not commissioned, externally peer-reviewed.


Leiomyomas of the prostate are uncommon benign tumors. We report the case of a 67-year-old man who underwent an emergent, open prostatectomy for symptomatic relief of clinically severe benign prostatic hyperplasia (BPH). Ultrasound showed a severe prostatic enlargement with urinary tract obstruction. Gross pathology findings showed a 134-g prostate gland containing a 2.5-cm-long, well-circumscribed lesion. Histological findings showed a bland, smooth muscle neoplasm with positive staining for smooth muscle markers. No necrosis, nuclear atypia, or mitoses are identified. In such cases, gross and microscopic examination of adequately sampled lesions is necessary to assure a conclusive diagnosis and to exclude overt stromal malignancies, such as leiomyosarcoma. Leiomyomas of the prostate are very uncommon benign mesenchymal tumors. This condition was first described by Kaufman and Berneike in 1951 . Fewer tThe historical case reports that described prostatic leiomyomas, including those described by Kaufman et al., were published prior to the advent of serum prostate-specific antigen (PSA) testing . Since tA 67-year-old Hispanic male with no known allergies presented to the emergency department with hematuria and acute urinary retention for several hours. He rated his pain as 5/10 and described it as pressure. He had never had these symptoms before. A month before, he described having a "good urinary stream" with nocturia two times per night. The patient had a significant medical history of hypertension, obesity, and an enlarged prostate. His at-home medications were tamsulosin, losartan, metoprolol, and low-dose aspirin. According to the patient, his outpatient urologist described a "lump" on the right side of his prostate gland but stated that his PSA levels are not elevated, thus not requiring alpha-reductase inhibitors, and may be followed up on a yearly basis.2. He reported that he did not use tobacco or alcohol.The patient’s past surgical history is significant for left total knee arthroplasty, right inguinal hernia repair, appendectomy, lumbar spine surgery, and cataract removal with the placement of intra-ocular lens implants. The patient’s weight and height were 106 kg and 167 cm, respectively, and his body mass index (BMI) was 37.6 kg/mThe patient was initially seen in the emergency department with a Foley catheter in place and subsequently discharged. However, the next day, the patient experienced significant hematuria with an increase in pain and returned to the emergency department. Urology was consulted for gross hematuria superimposed on urinary retention. Retroperitoneal  ultrasound Figure  showed mGiven the size of the prostate gland on ultrasound (147 mL) and the hematuria suspected secondary to urinary retention, the patient was evaluated for transurethral resection of the prostate (TURP) versus a simple prostatectomy procedure. The patient elected and subsequently underwent a simple prostatectomy. He was discharged home in stable condition. Subsequent post-operative outpatient follow-up was unremarkable.The gross specimen weighed 134 g and consisted of a tan-white, firm, well-circumscribed lesion, 2.5 cm in greatest dimensions, adjacent to tan-yellow, rubbery-nodular prostatic tissue. Microscopic sections Figure  demonstrLeiomyomas can develop in any organ containing smooth muscle tissue. The pathogenesis of prostatic leiomyomas includes chronic inflammatory or infectious disease processes in Mullerian embryonic remnants, peri-glandular smooth muscle, or the prostatic capsule . In the Histopathological examination is essential for a definitive diagnosis of prostatic leiomyoma, and the size of the lesion  should prompt consideration of stromal neoplasms aside from fibromuscular nodules. Similar to its uterine counterpart, morphologic features of leiomyomas include bundles of smooth muscle fibers with elongated, tapered nuclei, increased mitoses, and no nuclear or cytological atypia or the presence of necrosis. Special (trichrome) and routine immunohistochemical staining techniques can be very helpful in confirming whether differentiated smooth muscle tissue is present in these tumors, as opposed to strong, intense blue staining of fibrous tissue in fibromuscular nodules. In general, smooth muscle actin and desmin staining in prostate tissue specimens from patients with leiomyomas are positive, and Ki-67 staining should demonstrate minimal mitotic activity, a finding consistent with the benign nature of these types of tumors.A review of the published literature on leiomyomas identified six -8, singlTwo of the case reports mentioned the administration of alpha-blockade agents to treat BPH ,6. All pIt appears that the clinical presentation of a prostatic leiomyoma is similar or nearly identical to cases of BPH, which is far more common and prevalent in the general population, reaching up to 80% of individuals over the age of 80 . HoweverLimited data are available from which to draw conclusions on the treatment effect of alpha-blockade medications and their association with a diagnosis of leiomyoma. The emphasis of this case report and analysis rests on the uncommon presentation of clinically suspected BPH with PSA levels less than 4.0 ng/ml. Serum PSA increases with age and is frequently a good predictor of prostate volume. Patients with a mean prostatic volume of 37.9 and 64.3 mL correlate with mean serum PSA levels of 6.1 and 10.4 ng/ml, respectively [TURP may present as an equally feasible treatment method when compared to an open simple prostatectomy procedure when managing large prostates . While TProstatic leiomyoma, along with other benign and malignant stromal tumors of the prostate, should be considered by clinicians when evaluating a patient with an enlarged prostate and evidence of an atypical mass in the prostate. These tumors are typically identified after transurethral resection of the prostate or prostatectomy for symptomatic relief of acute urinary retention and histopathological examination of the entire excised tumor specimen. A thorough sampling of the tumor is necessary to exclude overt cellular atypia, necrosis, and increased and atypical mitoses. On the other hand, the presence of all of these findings would strongly favor a histopathologic diagnosis of malignancy. Fortunately, patients with benign stromal tumors have a very favorable prognosis, especially when these tumors are completely resected. Management may include an open simple prostatectomy for complete removal versus transurethral resection and laser prostatectomy methods.


Cystic dilatation of the bulbourethral gland duct  is a rare urethral pathology. No more than 150 cases of CS have been reported in the literature, of which the vast majority are children with a unilateral location. Bilateral CS has been reported in eight cases; however, detailed anatomy and clinical manifestations have not been reported. In this study, we report a case of bilateral CS with cavity junctions through the medial septum and its successful minimally invasive treatment in an adolescent.A 16-year-old adolescent patient complained of painful urination and post-micturition urinary dribbling. Magnetic resonance imaging (MRI), urethrography, and ureteroscopy data enabled the establishment of the diagnosis and determination of the type of CS. The surgical treatment that was performed was endoscopic marsupialization of both CS chambers. At follow-up examination after 7 months, the complaints had ceased, and there was complete normalization of urination. The maximum flow rate during uroflowmetry was 35 ml per second, on voiding cystourethrography, the residual cavities were not contrasted, and there was no residual urine or bacteriuria.MRI and retrograde urethrography made it possible to visualize changes in the bulbous part of the urethra, and ureteroscopy was the leading imaging modality. These studies was applied precisely because of the suspicion of the presence of a cavity communicating with the urethra. Minimally invasive surgical treatment for double-chamber CS was successful with no resulting complications. The bulbourethral glands were first mentioned by J. Mery in 1684 and subsequently described in detail by W. Cowper in 1699, after which they became known as the Cowper's glands . Cystic In November 2021, a 16-year-old boy was admitted to the urology department of Saint Petersburg State Pediatric Medical University. The patient demonstrated a clinical picture of painful urinary syndrome for the past 2 years, with post-micturition urinary dribbling of up to 10 ml for 3−4 min after each urination, without urinary tract infection (UTI) manifestations. Anamnesis: 2 years ago, hard seating on the chair, there was a short-term moderate urethrorrhagia and a severe urethral pain, followed by the appearance of post-micturition urinary dribbling, not accompanied by urinary urgency and frequency, nocturia, and persistent or intermittent pelvic pain in the absence of proven infection . There wWe treated the case described in the adolescent as bilateral perforated CS  , 8, withIn the case of post-vomiting urine dribbling, the patient is advised to undergo retrograde urethrography and urethroscopy to confirm the diagnosis of CS. Long-term observation after endourethral intervention is not required.The presented case of a teenager with bilateral syringocele is important due to its extreme rarity and will, therefore, be of interest to pediatric urologists.


Undifferentiated carcinomas of the pancreas with osteoclast-like giant cells (UCPOGC) are rare pancreatic neoplasms that account for less than 1% of all pancreatic malignancies. This case report of a 54-year-old male with metastatic UCPOGC adds to the existing literature and further ascertains the clinical and imaging features, treatment options, and prognosis of this rare entity.We present the detailed clinical course of a 54-year-old Asian male patient with UCPOGC, with focus on the relevant clinical features and imaging findings that are characteristic of this disease entity.UCPOGC is an extremely rare pancreatic tumor with a unique histopathology and clinical course. It is often difficult to distinguish UCPOGCs from other pancreatic tumors, such as traditional pancreatic ductal adenocarcinomas (PDAC), on imaging, and it therefore remains a pathological diagnosis. Surgery is generally regarded as the first-line treatment option, and the roles of chemotherapy and radiation are unclear. Due to the exceeding rarity of this tumor, large-scale clinical studies are not feasible. Therefore, it is important to share individual insights and experiences to improve our understanding and care for patients with this devastating disease. Undifferentiated carcinomas of the pancreas with osteoclast-like giant cells (UCPOGC) are rare pancreatic neoplasms that account for less than 1% of all pancreatic malignancies , and theCurrently, literature on UCPOGCs is lacking relative to other pancreatic malignancies, and our knowledge of UCPOGCs is largely based on case reports. Therefore, it is important to continue adding to current knowledge to further ascertain the clinical and imaging features, treatment options, and prognosis for this rare entity. Here, we present a case of metastatic UCPOGC in a 54-year-old male.A 54-year-old Asian male patient with a history of hypertension, pancreatic cysts, colonic tubular adenomas, and family history of colonic polyps presented for evaluation of a large peri-splenic and pancreatic mass that was discovered incidentally on endoscopic ultrasound (EUS). The patient had negative genetic testing for MUTYH-associated polyposis and familial adenomatous polyposis. The patient had experienced 30 pounds of weight loss over the past year, but he reported this was due to intentional efforts to lose weight. He was otherwise asymptomatic without abdominal pain, nausea, vomiting, hematemesis, hematochezia, melena, or jaundice.The patient’s abdominal physical examination was unremarkable without palpable mass. Laboratory examination revealed mild anemia with a hemoglobin of 11.7 g/dL . Carbohydrate antigen (CA) 19–9 was 138 U/mL , and carcinoembryonic antigen (CEA) was 2.4 ng/mL . Repeat EUS completed 2 months after initial EUS revealed a 12 cm, isoechoic to hyperechoic, heterogenous, cystic splenic mass. There was no abscess, mucinous, or solid component. Fine-needle aspiration of the cyst revealed serosanguinous, non-mucinous (negative string sign), and non-purulent material. The fluid cultures including an acid-fast bacilli culture were negative. The fluid CEA level was 2.6 ng/mL .Contrast-enhanced abdominal computed tomography (CT) demonstrated a large, heterogeneous, hypodense mass involving the pancreatic tail and spleen Fig. . AbdominAn en-bloc open distal pancreatectomy, splenectomy, left nephrectomy, left adrenalectomy, partial gastrectomy, and diaphragm resection were performed to remove the mass. The mass grossly involved both the distal pancreas and spleen but not the left adrenal gland, left kidney, or stomach. Gross inspection revealed a 11.0 × 8.1 × 7.0 cm tan-yellow to red-brown tumor that extended from the pancreas to the spleen and superior aspect of the left kidney Fig. A–D. FurtThe patient had no evidence of recurrent disease on six-week post-op CT, and he was started on six months of adjuvant modified FOLFIRINOX (mFFX) at nine weeks post-op. Unfortunately, on repeat CT scan 20 weeks post-op, a 1.2 cm right hepatic lobe liver lesion was discovered, and the biopsy was consistent with metastasis from the primary pancreatic UCPOGC. The mFFX was stopped and the patient was started on gemcitabine plus nab-paclitaxel. The patient completed two cycles of gemcitabine plus nab-paclitaxel before unfortunately expiring 11 months post-op.UCPOGC is a rare pancreatic tumor that may arise anywhere along the pancreas and typically presents in the fifth to seventh decades of life with symptoms such as abdominal or back pain, palpable mass, weight loss, and/or jaundice , 4–7, 10Involvement of the spleen in cases of UCPOGC is well-described , 4, 5. OOur patient had an elevated CA 19-9 of 138 U/mL  but normal serum CEA of 2.4 ng/mL  and fluid CEA of 2.6 ng/mL . In previous cases of UCPOGCs, both normal and elevated levels of CA 19-9 and CEA have been described , 16, 17.The sensitivity of CT, MRI, and EUS for the detection of UCPOGC is similar to that for the detection of traditional PDAC . The speIn our case, abdominal MRI of the UCPOGC demonstrated heterogenous intermediate T2-signal, marked restricted diffusion, and heterogenous peripheral T1 fat saturated post-contrast enhancement. In the literature, UCPOGCs have a variable appearance on MRI, with no consistent signal intensity described for each MRI sequence. UCPOGCs have been described as hypo- or hyperintense on T1, T2, and diffusion-weighted imaging , 10, 14.UCPOGCs are characterized by pleomorphic mononuclear neoplastic cells with intermixed, benign osteoclast-like giant cells (OGC), which are the histopathologic hallmark of UCPOGCs. In our case, the OGCs were CD68 positive and cytokeratin AE1/AE3 negative. This immunohistochemical profile is consistent with previously reported cases of UCPOGC and reinforces the idea that OGCs are derived from a benign histiocytic cell population , 20, 22.et al. reported a 5-year survival of 59.1% and median survival of 7.67 years for patients with UCPOGC, versus 15.7% 5-year survival and 1.59-year median survival for PDACs [et al. reported a median 15-month survival in a group of 9 patients with UCPOGC with associated PDAC, and our patient exhibited 11-month survival post-op [et al. study [et al. demonstrated loss of INI-1 in all four monomorphic anaplastic subtypes of pancreatic undifferentiated rhabdoid carcinoma [Muraki or PDACs , 9. Luch post-op . In our  post-op . Its exp post-op , althougarcinoma .The optimal treatment for UCPOGCs remains unstandardized. Surgery is considered first-line treatment , and in In summary, UCPOGCs are extremely rare pancreatic malignancies with a unique histopathology and clinical course. Certain radiologic findings may be helpful to distinguish UCPOGC from PDAC, but they are generally non-specific and UCPOGC remains a pathological diagnosis. If possible, surgery is generally accepted as the first-line treatment option, whereas the roles of chemotherapy and radiation are unclear, and their evidence is primarily anecdotal. Due to the exceeding rarity of this tumor, large-scale clinical studies are unlikely to be feasible, therefore contributing individual insights and experiences will be important in promoting better understanding and care for patients with this devastating disease.


Twin pregnancy with a complete hydatidiform mole and coexisting fetus (CHMCF) is an exceedingly rare condition with an incidence of about 1 in 20,000–100,000 pregnancies. It can be detected by prenatal ultrasonography and an elevated maternal serum beta-human chorionic gonadotropin (BhCG) level. Herein, the author reports a case of CHMCF which was incidentally diagnosed through pathologic examination without preoperative knowledge. The 41-year-old woman, transferred due to preterm labor, delivered a female baby by cesarean section at 28 + 5 weeks of gestation. Clinically, the surgeon suspected placenta accreta on the surgical field, and the placental specimen was sent to the pathology department. On gross examination, focal vesicular and cystic lesions were identified separately from the normal-looking placental tissue. The pathologic diagnosis was CHMCF and considering the fact that placenta accreta was originally suspected, invasive hydatidiform mole was not ruled out. After radiologic work-up, metastatic lung lesions were detected, and methotrexate was administered in six cycles at intervals of every two weeks. The author presents the clinicopathological features of this unexpected CHMCF case accompanied by pulmonary metastasis, compares to literature review findings, and emphasizes the meticulous pathologic examination. Complete hydatidiform mole (CHM) is one of the gestational trophoblastic diseases originating from fertilization of an empty ovum by a sperm and can be invasive or metastatic . In the A 41-year-old G3-P1 multigravida woman, with 28 weeks and 4 days of gestation, was admitted to the author’s institution because of preterm labor and a need for treatment in the neonatal intensive care unit (NICU). The patient had an obstetric history of dilatation and evacuation due to spontaneous abortion 4 years previously at GA  11 weeks, and 3 years previously she delivered a female baby weighing 3.2 kg at GA 41 weeks. The transfer record from an outside hospital presented a low-lying placenta with a suspicion of abruption and pelvic examination result of 3 cm and 50% effacement. In the first ultrasonographic finding of the present institute, the fetus was small for the gestational age  and due to the fetal position, the heart and extremities were not checked. Along with the low-lying placenta, hypervascularity and high blood flow in the subplacental area to the uterine fundus were identified. Other findings also included bridging vessels and multiple irregular lacunae within the placenta in the color Doppler ultrasound. The previous history of evacuation, maternal age, and ultrasonographic findings suggested the possibility of placenta accreta or placenta increta A. MoreovAfter removing the blood clot with a speculum, the membrane bulged, and the length of the cervix became 0 cm with U-shaped funneling. Although magnesium sulfate (Magnesin) and ritodrine (Lavopa) were administrated, labor pain persisted every 5 to 8 min with 30–80 torr. As ultrasound findings suggested placenta accreta, the obstetrician obtained informed consent for cesarean section with the possibility of uterine artery embolization and hysterectomy in case of excessive bleeding. An emergent cesarean section was conducted on the day after admission (at GA 28 + 5 weeks). On the surgical field, the uterus was slightly dextrorotated and enlarged to term size. Bilateral ovaries and fallopian tubes were grossly normal in size and shape. The clear amniotic fluid was noted. A living female baby weighing 1030 gm with an Apgar score of 7 (at 1 min) and 8 (at 5 min) was delivered in the left occiput transverse position. Intraoperatively, the uterus showed no obvious distension over the placental bed and the surface was clear without gross neovascularity. After an initial trial of manual removal of the mildly adherent placenta, bleeding was present but controlled after an intravenous Pitocin (10 unit) injection. Therefore, no further procedure was initiated. Although the operative findings were not fully sufficient for a placenta accreta spectrum (PAS) diagnosis, the preoperative ultrasound and the experienced clinician’s suspicion did not exclude placenta accreta, so the specimen was sent to the pathology department. The patient tolerated the entire procedure well and recovered in a stable condition. On gross examination at the pathology department, the placental specimen consisted of a discoid-shaped placental tissue, weighing 728 gm and measuring 23 cm × 16 cm × 2 cm. The umbilical cord inserted centrally 5 cm apart from the nearest margin and was measured 35 cm in length and 2.2 cm in diameter. On section, it had two arteries and one vein. The amniotic membrane was semitransparent. The fetal surface of the chorionic plate was smooth and semitransparent. The maternal surface was covered by intact cotyledons with blood clots and there were also separated multiple fragments of vesicular tissue, measuring up to 13 cm × 11 cm in aggregates A. ConsidBecause the placenta was removed manually during surgery, there was no clear distinctive border. Additionally, the surgeon originally suspected placenta accreta and only placenta was sent for pathologic examination without any uterine tissue, so the possibility of invasive hydatidiform mole was not excluded in the clinical context. The final pathologic report was twin pregnancy with CHMCF and indicated the possibility of invasive hydatidiform mole, so a BhCG level check and radiological work-up for excluding residual or metastasizing lesions were recommended. The BhCG level at 15 days after delivery was 1325 mIU/mL. There was no previous BhCG data because an emergent section was performed. Chest computed tomography (CT) revealed variably sized nodules in both lungs, indicating hematogenous metastasis . Brain CSix cycles of methotrexate injection were administered every two weeks. After each cycle, the BhCG level gradually decreased (399–33.9–7.2–2.4–1.2–0.4 mIU/mL). The last BhCG level was 0.2 mIU/mL at five months after delivery and follow-up CT confirmed no evidence of recurrence or metastasis in the chest and abdominopelvic cavity. The preterm baby had respiratory distress syndrome but improved and was discharged with a 2260 gm weight after two months of NICU care.Gestational trophoblastic disease is categorized by putative trophoblastic cells of placental origin; chorionic villous trophoblasts and intermediate trophoblasts . Of themIn the present case, the patient had not been diagnosed with CHMCF before and there was no serum BhCG results due to emergent admission. However, the absence of PIH, HTD, and HG might have contributed to the successful delivery. Placenta accreta was the initial clinical impression when the placental specimen was referred to the pathology department. Distinct vesicular tissues were observed on gross examination by the pathologist, so the hidden molar pregnancy obscured by a normal living fetus could be properly diagnosed. In this pregnancy, the patient was confirmed to be pregnant while living abroad but had entered South Korea during the second trimester due to the COVID-19 pandemic (patient’s delivery date: 9 May 2022). The limitations on hospital visits during the pandemic period of COVID-19 are considered as a possible explanation for the delay in the diagnosis of CHMCF. The significant amount of necrosis might also be another factor that made prenatal diagnosis difficult . MeanwhiAdditionally, the author attempted to compare this case with previous reports of CHMCF with lung metastasis. The Medline database was thoroughly searched using the PubMed retrieval service. The keywords used were “complete hydatidiform mole and surviving coexistent twin”, “complete hydatidiform mole twin metastasis”, “complete mole twin lung”, “complete mole twin pulmonary”, “complete mole fetus lung”, and “complete mole fetus pulmonary”. Among the studies, the cases without English publication were excluded. A total of 20 cases were collected, as those with an unspecified metastasis site and limited clinical information were omitted. Including the presented case, the clinical information from the 21 cases is displayed in In summary, an unexpected twin pregnancy with CHMCF and extrauterine metastasis which were clinically mimicking placenta accreta is reported. Such uncommon cases can be detected by pathological examinations, so it should always be conducted out of caution even for usual specimens. Furthermore, if placenta accreta is suspected, it is worth considering a serum BhCG check when only limited clinical information is available, such as in this case.


Fibrous histiocytomas can be differentiated into malignant fibrous histiocytoma or benign fibrous histiocytoma (BFH) and may involve soft tissue and hard bony tissue. A BFH is a rare group of tumors involving fibrocystic and histiocytic elements. Although BFH after a mosquito bite is rare, it must be a part of the differential diagnosis in unresponsive cases of insect bite reactions. A 57-year-old woman with a history of hypertension arrived at the clinic to discuss an 18-year-old lump in her left leg. The patient described the mass as painless and immobile on the anterior part of the left leg. She stated that it had started with a mosquito bite 18 years ago. The woman visited the clinic after her cat scratched the nodule and the erythema on the anterior area of her leg intensified. Physical examination revealed a 10 × 5 × 5 cm solid, stemmed, non-tender mass with erythema on the left leg. A CT scan revealed a stemmed soft tissue mass with well-defined borders. BFH is one of the common types of histiocytoma that is differentiated based on location, which can be dermis, subcutaneous tissue, and deep soft tissues. BFH is predominantly common in young-to-middle-aged females compared to males. BFH can emerge anywhere on the body. However, the occurrence on the lower extremities is high. This case is presented for its rarity and uncommon site of involvement and the significant clinical presentation and emerging condition following a mosquito bite. A fibrous histiocytoma is a distinctive group of tumors with common fibrocystic and histiocytic elements. Fibrous histiocytoma can be differentiated into malignant fibrous histiocytoma or benign fibrous histiocytoma (BFH) and may involve soft tissue and hard bony tissue .A BFH is a mesenchymal tumor composed of fibroblasts and histiocytes arising in cutaneous and non-cutaneous soft tissues. BFH can grow as a fibrous mass anywhere in the human body, such as the upper or lower extremities, neck, orbit, pelvis, and buccal mucosa . This tuA 57-year-old female with a history of hypertension was bought to the facility for the examination of an 18-year history of a mass in her left leg. The mass was described as painless, pruritic, well-circumscribed, and immobile and was located on the anterior aspect of the left leg. The patient stated that it had started with a mosquito bite 18 years ago. However, the patient visited the clinic when her cat scratched the nodule and the previously present erythema on the anterior part of the leg worsened.Physical examination indicated a firmly stemmed, immovable, well-circumscribed, non-tender mass with erythema on the left leg measuring 10 × 5 × 5 cm. According to the patient, the tumor was initially modest but steadily grew (Figure A computed tomography scan revealed a stemmed soft tissue mass with well-defined borders. Incisional biopsy of the mass done under local anesthesia revealed fibroblast and histiocytic infiltrate with mesenchymal origin. Immunohistochemical staining was positive for factor XIIIa and negative for CD34.An excisional biopsy performed by the surgeon revealed a symmetrical proliferation of histiocytic cells and spindle cells in the dermis on hematoxylin and eosin staining. Excisional biopsy and immunohistochemical studies provided a definitive diagnosis of BFH based on the consistent presence of fibrous tissue containing rounded histiocytes, irregularly arranged spindle cells, and added collagenous and vascular elements of the lesion.BFHs constitute a group of predominantly benign neoplasms, which exhibit fibroblastic and histiocytic features on histopathology . It is oBFHs are characterized by the proliferation of fibroblasts and histiocytes, the presence of foam cells, the absence of cellular atypia, and mitotic changes. Clinically, it can occur as single or multiple well-circumscribed, hyperkeratotic, reddish-brown papules, usually asymptomatic and slow-growing, and measuring 0.5-2.0 cm in diameter. The typical immunohistochemical response pattern of BFH is positive for factor XIIIa and vimentin while negative for CD34, as validated by the spindle tumor cells of BFH in our patient [The histologic variants of this lesion include cellular, epithelioid, aneurysmal, clear cell, lipidized fibrous histiocytoma, which can cause diagnostic difficulty with other benign and malignant tumors, including DFSP, deep fibrous histiocytomas, undifferentiated pleomorphic sarcomas, cutaneous leiomyosarcoma, solitary fibrous tumor, and tenosynovial giant cell tumor . ImmunohThe etiology behind the occurrence of BFH after a mosquito bite is unknown. Although BFH is commonly detected in the lower extremities, it is uncommon to be associated with a mosquito bite; nonetheless, we discovered a BFH s/p mosquito bite case in our literature search . Wide suAlthough the incidence of BFH after a mosquito bite is rare, it can be used as a differential diagnosis in unresponsive cases of insect bite reactions. As these tumors have a wide range of morphology, BFH requires exhaustive histopathological examination and immunohistochemical tests due to their inconclusive baseline investigations. Immunohistochemical staining is extremely useful in differentiating between BFH and DFSP. Complete resection of the lesion is recommended with careful evaluation of the surgical margins. Both benign and malignant fibrous histiocytoma can show local recurrence very rarely and must be treated aggressively.


Primary cardiac tumors are exceptionally rare, with malignant tumor occurrences ranging from 0.0017% to 0.28%. Among these, primary cardiac angiosarcoma (PCA) stands as the most prevalent malignancy, primarily impacting the right cardiac system. In this case report, we present the instance of a 44-year-old woman who recently exhibited acute chest discomfort and was subsequently diagnosed with a microangiosarcoma within the right atrium and superior vena cava. Diagnostic modalities including chest x-rays, CT, MRI, and PET-CT were instrumental in pinpointing the tumor's location and nature. Surgical excision followed by pathological and immunological examinations confirmed the diagnosis. The patient's recovery post-surgery has been encouraging, with successful follow-up chemoradiotherapy administered. Despite advancements, devising optimal strategies for enhancing patient survival and quality of life in angiosarcoma cases remains a pressing research challenge. Primary cardiac tumors are infrequently encountered, with a subset manifesting as malignant tumors at an incidence ranging from 0.0017% to 0.28% . DespiteA 44-year-old woman presented with sudden chest discomfort of unknown origin, prompting a comprehensive medical examination conducted one month prior. This examination revealed the presence of a mass in her right atrium. The patient's chest discomfort occurred without accompanying symptoms such as shortness of breath, coughing, or other pulmonary issues. These symptoms typically subsided after a brief 2-minute rest. Through thorough patient interviews, we established the absence of significant medical history and a lack of familial occurrence of similar medical conditions. Notably, prior to admission, a thorough evaluation had unveiled a substantial pericardial effusion, promptly addressed via pericardiocentesis upon admission. No significant abnormal findings were observed in the cytology of the pericardial fluid. Subsequently, a battery of diagnostic procedures was conducted post-admission, encompassing a chest x-ray, cardiac ultrasound, electrocardiogram, cardiac CT, cardiac MRA, and PET-CT. The patient exhibited a normal electrocardiogram indicative of sinus rhythm. Preoperative echocardiography indicated an enlarged heart shadow, delineating multiple masses of uncertain nature in the right atrium, including a minor pericardial effusion . The car2) for 6 cycles]. During the ensuing six-month follow-up period, the patient exhibited a favorable recovery trajectory devoid of complications, ultimately experiencing a resumption of normal activities without the recurrence of symptoms. The postoperative echocardiography revealed that the right atrial mass was totally resected, no hemodynamic abnormality and no recurrence signals (Following the comprehensive evaluation, immediate surgical resection of the cardiac tumor was performed. A giant mass was observed extent encompassing from the right atrial appendage and the superior vena cava, to the right atrioventricular sulcus, the posterior atrial wall, and approximately 2 cm downward from the inferior vena cava opening . A clust signals ,B.Angiosarcoma, a highly malignant endothelial cell tumor, constitutes 1%–2% of soft tissue tumors. It manifests as an exceptionally aggressive cancer with a bleak prognosis, capable of affecting any anatomical region . NotablyDiagnostic techniques for primary cardiac lesions encompass x-ray, echocardiography, CT, MRI, and PET-CT, with CT and MRI being pivotal for diagnosis . EchocarDue to the rarity of these tumors, optimal management strategies remain under debate. Presently, available treatments encompass surgery, radiation therapy, and chemotherapy. Surgical excision remains the preferred approach for primary malignant cardiac tumors, yielding the best potential for long-term survival and curative outcomes , 20. MedIn conclusion, primary cardiac angiosarcoma, especially within the right atrium, represents an unusual clinical entity. While various imaging modalities aid in diagnosis, treatment strategies for PCA remain elusive, necessitating prompt interventions post-surgical resection. Given the short time follow-up period and rarity of this malignancy, the challenges it poses underscore the imperative of ongoing research to unravel improved diagnostic and therapeutic approaches.


Lumbar disc herniation (LDH) is prevalent among adults aged 25-55 years who spend a considerable proportion of their time sitting or standing with heavy workloads. We report the case of a 33-year-old male waiter with severe LDH, causing compression of the nerve roots and spinal cord with neurological dysfunction, who presented to a chiropractic clinic. Magnetic resonance imaging (MRI) revealed a radiological differential diagnosis comprising LDH and an epidural mass lesion. To rule out serious pathology, a second MRI with contrast was ordered, which confirmed the diagnosis of severe LDH. Diagnosing large LDH may be challenging, and severe disc herniation often mimics spinal tumors. This study offers insights into the differential diagnosis of LDH and spinal tumors, as well as the design of a treatment strategy for severe LDH in the chiropractic clinic. The incidence of sciatica is between 13% and 40%, and the most prevalent cause of sciatica in adults is lumbar disc herniation (LDH) . LDH is The clinical presentation is challenging to distinguish from other causes of lumbar canal stenosis, including disc herniations, synovial cysts, epidural hematomas, and tumors. It is clinically known to be a chronic condition with a high rate of relapse and limited potential for successful outcomes from radical treatments, leading to long-term patient suffering . ConsequA 33-year-old male waiter has been experiencing low back pain for the past month, mostly on his left side. He typically stands for 10 hours at work, and the pain has a pulling sensation that radiates from the left gluteal region, lateral hip, and calf. The onset of pain was insidious and aggravated by prolonged sitting for more than 30 min. Furthermore, he experienced a pulling sensation in his left hip flexor when climbing the stairs. He denied any change in bladder function, sensation in the saddle area, or sexual sensation. The patient had tried traditional Chinese medicine and acupuncture one month ago; however, the pain only worsened as he experienced numbness in his left lateral calf. He was unable to work for over one month. He visited the emergency department one week prior, and the radiology department reported negative findings. He was diagnosed with lumbar sprain/strain where he received a corticosteroid injection and a prescription for hydrocodone-acetaminophen every four to six hours. The patient was subsequently referred to an orthopedic surgeon for surgical treatment. The patient then sought chiropractic therapy for a second opinion of treatment.The patient was a nonsmoker with a history of low back pain that began eight years ago when he was performing 10 kg deadlifts. He went to the emergency room and was prescribed codeine, after which his symptoms disappeared. He is currently taking serotonin and benzodiazepines for insomnia. In the past, he has had no other health complaints, and no record of any other injury, surgery, or trauma.The patient presented with antalgic gait at the chiropractic clinic. Upon examination, orthopedic examinations revealed aggravated pain with lumbar flexion and extension in the passive range of motion. Additionally, the slump test was positive on the left side, and the Kemp test was positive for both the right and left hip. The left straight leg raise was positive at 45°. Muscular palpation revealed tenderness in the left quadratus lumborum, gluteal muscles, and hip flexors. Furthermore, reduced sensation was identified in the left L5 dermatome, and left L4 (knee flexors) strength was graded 4 on a scale of 0-5. Osseous palpation revealed joint restriction at the L4/5 and sacroiliac joints. The differential diagnoses were lumbar disc herniation, synovial cysts, and epidural hematomas. To confirm the diagnosis, a lumbar MRI Figure  was ordeThe chiropractor prescribed a three-week treatment plan consisting of three visits per week. During each visit, the patient underwent spinal manipulation, non-surgical spinal decompression therapy  Figure , and insDiagnosing large LDH may be challenging, and severe disc herniation often mimics spinal tumors -10. ThorThe fundamental challenge in managing patients with lumbar disc disease and neurological dysfunction is to correlate radiological findings with clinical history and symptoms to direct treatment and advice . RadioloChiropractic treatment included spinal manipulation, noninvasive spinal decompression therapy, and scraping therapy (IASTM). In randomized controlled studies for lumbar disc herniation, spinal manipulation was effective in relieving acute low back pain and sciatic symptoms ,20, and Large LDHs can be difficult to diagnose because they frequently mimic spinal tumors. MRI with contrast is particularly helpful when evaluating differential diagnoses. Severe disc herniation with a high T2 signal may heal quickly under conservative treatment, such as chiropractic therapy and lifestyle modifications. If conservative treatment fails, surgery may be necessary to remove the herniated disc and relieve pressure on the spinal nerve roots and spinal cord. Chiropractors should be able to use the diagnostic tools in making the proper management of LDH.


A 53-year-old woman with no medical history was hospitalized with right hypochondriac pain for 3 days. Liver function tests included aspartate aminotransferase of 102 IU/L , alanine aminotransferase of 114 IU/L  and gamma-glutamyl transpeptidase 145 IU/L . Hepatitis virus tests were negative. She denied any history of previous hepatitis and history of recent drug. Ultrasonography showed multiple small hypoechoic lesions 2–10 mm in diameter with multiple cometary tail echoes. Computed tomography (CT) scan of her abdomen shortly thereafter revealed numerous small-sized, low-density lesions in the entire liver parenchyma and no enhancement was observed in these lesions . BecauseMultiple biliary hamartomas (Von Meyenburg complexes) are benign congenital bile duct malformations. These lesions are supposed to arise from failed involuted embryonic bile ducts. Histologically, they are cystic lesions consisting of focal collections of duct structures lined by a single layer of columnar or cuboidal epithelium and submerged in abundant fibrous stroma. In most cases, they are asymptomatic and detected incidentally at imaging, laparotomy or autopsy. Multiple biliary hamartomas have very low incidence ranging from 0.69 to 5.6% in the autopsy series and 0.6% in the needle biopsy seriesation. Although they are usually asymptomatic, a few cases have been reported in association with malignant transformation. They are easily diagnosed on ultrasound when a comet tail is present , 2.On CT, multiple biliary hamartomas appear as multiple hypoattenuating structures less than 10 mm in size and without contrast enhancement. Their differential diagnoses include (i) liver metastasis ; (ii) diffuse primary hepatocellular carcinoma ; (iii) simple hepatic cysts ; (iv) polycystic liver disease ; (v) Caroli disease ; and (vi) hepatic abscesses  .


Among the extensive variety of disorders that can cause acute abdominal pain are hepatocellular adenomas (HCAs), pathological entities that otherwise are asymptomatic. Here, we describe a 33-year-old female who presented in the emergency department with acute abdominal pain and a history of liver focal nodular hyperplasia (FNH) diagnosed 10 years ago. An abdominal magnetic resonance imaging (MRI) revealed that the cause of the pain was an intrahepatic hematoma. The mass was surgically removed, and the biopsy revealed inflammatory adenomas, a subtype of HCA. Hepatic adenoma diagnosis remains challenging by clinical and imaging techniques, and usually, a biopsy is the main diagnostic tool. HCA should be differentiated from hepatocellular carcinoma (HCC), FNH, hepatic angioleiomyoma, and hepatic hemangioma. In our case, HCA was misdiagnosed in the past as FNH. HCA rarely may present as acute right abdomen pain, and a potential catastrophic hemorrhage or rupture must be excluded. With the growing use of various imaging modalities in the diagnosis of abdominal and other symptoms, liver masses represent a relatively frequent finding . Liver mWe report a case report of a 33-year-old female who presented at the emergency department with pain in the right upper quadrant of the abdomen. A mass measuring 19 × 14 cm was found on the right liver lobe.This article was previously presented as a meeting abstract at the 21st European Congress of Internal Medicine and the 12th International Congress of Internal Medicine, Athens, Greece, on March 15-18, 2023.We present a case of a 33-year-old Caucasian female patient with a history of anxiety disorder treated with sertraline 100 mg once daily and liver focal nodular hyperplasia (FNH) diagnosed 10 years ago without follow-up. Additionally, she was diagnosed with polycystic ovary syndrome and received a combined oral contraceptive pill for a small period of time, which she discontinued a few years ago.She presented at the emergency department with 24-hour pain in the right upper quadrant of the abdomen. The pain was getting worse with breathing movements. Initial laboratory analysis showed elevated white blood count (WBC) and abnormal levels of liver enzymes Table .An abdominal CT scan with contrast was performed that revealed a giant heterogeneous hepatic tumor with clear boundary measuring 19 × 14 cm, which completely replaced the right hepatic lobe. The contrast showed patchy enhancement  values within a few days, and the level of hemoglobin (Hb) remains the same. To further diagnose the patient’s condition, magnetic resonance imaging (MRI) was also performed that revealed a giant heterogeneous lesion on the right hepatic lobe with echo sequences of intrahepatic hemorrhagic elements Figure .The patient had CT scan and MRI images from 10 years ago that revealed that the mass was getting bigger. According to the diagnosis 10 years ago, the mass was a liver focal nodular hyperplasia. Based on our imaging manifestations, the tumor was initially considered to be an HCA.At this time, the admission to the surgery room was decided to completely remove the mass, and a right hepatic lobectomy was performed. Perioperative images showed a grayish-yellow tumor with a complete fibrous capsule and varying degrees of hemorrhage and necrosis Figure . PatholoHCA can remain asymptomatic for many years, and the diagnosis of this benign tumor is mainly made by imaging . In our The major risk factors for HCA other than oral contraceptive pills are metabolic syndrome, obesity, alcohol intake, and the use of anabolic steroids, which in our case were absent . EstrogeFour subtypes of HCA exist: (1) HCA inactivated for HNF-1a 30%-40%), (2) inflammatory adenomas 40%-50%), (3) β-catenin-activated HCA (10%-20%), and (4) unclassified HCA (5%-10%). The mass in our case had a concentration of inflammation, thick arteries, and sinusoidal dilatation, the histological features of inflammatory adenomas [0%, (3) β0%-40%, (HCA should be differentiated from hepatocellular carcinoma (HCC), focal nodular hyperplasia (FNH), hepatic angioleiomyoma, and hepatic hemangioma -12. The The management plan of HCA is different between males and females. Recent guidelines suggest surgical resection in all sizes of tumors in males . In femaWe report a case of a giant HCA in a young female that presented as acute abdominal pain due to spontaneous intrahepatic hematoma. HCA is a rare benign tumor that may present as acute right abdominal pain, and a potential catastrophic hemorrhage or rupture must be excluded. Hepatic adenoma diagnosis remains challenging by clinical and imaging techniques, and usually, a biopsy is the main diagnostic tool. In our case, CT scan and MRI images were essential for the diagnosis of HCA. Special attention must be given to patients with a history of a benign liver mass and oral contraceptive pill use.


The application of robot-assisted thoracoscopy to cardiac surgery affords an opportunity to leverage the exceptional intraoperative exposure, visualization, and dexterity of the robotic platform. Here, we report the case of a 72-year-old woman who presented to our institution for evaluation of a left ventricular mass that was identified following workup for an embolic event. We present an intraoperative video that provides technical details of the robot-assisted resection of the lesion, which was found to be a left ventricular papillary fibroelastoma arising from the mitral chordal apparatus. This case highlights the advantages provided by the robotic platform, which permitted complete, minimally invasive surgical excision of the lesion while minimizing the burden of surgical trauma.  Although resection of these lesions has traditionally been achieved via median sternotomy, minimally invasive approaches offer the opportunity to achieve complete excision while minimizing the burden of surgical trauma. We describe a robot-assisted approach for resection of a left ventricular papillary fibroelastoma arising from the mitral chordal apparatus and provide an intraoperative video demonstrating technical details of the operation.Papillary fibroelastomas are benign proliferative lesions arising from the endocardial surface, most commonly in the left-sided chambers.The patient was a 72-year-old woman who presented as a transfer to our institution following central retinal artery occlusion with acute unilateral vision loss. Her medical history was notable for hypertension, hyperlipidemia, and tobacco use disorder (current smoker with 52-pack-year history). Diagnostic workup at the outside facility included a transesophageal echocardiogram that demonstrated a left ventricular ejection fraction of 55% to 60%, an 8 mm mobile mass in the left ventricle , and a cAfter induction of general anesthetic and placement of a double-lumen endotracheal tube, the patient was positioned in a similar fashion as for a robot-assisted mitral valve repair, with the right side slightly elevated. The right common femoral artery and vein were dissected and prepared for peripheral cannulation , and systemic heparin was administered.A limited anterior right thoracotomy was made with a 5 cm incision in the fourth intercostal space above the nipple-areolar complex without rib spreading . Additional 8 mm trocar sites were placed 2 intercostal spaces superior (working port), 2 intercostal spaces inferior (working port), and just anterior and inferior  to the minithoracotomy. After creation of a pericardial well, placement of an aortic root vent, docking the robot , and initiation of cardiopulmonary bypass, the aorta was cross-clamped via a right lateral chest wall incision. The left atrium was approached via Sondergaard’s groove. A robotic atrial retractor was used to expose the mitral valve. The mass was easily identified in the left ventricle and was found to be arising from the mitral chordal apparatus. The mass was resected in its entirety with limited en bloc resection of its insertion on the chord. The valve was tested and was found to be competent with no regurgitation. The left atriotomy was closed, the heart de-aired, and separation from cardiopulmonary bypass achieved. Postoperative echocardiography demonstrated preserved left ventricular ejection fraction without any evidence of mitral regurgitation. Cardiopulmonary bypass and aortic cross-clamp times were 106 and 52 min, respectively.The patient’s postoperative recovery was uneventful, and she was discharged home in good condition on the fourth postoperative day. Pathologic examination of the resected mass was consistent with a papillary fibroelastoma –d. Histopathologically, they are characterized by a matrix consisting of a variable distribution of subendocardial elastin fibers. Clinically, they may be identified upon echocardiographic workup for an embolic event but may also be identified incidentally in an asymptomatic patient or upon autopsy following sudden death.3 In cases in which echocardiographic findings are indeterminate, cardiac magnetic resonance imaging has been reported to be helpful in distinguishing intracardiac tumor from thrombus. Given the risk of thromboembolism, particularly for mobile lesions, surgical resection is recommended in medically operable patients. Excision is curative and recurrence is rare.Papillary fibroelastomas are pedunculated, frond-like lesions rising from the endocardial surface. They usually arise from a left-sided location and, when associated with a valve , generally arise directly from the valvular surface.6 have previously reported successful less invasive and/or thoracoscopic-assisted excision of papillary fibroelastomas and there is a single previous report of robot-assisted resection, these lesions have traditionally been approached via median sternotomy.4 The present report and its accompanying video highlight the utility of the robotic platform to facilitate minimally invasive approaches to lesions arising from the mitral subvalvular apparatus while maintaining excellent exposure, visualization, and dexterity in the surgical field.Although other groupsIn summary, the case and intraoperative video presented here of a resection of a papillary fibroelastoma arising from an uncommon location highlight the technical advantages of a surgical approach leveraging the robotic platform. In light of the benefits afforded by the robotic platform, we feel that minimally invasive approaches to resection of these uncommon lesions should be considered whenever surgeon and institutional experience allow.


Epidermoid cysts represent roughly 1% of all intracranial tumors. They are frequently located in the cerebellopontine angle but rarely extend to the supratentorial brain. Epilepsy is an extremely uncommon manifestation of this neoplasm. We suggest the surgical management of a 35-year-old male who presented with a six-month history of intractable temporal lobe epilepsy. His seizures were characterized by a focal onset in the form of déjà vu experiences, followed by a secondarily generalized tonic-clonic seizure. Imaging revealed a heterogeneous cystic mass in the right cerebellopontine angle, extending supratentorially causing a mass effect on the mesial temporal region. Gross total resection was achieved through a combined subtemporal-retrosigmoid approach. Histopathology revealed an epidermoid cyst. The patient was entirely seizure-free at the three-month follow-up. Epidermoid cysts may present with epileptic seizures. Seizure freedom can be achieved with surgical management in most cases. The patient’s symptoms, imaging findings, and epileptogenic focus must be considered to select the appropriate surgical strategy. Intracranial epidermoid cysts are rare, benign, and slow-growing lesions, representing 0.3-1.8% of all intracranial tumors . HoweverEpilepsy, however, is an extremely uncommon manifestation rarely reported in the literature. Gross total resection of the cyst along with its capsule should be attempted. However, these tumors may be strongly attached to the brain parenchyma, rendering complete resection difficult. We here present the rare case of epidermoid cyst-related drug-refractory temporal lobe epilepsy in a male patient and provide an overview of all reports of epilepsy secondary to epidermoid cysts found in the literature ,8.A 35-year-old man was referred after a neurological consultation to our neurosurgical department with a six-month history of drug-refractory epilepsy. He had a long history of substance abuse. His past medical history was otherwise uneventful. The patient’s seizures were characterized by déjà vu experiences and feelings of fear, suggestive of focal temporal lobe epilepsy. Seizures occurred one to two times per month. After focal onset, the seizure was secondarily generalized into a bilateral tonic-clonic seizure with three to four minutes in length. The postictal phase was typically characterized by a 30-min episode of prosopagnosia and disorientation to time and place. The patient further complained about occasional diffuse headaches within the last six months. He had no focal neurological deficits and achieved the maximum score of 30 in the mini-mental state status (MMSS).In our department, the patient underwent a computer tomography (CT) showing a hypointense well-delimited cystic mass in the right CP angle Figure .The cystic content appeared heterogeneous in MRI. The mass measured roughly 6 x 2 x 5 cm and extended supratentorially compressing the right-sided mesial temporal region. It occupied the right CP and interpeduncular cisterns as well as the entire prepontine cistern, extending into the foramen magnum. The basilar artery was displaced contralaterally. A sleep-deprived electroencephalogram (EEG) showed epileptiform activity in the frontal and temporal regions (Figure We hypothesized the patient’s epilepsy to originate from the mass effect of the cystic lesion and decided to perform a microsurgical resection with intracranial EEG, through a combined subtemporal-retrosigmoid approach, to expose the whole lesion. We started with the retrosigmoid craniotomy to visualize the most caudal part of the mass. We drained cerebrospinal fluid from the cisterna magna to achieve cerebellar relaxation and to access the CP angle. The cyst wall ruptured when trying to prepare a resection plane, releasing yellowish-crystalline fluid. We immediately aspirated the intracapsular content and could significantly debulk the infratentorial part of the lesion. We then irrigated copiously to aspirate any remaining cyst content from the prepontine cistern. As the cyst capsule was adherent, particularly to cranial nerves six, seven, and eight, thorough visualization of the lower cranial nerves was paramount before meticulous sharp dissection of the capsule residuals. We then moved on to the temporal craniotomy. Dural opening was performed with a T-shaped durotomy. The temporal lobe was retracted to visualize the optico-carotid and suprachiasmatic cisterns as well as the interpeduncular and quadrigeminal cisterns. The remaining cystic content was aspirated and the residual capsule was sharply dissected off the third and fourth cranial nerves. The mesial temporal cortex had been fully decompressed after successful debulking of the mass. Radical detachment of the capsule from the cortical surface was thus not attempted. The surgery was completed with no major blood loss and the postoperative course was uneventful. Histopathological examination confirmed the diagnosis of epidermoid cyst Figure .The patient was discharged in good condition one-week post-surgery, after surgical mobilization and rehabilitation. In the follow-up MRI at three months post-surgery, no evidence of growth of the capsular remnant was seen Figure . The patTemporal lobe epilepsy secondary to epidermoid cysts is a rare and poorly understood phenomenon. Data are scarce, and there is no guideline on which surgical strategy to opt for. However, previous case reports have shown seizure-free after radical surgical management of these lesions Table  1,10-15-1510-15.Gross total resection should be attempted whenever possible. The appropriate treatment, however, whether lesionectomy alone or lobectomy or amygdalohippocampectomy, must be chosen for every individual patient. Trindade et al. reported the case of a 59-year-old man suffering from a giant epidermoid cyst, presenting with bad smell sensations followed by tonic-clonic convulsions. Their patient remained seizure-free at a one-year follow-up post-lesionectomy . Wong etTemporal lobe epilepsy is a rare manifestation of epidermoid cysts. No treatment guidelines exist, but surgical management can lead to seizure freedom in most cases. The clinical presentation, imaging studies, and the epileptogenic focus can guide the selection of the appropriate surgical strategy in the individual patient.


A full-term newborn female presented with non-bilious emesis immediately after feeding and abdominal distension on day one of life with neither palpable abdominal mass nor electrolyte derangements. The baby was initially admitted to rule out gastrointestinal obstruction versus sepsis as a cause of vomiting and abdominal distension. Initial imaging studies involving an upper gastrointestinal (GI) series showed obstruction at the level of the duodenum, but it was only during surgical exploration that the diagnosis of infantile hypertrophic pyloric stenosis was made. This case report highlights the atypical presentation of pyloric stenosis and the need to investigate cases of vomiting immediately after feeding in a newborn with ultrasonography at the least to minimize complications. Vomiting in neonates can result from a wide range of causes, including surgical as well as nonsurgical, such as sepsis, metabolic derangements, infectious causes, and obstructions within the gastrointestinal (GI) tract. Pyloric stenosis typically presents with postprandial projectile, non-bilious vomiting, hypokalemic and hypochloremic metabolic alkalosis, dehydration, and weight loss . We presThe patient was a full-term female born at 37+0 weeks of gestation via elective C-section to a 41-year-old mother para 1001. The pregnancy had been complicated by advanced maternal age, obesity, and chronic hypertension. However, the delivery had been uncomplicated and the baby had been sent to the newborn nursery for routine care. The baby’s birth weight was 3140 g and she had a normal physical exam and stable vital signs. At six hours of life, the baby was noted to have non-bloody, non-bilious emesis, and the subsequent exam was significant for abdominal distension. An orogastric catheter was inserted with the aspiration of milk and air, resulting in mild improvement in distension. On further exam, normal bowel sounds were heard in all quadrants and there was no palpable mass. The baby was admitted to the NICU due to the suspicion of early-onset sepsis as a likely cause of this vomiting and abdominal distention. CBC and electrolytes were unremarkable. Empiric antibiotics were started pending blood culture results. The baby passed urine and stool within 24 hours of life. Abdominal X-ray on admission showed a normal gas pattern with no other obvious abnormalities . A pyloric mass, which is described as olive-shaped, can be palpated in the right upper quadrant and gastric peristaltic waves are often visible just prior to vomiting. When symptoms are prolonged, vomiting may result in hypokalemic and hypochloremic metabolic alkalosis . Also, oConventionally, the modality of choice for the diagnosis of pyloric stenosis is an abdominal ultrasound, which shows pyloric length >18 mm or pyloric muscle thickness >4 mm . A sonogThis case report highlights the need for a higher index of suspicion for pyloric stenosis despite the absence of “typical risk factors.” Our objective was to emphasize the need to consider pyloric stenosis as a possible differential when encountering infants with vomiting in the first two weeks of life. There should be a low threshold for using ultrasound in such cases as it is the diagnostic method of choice and is a cheap, readily available imaging option with no radiation exposure.


Spinal synovial cysts are rare entities for which standard surgical strategies are inconsistent. Here, we present an uncommon intraspinal gas-containing synovial cyst treated by percutaneous transforaminal endoscopic cystectomy. A 52-year-old man presented with radicular pain and intermittent claudication that had persisted for one month. Computed tomography revealed an intraspinal cystic lesion anteromedial to the left L4-L5 articular joint and the center of the lesion manifested gas contents. A transforaminal endoscopic procedure was performed and confirmed as a safe and minimally invasive technique for gas-containing lumbar synovial cysts. It provides a valuable substitution and supplementation to open surgery. The underlying formative mechanisms of synovial cysts include spinal instability, degenerative spondylolisthesis, and facet joint arthritis . Most sySynovial cysts containing gas are even rarer in the clinic. To our knowledge, only 9 cases of gas-containing lumbar synovial cysts have been reported in the English literature thus far, most of which have been treated by open cystectomy –12. Here2A 52-year-old man referred to our department for radicular pain and intermittent claudication that had persisted for one month. The onset of the pain was insidious, and the patient denied a history of trauma. The pain radiated from the left hip to the posterolateral aspect of the left leg and ankle. The pain was exacerbated by walking, whereas it could be immediately relieved by bed rest or sitting down. The patient tried anti-inflammatory medications but the effect was unsatisfying.On physical examination, flexion, extension, and lateral bending of the lumbar spine were not restricted. Mild L4-L5 interspinous tenderness was detected, and hypoesthesia was present over the left L5 nerve dermatome. Full muscle strength was recorded for the lower extremities, and both knee and ankle reflexes were symmetrical and active. Straight leg raising tests revealed negative results. Computed tomography (CT) found an intraspinal cystic lesion adjacent to the ligamentum flavum, anteromedial to the left L4-L5 articular joint, bulging to the lateral aspect of the canal, and leading to lateral recess stenosis . RemarkaA transforaminal endoscopic procedure with local anesthesia was planned. After partial facetectomy with an endoscopic trephine, a cyst with a fistula connecting to the resected facet joint appeared in the endoscope field . Bubbles3A more common intraspinal gas-containing lesion is the disc herniation or discal cyst, both of which are characterized by predominant disc degeneration and vacuum phenomenon of the disc. The lesion is usually connected to the annulus fibrosus and impinges on the dura sac or the nerve root from the ventral side. On the contrary, as showed in our patient, an intraspinal gas-containing synovial cyst generally manifests minimal degeneration of the disc but obvious arthritis and vacuum clefts of the facet joints. The neural structures commonly suffer from compression at the dorsolateral direction. Intraspinal synovial cyst should also be distinguished from neurogenic tumor, such as cystic schwannoma. An enhanced MRI is helpful in differentiation since the cystic schwannoma typically shows ring enhancement while no enhancement is seen for the synovial cyst. Moreover, the gas-containing feature strongly indicates a degenerative, rather than a neoplastic lesion. Thereafter, the patient was not required for an additional enhanced MRI preoperatively.To our knowledge, only 9 cases of gas-containing spinal synovial cysts have been previously published in the English literature. The key characteristics of the previously published 9 cases and this present case are presented in Cystectomy, whether by open or endoscopic procedure, achieved satisfactory clinical results for patients resistant to conservative therapies. Percutaneous endoscopic technique provides a novel avenue for surgical intervention. A recent case series preliminarily elucidated the feasibility and effectiveness of this technique in the treatment of lumbar synovial cysts , 16. Comen bloc, piecemeal resection of the cyst in the endoscopic surgery gets only tiny shreds, most of which is washed away by flushing saline. Thereafter, the sample for pathology was not deliberately collected. Emphasis shall be given for the importance of the definitive pathological diagnosis in future.In this case, we facilitated the cystectomy by the transforaminal approach and an additional facetectomy to directly target the lesion. Considering the close relationship between the cyst and the degenerative facet joint, limited removal of the adjacent ipsilateral facet joint and accessories may help reduce the risk of recurrence whilst preserving segmental stability. The water medium makes the gas-containing lesion more distinguishable and easier to identify since the gas in the cyst will be expelled when the cyst is cut open under monitoring. One of the limitations focuses on the concerns of segmental stability, which warrants long-term follow-up. Another limitation is that unlike open surgery, in which the specimen can be obtained In conclusion, percutaneous endoscopic cystectomy is a safe and minimally invasive technique for gas-containing lumbar synovial cysts. It provides a valuable substitution and supplementation to open surgery. Long-term follow-up is warranted for evaluation of segmental stability and recurrence.