An elderly gentleman presented with bilateral pulmonary nodules found incidentally during the workup of acute pancreatitis. He did not have any respiratory or urogenital symptoms. A biopsy of the lung nodule revealed myxoid mesenchymal neoplasm of extraosseous origin. As the patient was asymptomatic, only the increased uptake in the penile shaft base on the whole-body PET-CT study yielded a diagnosis of primary penile chondrosarcoma after biopsy. A rare presentation of chondrosarcoma in an elderly gentleman highlighting the importance of obtaining a histopathological specimen, as the prognosis of metastatic diseases is widely variable. They originate from the hyaline cartilage differentiation and commonly affect middle age groups of equal gender distribution patients . 10–15 %2An 80-year-old man has presented with acute pancreatitis secondary to biliary stones. He did not have any shortness of breath, cough, or chest pain; he also denied fever and change in appetite or weight. Physical examination was remarkable for abdominal tenderness, which has resolved gradually in response to the supportive management. Except for raised Pancreatic enzymes, his laboratory investigations were unremarkable . Chest XThe lung nodule's CT-guided biopsy confirmed a myxoid mesenchymal neoplasm and showing tumoral proliferation of spindle to stellate-shaped cells forming anastomosing cords and lobules within the myxoid stroma A. Viment3Pulmonary metastases are seen in 20–54 % of extrathoracic malignancies and are the second most frequent site of metastases from other organs . The hemNot exclusively malignant, bilateral pulmonary nodules can be from benign etiologies like granulomas, chondromas, hamartomas, intrapulmonary lymph nodes, fibrosis, and inflammatory nodules .Penile tumors are commonly either metastatic disease or squamous cell carcinomas; however, after an extensive review of the literature, one young patient with primary high-grade penile chondrosarcoma was reported by Alhubaishy et al. after presenting with a painless mass .Herein we report a patient with primary penile chondrosarcoma diagnosed after presenting with incidental finding of multiple lung metastases in the elderly population. A finding that ideally triggers a series of radiological and histopathological workups essential to diagnose, identify the primary source, and subsequently plan the treatment.The presence of an old radiograph with similar findings reassured the medical team about the tumor's slow-growing nature. A whole-body PET CT scan was deemed necessary to identify the metastases' source after the nodule's biopsy results showing myxoid mesenchymal neoplasm. After the MRI pelvis confirming the penile shaft base tumor, a biopsy revealed myxoid sarcoma compatible with extraskeletal chondrosarcoma.Data are scarce about the best diagnostic and treatment approach for such patients, given its rarity. According to the European Reference Network for rare adult solid cancers (EUROCAN), all pelvic chondrosarcomas should be treated by excision with wide margins followed by chemotherapy, particularly those who are dedifferentiated and high-grade . After m4A high index of suspicion should always be maintained during the investigation of multiple pulmonary nodules. Patients sometimes have an atypical presentation with incidental findings during the workup of other clinical conditions. In Our patient, the biopsy was a game-changer as their results led to a more comprehensive workup approach and, eventually, favorable results despite the patient's advanced age. This is the first case of penile extraskeletal chondrosarcoma presenting with metastatic slow-growing pulmonary nodules.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Colonic lipomas are benign tumors of adipose tissue that are often asymptomatic, but they may present with rectal bleeding or obstructive symptoms. These tumors are unique in that they are rarely encountered within the gastrointestinal system and can mimic malignant tumors in appearance. Surgical resection and endoscopic removal of tumors have been shown to be successful in their management.In this report, we present 3 cases of colonic lipomas, 2 of which are located in the cecum and the other within the sigmoid colon. The presenting symptoms of the patients included abdominal pain, constipation, and dyspepsia.Patients typically presented with anemia and an elevated C-reactive protein count. Colonoscopic and computerized tomography findings were used for diagnosis.Hemicolectomy was performed, depending on the localization, and the pathologic specimens were consistent with lipoma.Surgical resection was curative in all patients. The postoperative period was uneventful in all patients and all patients are symptom-free and alive at 3 years follow-up.Colonic lipomas are benign mesenchymal tumors of the gastrointestinal system with a male predominance and are observed within the fourth to sixth decades of life. Various genetic abnormalities have been reported and they have been linked to the formation of intussusception. The squeeze sign on radiological imaging, cushion sign and tenting sign in colonoscopy, and naked fat sign during pathologic examination is helpful towards reaching a diagnosis. Surgical resection is the treatment of choice but minimally invasive endoscopic approaches have also been shown to be successful. Lipomas are often discovered incidentally and patients become symptomatic when the tumor causes obstruction, leading to abdominal pain, and becomes eroded, leading to bleeding within the bowel.Lipomas are benign mesenchymal tumors of the subcutaneous tissue composed of adipose tissue encapsulated by a fibrous layer. A solid component within the mass should raise a concern for the diagnosis of a possible liposarcoma, which is the main disease to be considered in the differential diagnosis. Benign polyps such as an adenoma or malignant lesions such as an adenocarcinoma should also be included in the differential diagnosis.Since lipomas are entirely composed of fat density without any solid component, their radiographic features make them easy to diagnose on imaging modalities such as computerized tomography (CT) and magnetic resonance imaging (MRI). Increased signal intensity on T1- and T2-weighted MRI imaging and low signal intensity on fat-suppressed T2-weighted imaging are supporting evidence towards the diagnosis of a lipoma. In this case series, we present 3 patients with symptomatic colonic lipomas and discuss the relevant literature.Treatment of lipomas is often unnecessary and is usually reserved for symptomatic cases. Various surgical resection procedures are available and recently endoscopic removal has also been shown to be effective.2The colonic resection specimens were fixated in formalin. The specimens were prepared for histopathological examination with the standard paraffin technique and routine hematoxylin & eosin staining. CDK4  was used as the primary antibody in the immunohistochemical study. Ethical approval was not obtained since this study involved case reports. Informed consent was obtained from the patients for publication of the case details and accompanying images.33.1A 54-year-old male patient presented to the outpatient clinic with a 1-year-long duration of abdominal pain in the right lower quadrant. Past medical history was remarkable for chronic anal fissure and hepatosteatosis and the past surgical history included laparoscopic cholecystectomy. The laboratory parameters were normal except for a low white blood cell count (4100/μL), low hemoglobin (11.8 g/dL), low platelet count , and an elevated C-reactive protein 102.2 mg/L). Further work-up of the patient included a CT that showed a non-obstructive mass within the cecum and colonoscopic examination which revealed a lipomatous lesion located on the ileocecal valve  and a high C-reactive protein (25 mg/L). The CT showed a lipomatous non-obstructive 4 × 3 cm mass within the sigmoid colon leading to a nearly 10 cm colocolic intussusception  and an elevated C-reactive protein 71.5 mg/L). A non-obstructive 4 × 2.5 × 1.5 cm mass was located in the cecum and a right hemicolectomy was performed. The pathological report was consistent with a lipoma (Fig.  mg/L. A In all of the cases, lesions were located in the submucosal region composed of mature lipocytes. Necrosis and atypia were not observed in any of the cases. In the immunohistochemical study performed with CDK4, no staining was detected in tumor cells.4 The exact pathophysiology of subcutaneous lipoma formation is still not known. However, theories showing a link between soft tissue trauma and lipoma formation, either through the formation of pseudolipomas by prolapsing adipose tissue or through preadipocyte proliferation by cytokine release, have been previously described.,8Lipomas are the most common benign mesenchymal tumors that are observed anywhere in the body and are rarely encountered within the gastrointestinal system. They have a higher tendency to occur in men and usually arise between the fourth and sixth decades of life. They are also known to be associated with several genetic disorders such as multiple hereditary lipomatosis, adiposis dolorosa, Gardner syndrome, and Cowden syndrome.,10 It is essential to differentiate lipomas from liposarcomas, as the latter poses a threat to life, and this is accomplished by the amplification of the murine double minute-2 gene observed within the malignant liposarcoma.Several genetic abnormalities have been identified in the formation of lipomas. These include mutations in chromosome 12q13-15, deletions of 13q, and rearrangements of 6p21-33.–15 Intussusception due to a colonic lipoma usually occurs between ages 40 and 70, observed in lesions >4 cm in diameter, and it is more frequently encountered in women.,13 Their treatment usually involves surgical resection.When lipomas become symptomatic, they often bleed or lead to obstruction. In some cases, it may lead to constipation. As observed in the 3 cases presented earlier, abdominal pain is a commonly encountered clinical finding. A common complication of colonic lipomas is that they may lead to colocolic intussusception, as it is widely reported in the literature.,17 The cushion sign, or the pillow sign, occurs when pressing the forceps on the lipomatous tumor leads to pillowing. The tenting sign occurs when grabbing a pulling a part of the tumor leads to a tent-like appearance. Finally, the naked fat sign is the finding of mature fat cells in the biopsy specimen of the lipomatous tumor.Various diagnostic features aid in diagnosing colonic lipoma. A radiological pathognomonic sign of a colonic lipoma is the squeeze sign, in which a radiolucent filling defect with visible margins is shown to change size and shape due to peristaltic activity when administering barium enema.,19 Hemicolectomy, segmental colonic resection, or local excision are the options of choice for surgical resection. An intraoperative frozen section is usually needed to ensure negative surgical margins and limit the excision of the tumor to a confined area, which can then eliminate the need for a more radical procedure such as hemicolectomy. Endoscopic submucosal resection is another treatment modality that is usually recommended for pedunculated lipomas or lipomas with a diameter <2 cm.,21 The endoscopic submucosal resection method allows for a complete en bloc resection, however, it takes longer to perform and is associated with higher rates of bleeding and perforation. Although Katsinelos et al support the idea that endoscopic removal of lipomas >2 cm in diameter is associated with colonic perforation and hemorrhage due to fatty tissue being an inefficient conductor for electric current, advances in endoscopic techniques led to the use of endoscopic resection even in tumors larger than 2 cm. Other possible surgical techniques include the unroofing technique that was first described by Mimura et al and endoscopic ligation of the base of an elevated lipomatous lesion, so-called the endoloop technique, which was described by Hachisu. An advantage of the endoloop technique is that electrocautery is not needed, which eliminates the risk of perforation or hemorrhage. Endoscopic unroofing is another treatment modality, however, this may leave residual tissue that may require additional resection.,27 Only the upper half of the tumor is cut open with the unroofing technique and the lipomatous lesion is propelled outwards towards the opening, which then results in a scarred mucosa.,28 Complete removal of the tumor, either surgical or endoscopic, shows favorable outcomes with no known recurrence.Surgery is the basis of therapy for colonic lipomas, and important advancements in endoscopic approach have emerged. Surgical resection is the treatment of choice for sessile lipomas, lipomas with a diameter >4 cm, lesions with an unclear preoperative diagnosis, lipomas with limited peduncles, giant lipoma leading to intussusception or obstruction, presence of serosa or muscularis propria extending into the pedicle, and failure to perform endoscopic resection.5Colonic lipomas are benign mesenchymal tumors that are often diagnosed incidentally. Most lesions are small and asymptomatic, however, larger lesions may lead to bleeding or cause obstructive symptoms such as abdominal pain. Various diagnostic modalities such as CT or MRI can be used in diagnosis. Resection of the tumor, either surgical or endoscopic, is the treatment of choice and result in a good prognosis if the tumor is removed completely.Conceptualization: Ergin Erginoz, Server Sezgin Uludag, Mehmet Faik Ozcelik.Data curation: Ergin Erginoz.Formal analysis: Kagan Zengin.Investigation: Kagan Zengin.Methodology: Server Sezgin Uludag, Gokce Hande Cavus.Project administration: Server Sezgin Uludag.Resources: Ergin Erginoz.Supervision: Kagan Zengin, Mehmet Faik Ozcelik.Validation: Gokce Hande Cavus.Visualization: Ergin Erginoz, Server Sezgin Uludag, Gokce Hande Cavus, Mehmet Faik Ozcelik.Writing – original draft: Ergin Erginoz, Gokce Hande Cavus.Writing – review & editing: Ergin Erginoz, Gokce Hande Cavus.


Gliosarcoma is a rare malignant brain tumor, characterized by a biphasic tissue pattern with alternating areas displaying glial and mesenchymal differentiation. We first report a case of temporo-mesial gliosarcoma, extended to the crural and ambient cisterns, with direct involvement of the ipsilateral third cranial nerve and encasement of anterior choroidal, posterior communicant and posterior cerebral arteries, presenting without symptoms of peripheral neuropathy. A 61-year-old woman with 1-month history of intense bilateral frontal-temporal headache resistant to pharmacological therapy and paresis of the left lower midface underwent surgical resection, through pterional trans-sylvian approach, of a right temporo-mesial gliosarcoma which directly involved the ipsilateral oculomotor nerve. Reported cases of gliomas with direct involvement of a cranial nerve, from the third to the twelfth, are very rare, whit no cases of gliosarcoma described. Because of its rarity, sometimes this entity is not considered as diagnostic hypothesis and is misdiagnosed, both during preoperative diagnostic evaluation and during the surgery. Gliosarcoma is a strong challenge for neurosurgeons and neurooncologists because of low incidence, poor prognosis and limited reported cases on literature. This case shows unique features for localization, pattern of growth and clinical presentation. Gliosarcoma, a variant of IDH-wildtype glioblastoma, is a rare malignant brain tumor , characterized by a biphasic tissue pattern with alternating areas displaying glial and mesenchymal differentiation A 61-year-old woman with 1-month history of intense bilateral frontal-temporal headache resistant to pharmacological therapy and paresis of the left lower midface was observed. The brain computed tomography  showed aThe neurologic examination at admission showed static signs of central paresis of the seventh cranial nerve on the left side while no deficit of the third cranial nerve involved by the lesion was evident after accurate clinical exploration.The patient underwent right pterional trans-sylvian approach. Firstly, the surgical removal was addressed to the tumoral component involving the temporal pole, which appeared as a soft, greyish-pink mass, with central necrotic yellowish area, moderately vascularized; then, once sylvian fissure was opened, the neoplastic component involving the medial part of the temporal lobe and extending to the ambiens and crural cisterns was exposed: it appeared as a firm greyish mass with a small yellowish central core. This last component was strongly adherent to the cisternal part of third cranial nerve and encompassed the anterior choroidal, the posterior communicant and the posterior cerebral arteries, thus the complete resection was not possible.Postoperative course was characterized by transient right ptosis and mydriasis, which disappeared on the POD 3, and by improvement of the central paresis signs of contralateral midface. Post-contrast brain MRI performed 48 hours after surgical procedure showed a satisfactory tumor removal, with a small residual area of contrast enhancement.The histological and immunohistochemical studies  reportedAt discharge, the patient was addressed to the oncological team for the Stupp protocol administration.No progression-disease was detected on brain MRI with contrast performed 3 months after surgery.Reported cases of gliomas with direct involvement of a cranial nerve, from the third to the twelfth, were very rare Because of the small number of cases reported in the literature due to the low incidence of GBM with direct cranial nerve involvement and no cases of gliosarcoma, sometimes this kind of lesion is not considered and is misdiagnosed, both during preoperative diagnostic evaluation and during the surgery, hypothesizing the tumor origin from the nerve with secondary extension to the near brain parenchyma, or from heterotopic neuroglial cell dissemination from leptomeningeal gliomas or gliomatosis Concerning the macroscopic features, based on sarcomatous component amount, gliosarcoma with high connective tissue percentage have the appearance of a firm, well-circumscribed mass, which can be mistaken for a metastasis or, when attached to the dura, for a meningioma, whereas lesions less rich in connective tissue may have features more similar to a glioblastoma. Concerning imaging features, gliosarcoma usually presents as a well-demarcated solid mass, often on peripheral location, with heterogeneous enhancement, moderate or marked surrounding edema and abutting dura , but witThe pattern of growth shows a rate of extracranial metastases upon 11% for gliosarcoma Glioblastoma and gliosarcoma are similar in terms of clinical behavior, treatment and prognosis Gliosarcoma is a strong challenge for neurosurgeons and neurooncologists because of its low incidence, poor prognosis and limited reported cases on literature. This case shows unique features for localization, pattern of growth and clinical presentation.Informed consent was obtained from the patient involved in this case.


To evaluate gadoxetic acid-enhanced liver MRI (EOB-MRI) versus contrast-enhanced computed tomography (CECT) for preoperative detection of liver metastasis (LM) and reduction of open-close laparotomies for pancreatic ductal adenocarcinoma (PDAC).Sixty-six patients with PDAC had undergone preoperative EOB-MRI and CECT. LM detection by EOB-MRI and CECT and their impact on surgical planning, open-close laparotomies were compared by clinical and radiology reports and retrospective analysis of imaging by two blinded independent readers. Histopathology or imaging follow-up was the reference standard. Statistical analysis was performed at patient and lesion levels with two-sided McNemar tests.p = 0.009), comparable specificity  for LM detection. An incremental 7.6% of patients were excluded from surgery with a potential reduction of up to 13.6% in futile open-close laparotomies due to LM detected on EOB-MRI only.EOB-MRI showed higher sensitivity versus CECT (71.7% [62.1-80.0] vs. 34% [25.0-43.8]; Preoperative EOB-MRI has superior diagnostic performance in detecting LM from PDAC. This better informs surgical eligibility with potential reduction of futile open-close laparotomies from attempted curative intent pancreatic cancer surgery.The online version contains supplementary material available at 10.1186/s40644-021-00416-4. Gadoxetic acid-enhanced liver MRI has superior diagnostic performance to CT for detection of liver metastases from pancreatic carcinoma.Gadoxetic acid-enhanced liver MRI provides incremental value for preoperative staging and surgical resection eligibility of pancreatic carcinoma.Inclusion of gadoxetic acid-enhanced liver MRI can reduce the incidence of failed curative intent pancreatic cancer surgeries (open-close laparotomies).Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis with an overall 5-year survival rate of approximately 8% (range 3-32% depending on the stage) . GeneralGadoxetic acid (Gd-EOB-DTPA) is a hepatobiliary MRI contrast agent  with both extracellular and liver-specific properties. Its uptake by hepatocytes and biliary excretion enhances the contrast between the liver parenchyma and hepatic lesions, thereby improving liver lesion detection . Some stThis study aimed to compare the diagnostic performance of EOB-MRI versus CECT in the preoperative detection of LM in patients being considered for curative-intent PDAC surgery and its impact on surgical planning and reduction of futile (open-close) laparotomies.This was a single-institution HIPAA compliant, retrospective study with research ethics board approval and patient consent waiver. All consecutive patients with PDAC who had undergone preoperative CECT and EOB-MRI as per institutional standard of care from January 2018 to October 2019 were included. Those with incomplete or unavailable clinical, imaging or surgical data were excluded. Patient demographic characteristics (age and sex), pancreatic tumor location, tumor histopathology, carbohydrate antigen 19-9 [CA19-9], intraoperative observations, surveillance imaging and clinical outcomes were collected from the institutional electronic patient record (EPR) system. One hundred twenty-one patients with PDAC were referred to our institution for pancreatic cancer management during the study period. Seven patients were excluded due to lack of preoperative imaging and forty-eight patients because of unavailability of EOB-MRI. The final study cohort comprised of 66 patients with PDAC  who had undergone both preoperative CECT and EOB-MRI.  using arterial and venous phases. Scanner parameters were as follows: axial slice thickness, 2 mm; interval, 2 mm; detector configuration, 64 × 0.5 (32 mm); tube voltage, 120 kV; automated tube current of 100–500 mA, helical pitch, 53; pitch factor, 0.828; tube rotation time of 0.5 s; and slice thickness for reconstructed coronal and sagittal planes, 3 mm. The craniocaudal coverage for arterial phase was from top of the liver to below the duodenum, including the entire liver, and for venous phase was from top of the diaphragm to the iliac crest. A dose of 2 ml/kg to a maximum of 150 mL non-ionic contrast agent  was administered intravenously, through a 22-gauge intravenous catheter inserted into a forearm vein, with a power injector [Medrad® Stellant® Dual Head] at a rate of 3 mL/s. Arterial and venous phases were performed on abdominal aorta at 100 HU plus 25 s and 60 s, respectively. Multiplanar reformatted images in coronal and sagittal planes were reconstructed for all phases with a slice thickness of 3 mm.EOB-MRI was performed on 1.5 T  or 3 T MR system  with multichannel phased array coils 16 or 32 channels) using a standard liver EOB-MRI protocol  for the diagnosis of LM verified as per the reference standard. The number, location, size, and final radiologist diagnosis of all reported liver lesions were recorded from the reports according to a 3-point confidence scale scoring system . The final imaging diagnosis  per patient was also categorized according to the most concerning liver lesion reported on CECT and EOB-MRI. The actual impact of EOB-MRI during preoperative surgical planning was determined by the number of patients excluded from curative surgery because of LM detected incrementally on EOB-MRI over CECT as documented in clinical charts.Additionally, two subspecialized abdominal radiologists each with 20 and 10 years of experience, independently and in blinded fashion retrospectively evaluated the anonymized EOB-MRI and CECT examinations with a gap of more than 4 weeks between the two modalities to minimize recall bias probability. All images were reviewed on the imaging workstations . All visible liver lesion locations based on Couinaud segmental anatomy were recorded and measured on the axial T1-weighted post-contrast hepatobiliary phase of EOB-MRI and portal venous phase of CECT. The lesion imaging characteristics and final imaging diagnosis were again recorded, utilizing the same 3-point confidence scale scoring system for both modalities using standard diagnostic imaging criteria used in clinical practice  surgery attempts, was calculated for each reader. Inter-reader agreements for LM detection and simulated decision-making process were also evaluated.Histopathology, intraoperative observations, and/or interval follow-up were considered as the reference standard for the diagnosis of LM. Suspected LM were evaluated by either pre−/intra-operative biopsy or interval follow-up imaging. In the presence of multiple suspected LM with similar imaging characteristics, a preoperative biopsy was performed only from one of the lesions, and the remainder were evaluated on follow-up imaging for change in lesion size/morphology. On follow-up imaging, a suspicious liver lesion was considered as metastasis if it showed ≥20% increase in axial diameter within a 3-month interval.A patient-level analysis of preoperative EOB-MRI and CECT original reports to measure the diagnostic performance of the modalities in detection of LM and the actual impact of EOB-MRI on surgical planning during the prospective clinical decision-making process was performed. Additionally, patient-level and lesion-level analyses to evaluate the diagnostic performance of CECT and EOB-MRI imaging in detection of LM and the impact of EOB-MRI versus CECT on simulated surgical eligibility and differences in potential futile (open-close) laparotomies, for which McNemar tests were carried out. Imaging scores were summarized for each reader by modality  on a 3-point scale . Inter-observer agreement in scoring hepatic lesions based on a binary classification treating indeterminate as benign was evaluated by reporting the concordance rate (%) of diagnosis between the readers for both EOB-MRI and CECT. To calculate the sensitivity and corresponding 95% confidence intervals (CIs) of EOB-MRI and CECT in detecting LM in correlation with the reference standard, we used generalized estimating equations (GEE) to account for repeated measurements within a patient . The CIsP-value < 0.05 was considered an indicator of a statistically significant difference. Statistical analyses were performed using R version 3.5.0 . Amongst 51 patients with attempted curative-intent surgery, 45 had successful surgeries, while 6 had open-close laparotomies. The reasons for open-close laparotomy were surface LM , and accuracy were 98% [87.7-99.7], 92.3% [55.2-99.1], 90.6% [74.9-96.0], and 90.9% [81.2-95.9] versus 100% [92.7-100], 100% [47.8-100], 80.3% [59.4-88.4], and 81.8% [70.7-89.4] for EOB-MRI and CECT, respectively. Although two patients were diagnosed with intraparenchymal LM on preoperative EOB-MRI, the clinical decision was to attempt surgery and perform excisional biopsies, which confirmed metastasis in both patients leading to open-close laparotomies  [46.6-86.8], vs 29.4% (5/17) [13.9-51.8], /17  vs. 34% [21.5-48.3]; p = 0.009; R2, 67.9% [53.7-80.1] vs. 34% [21.5-48.3]; p = 0.018). Also, EOB-MRI had comparable mean specificity  for LM detection. Table p = 0.009; R2, 56.6% (30/53) vs. 35.8% (19/53), p = 0.008]. Moreover, the number of indeterminate lesions was lower on EOB-MRI compared to CECT for both readers, and this difference was statistically significant for one of the readers (R1: 6.1% (16/261) vs. 13.0% (34/261), p = 0.039; R2: 7.7% (20/261) vs. 14.9% (39/261), p = 0.081). Amongst 10 LM characterized as indeterminate on CECT by both readers, 80 and 50% of those lesions were accurately diagnosed on EOB-MRI as metastases by readers 1 and 2, respectively.  and 53 metastases  in 66 patients as per reference standard, including. Reader 1 and 2 reported 40 and 36 LM respectively on EOB-MRI compared to 18 LM by both readers on CECT. Mean reader results revealed that 81% (43/53) of LM were diagnosed on EOB-MRI and 38% (20/53) on CECT. The overall sensitivity of EOB-MRI was significantly greater than CECT for both readers . In addition, for both readers, the incidence of indeterminate diagnosis (score 3) was lower on EOB-MRI; and this difference between the two modalities was significant for reader 1 , p = 0.159). Table p = 0.008) and 10.6%  decrease in futile (open-close) laparotomies is realized when surgical planning included EOB-MRI instead of CECT alone. The inter-reader agreement for this simulated decision-making process was substantial for both CECT and EOB-MRI [κ = 0.744 (95% CIs 0.468-1.02) for CECT and κ = 0.691 (95% CIs 0.478-0.904) for EOB-MRI].In a patient-level analysis of readers’ observations by considering only the presence or absence of LM, the sensitivity of EOB-MRI for detecting metastatic liver disease was again superior to that of CECT for both readers  guidelines (2021), the preferred imaging tool for pancreatic imaging is dual-phase pancreatic protocol CECT, whereas MRI is mostly used as a problem-solving tool  . HoweverAt a lesion level, our study showed that EOB-MRI had very high PPV and NPV for diagnosis of LM from PDAC. Likewise, at patient level, EOB-MRI had higher sensitivity and NPV than CECT for accurately identifying patients with LM. The high PPV of EOB-MRI for metastatic liver disease guides appropriate exclusion of curative-intent surgery in those patients, while the higher NPV compared to CECT can provide greater confidence towards proceeding with curative-intent surgery should there be no other contraindications. At lesion level, EOB-MRI was also significantly better than CECT in detection and characterization of small LM (≤1.0 cm). This result is also compatible with previous studies that evaluated the detection of LM on EOB-MRI , 24.The incremental yield of EOB-MRI in detecting LM compared to CECT can reduce futile open-close laparotomies. Practically, in this study, surgery had been planned after the inclusion of both EOB-MRI and CECT findings. Therein EOB-MRI led to a two-fold exclusion of patients from attempted curative-intent PDAC surgery versus CECT due to detection of LM on EOB-MRI only. Additionally, the simulated rate of open-close surgery was significantly lower when the surgical plan was based on the detection of LM on EOB-MRI compared to CECT alone. This difference represents the potential incremental impact of EOB-MRI on clinical decision making and can reduce unnecessary open-close laparotomies. Additionally, reader interpretations of EOB-MRI demonstrated greater diagnostic confidence for lesion characterization with a lower incidence of indeterminate liver lesion diagnoses compared to CECT. Since conclusive preoperative imaging reports are, incontrovertibly, more helpful in making surgical decisions than those with indeterminate diagnosis, EOB-MRI further also helps in reducing diagnostic uncertainty regarding the presence or absence of LM during the preoperative clinical decision-making process.Staging laparoscopy (SL) is not routinely utilized at our institution during the preoperative staging of PDAC. Although some NCCN member institutions routinely use laparoscopy before surgery or chemoradiation to rule out undetected metastases on imaging, there is a lack of consensus on the routine use of staging laparoscopy (SL) , 26. FurLess than one-fifth of our patients had neoadjuvant chemotherapy, which may potentially increase the incidence of liver steatosis, and therefore decrease the sensitivity of CECT to detect LM. A previous study showed the superiority of EOB-MRI to CECT in the detection of small colorectal metastasis following chemotherapy, particularly in patients with hepatic steatosis . They foDual-energy CT (DECT), a relatively new imaging technology, allows characterization of tissue composition, such as calcium, iodine, and fat, and improves detection of pathologies by using two X-ray beams of different kVp energies , 31. OneWe must acknowledge some limitations of our study. First, this is a retrospective analysis with a relatively small patient cohort at a single site. However, all the study cohort patients underwent both EOB-MRI and CECT for direct head-to-head comparison of LM detection and impact on surgical decision-making process. In order to justify routine inclusion of EOB-MRI in all patients under consideration for curative pancreatic surgery, perhaps a prospective multi-center study with a larger cohort is required. Second, we did not specifically evaluate DWI diagnostic performance separately against the hepatobiliary phase of EOB-MRI. Our study aimed to perform a comprehensive evaluation of EOB-MRI rather than assessing portions of the MRI examination. A systematic meta-analysis assessing LM detection in patients with colorectal or non-colorectal cancer has shown lower sensitivity of DWI compared to EOB-MR imaging or the combination of both sequences in  with theEOB-MRI provides superior diagnostic performance compared to CECT in the preoperative detection of LM from PDAC. Moreover, this incremental yield of EOB-MRI better informs the surgical decision-making process and can lower the incidence of failed curative-intent pancreatic surgery. Consideration should be given to inclusion of EOB-MRI in the preoperative assessment of PDAC deemed potentially resectable on CECT.Additional file 1: Table S1. Diagnostic Imaging Interpretation Criteria.


Retroperitoneal non-pancreatic or idiopathic pseudocysts are very rare lesions. This case report aimed to present our patient and to check all the available literature on this kind of rare disease.Our patient was a 67-year-old Iranian man admitted with mild abdominal discomfort for three months. Ultrasonography and CT scan revealed a huge cystic structure within the retroperitoneal space. The lesion was excised through midline laparotomy and opening of the retro-peritoneum. The histopathology of the cyst wall revealed a benign cystic lesion with no epithelial lining. A histologic diagnosis of non-neoplastic retroperitoneal pseudocyst was made.The primary non-pancreatic retroperitoneal pseudocysts are rare lesions and have to be distinguished from other differential diagnoses of retroperitoneal lesions, and a surgeon should be aware of the possible occurrence of these lesions with unknown origin. Surgical excision is the only way to exclude malignancy and confirm the diagnosis. The retro-peritoneum is a space situated behind the parietal peritoneum and in front of the transversalis fascia . The retMost of the retroperitoneal masses originate from the retroperitoneal organs and are not considered as the primary retroperitoneal masses. A primary retroperitoneal mass is diagnosed once the location is inside the retroperitoneal space and after exclusion of the originity from an organ . PrimaryPrimary retroperitoneal cysts are structures not originating from any retroperitoneal organs and are very rare. They reach large sizes before causing any symptom and are often discovered accidentally –6. The eThough vague abdominal pain and distension are present in half of the cases, there are no clinical signs of retroperitoneal cysts in half of the patients, and they are diagnosed accidentally . They maMost retroperitoneal pseudocysts are originating from the pancrease . PancreaNon-pancreatic or idiopathic pseudocysts are rare lesions. This case report aimed to present our patient and to check all the available literature on this kind of rare disease.A 67-year-old Iranian man was admitted to Shahid Beheshti hospital affiliated with Yasuj University of Medical Sciences with mild lower abdominal discomfort  with a three-month duration. His bowel habits were normal, and he had no urgency, hesitancy, weak stream, or burning sensation when urinating. There was no fever, body weight loss, or recent history of trauma, surgery and chronic pancreatitis, or other diseases of the pancreas. Before presenting to the hospital, the patient visited other healthcare facilities and clinics and had received some unspecific oral medications like pantoprazole and hyoscine hydrobromide. His vitals were within normal range. A proper abdominal physical examination including inspection, auscultation, palpation, and percussion was done; the abdomen was soft, non-distended, without a palpable mass. The digital rectal exam was normal.Ultrasonography of the abdomen showed a large retroperitoneal, cystic structure measuring 135 × 88 mm in mid-line position in the level of bifurcation of the aorta, and the urinary bladder was well distended with mildly increased wall thickening (5.5 mm) associated with some trabeculation in the wall without any stone. As the patient had no history of abdominal dysfunction, and there was no suspicion for bowel obstruction, foreign bodies, and urolithiasis, abdominal radiography was not ordered. However, contrast-enhanced CT scan of the abdomen and pelvic revealed a well-defined huge (140 × 120 mm), unilocular, thickened wall cystic structure within the left hemi-pelvic cavity extended from recto-sigmoid junction to the level of upper end of iliac crests and crossing mid-line, as well as with pressure effect over recto-sigmoid, lower rectus muscle, and urinary bladder. The cystic structure showed no solid components or gross internal septations and the content was homogenous. There was no overt connection the cystic structure and the surrounding organs  on the 1st day after the operation, and became pain-free, had passed stool, had acceptable urine output on the second day after the operation, so then was discharged home on day 3 post-operation. The patient was followed up in the clinic with a normal abdominal examination and well-healing wounds after one week, and one month after discharge from the hospital, and there has not been any evidence of recurrence after 3 months of follow-up. He is optimistic about the future and says that this event has helped him to pay more attention to his health afterward.A retroperitoneal non-pancreatic pseudocyst is a rare surgical entity that carries a range of differential diagnoses with the incidence rate of 1 in 5750 to 1 in 250,000 . In thisOf the total 15 reports, 4 reports were for India, and that was amazing. Males were the dominant sex encountered in 10 cases. The mean age was 50.7857 ± 10.977 with a 95% confidence interval. The youngest patient was a 3-year-old girl and the oldest was an 80-year-old woman. Physical examination was not mentioned in one, and in two patients, the abdomen was non-tender, non-distended, and soft to touch, and no definite mass palpated, but in the majority of the cases (10 patients), a palpable mass was detected 9 cases in the abdominal, and one in the rectal examination. Abdominal radiography was used as the only diagnostic modality in one case and showed a grape-fruit-sized mass. Trans-abdominal ultrasound was used in 6 cases and revealed a retroperitoneal cystic/mass lesion in 5 patients and a multi-cystic lesion in one patient . Endo-rectal ultrasound was used in one patient and showed a retro-rectal mass. CT scan was the most common modality used in detecting the pathology and was used in 13 patients. MRI was used in two patients and confirmed the ultrasound and CT scan findings in one patient each retrospectively. Barium enema was done in only one case and showed the compression of the rectum by the lesion in this case.Location of the cystic structure was reported to be in the pelvic cavity in 2 patients, retro-peritoneum in 3, and left upper quadrant of the abdomen within the small bowel mesentery, just mentioned right-sided, right-sided with the extension from the liver to the pelvis, right-sided lumbar and iliac region, pancreatic head and neck with the extension into the sub-hepatic space, in the right hepato-renal space, adjacent to the medial border of the spleen, and the left adrenal gland in one patient each retrospectively. Dislocation or displacement of the viscera was seen in the right kidney and adrenal gland, rectum, and transverse colon in one patient each retrospectively. Pressure effect of the lesion was seen over the urinary bladder in two cases, and recto-sigmoid, and lower rectus muscle in one patient each retrospectively.Laparoscopic surgery was performed in four cases , 12, 15,The retroperitoneal pseudocysts are asymptomatic before reaching a large size, and compress over the adjacent structures, and are often diagnosed accidentally , 12. TheComplete excision is a cure for these retroperitoneal cysts. Marsupialization and partial excision are not recommended, because recurrence is common. The surgical methods are conventional laparotomy , extraperitoneal approach, and transperitoneal flank approach , althougPrimary non-pancreatic retroperitoneal pseudocysts are very rare lesions and have to be distinguished from other differential diagnoses of retroperitoneal lesions, and a surgeon should be aware of the possible occurrence of these lesions with unknown origin. Surgical excision is the only way to exclude malignancy and confirm the diagnosis.


The artery of Percheron (AOP) is a rare anatomical variation emerging from the posterior circulation and supplies both thalami in the brain. As per the literature, the AOP infarction constitutes less than 2% of all stroke cases. AOP infarctions are usually caused by a combination of risk factors and a predisposing vascular territory. The areas most affected by AOP are the paramedian thalami with or without the involvement of the midbrain. AOP can be challenging as it is infrequent and mostly can be missed on the initial scans. We present a 58-year-old previously healthy male known to have hypertension with poor follow-up who presented with dysarthria and facial weakness, which he felt after waking up from sleep. After the initial physical examination and investigations, a preliminary diagnosis of stroke was made. As the patient was worked up for the stroke, his symptoms improved, and he was back to his baseline function within 48 hrs of presentation. What came to our surprise was that the stroke workup, including the initial CT scan with an angiogram, blood works (Hba1c and lipid panel), echocardiogram of the heart (ECHO), and Holter monitor was all unremarkable until an MRI head was done, which showed bilateral thalamic acute-sub acute infarct. This shows that AOP can be easily missed as it may not appear on the initial scans and workup and needs an adequate radiological study for diagnosis. Although some cases of AOP infarction are reported in the literature, the presentation with transient mild symptoms makes our case an interesting one. The thalamus’ blood supply is complex and comprises small end arteries emerging the P1 and P2 segment of the posterior cerebral artery (PCA) and the posterior communicating artery. The thalamic vasculature can be divided into four territories: anterior, paramedian, inferolateral, and posterior. Artery of Percheron (AOP) is a single perforating vessel that is an anatomical variant of paramedian thalamic arterial supply arising from the p1 segment of either PCA and ends up supplying bilateral thalami [The acute artery of Percheron infarcts comprise 0.1 to 2% of all ischemic strokes. However, of all thalamic stroke, occlusion of the artery of Percheron is attributed to around 4-35% of cases. Early detection of AOP can be missed due to its rare occurrence and can be negative on early imaging, including computed tomography or magnetic resonance [A 58-year-old gentleman, a non-smoker known to have hypertension, presented to the emergency department with new-onset slurring of speech that he noticed at noon after waking up from sleep. The patient had no other past medical condition and reported this as the first episode. According to the patient, he slept well and woke up with the symptoms of slurring of speech and involuntary spilling of water during an attempt to drink, which made him visit the hospital. He denied any headache, vision problems, fever, weakness in upper or lower limbs, loss of consciousness, sphincter incontinence, and sensory symptoms. He had no family history of stroke and denied any drug abuse.On initial inspection, the patient was afebrile with a heart rate of 75 per minute, blood pressure of 155/85 mm of Hg, and normal oxygen saturation at room air. Physical examination was remarkable for dysarthria, and facial weakness due to the inability to close the mouth or fully blow cheeks or sensory deficit noted in both upper and lower limbs. His reflexes were intact with a normal gait, and no cerebellar signs were present. The rest of the systemic examination was unremarkable as well. Based on these findings, an initial impression of stroke was made, and the patient was urgently sent for computerized tomography (CT) scan and angiogram of the head, which was later reported unremarkable  and Holter monitor, was unremarkable. So far, the diagnosis was going with transient ischemic attack (TIA) until an MRI was done, which displayed bilateral anterior thalamic areas of diffusion restriction Figure  demonstrGerard Percheron first described the artery of Percheron as being one of the four anatomical variants of arterial supply to the paramedian thalami in which one dominant thalamic perforating artery arises from P1 and bifurcates to produce both paramedian thalami and, in some cases, the rostral mesencephalon -7. ArterThe spectrum of clinical features evident in AOP infarcts span over seven patterns:1. Mental status changes, including stupor, somnolence, and coma2. Aphasia/slurred speech/dysarthria3. Behavior and memory impairment incorporate confusion, agitation, apathy, disinhibition, hyperphagia, amnesia, and pseudobulbar affect4. Ocular movement abnormalities which include horizontal, vertical gaze paresis with or without pupillary involvement5. Cerebellar signs and symptoms like ataxia and dysmetria6. Motor deficits 7. Other nonspecific clinical presentations such as hypersomnia, seizures, and hyperthermia .AOP occlusions present a neurodiagnostic challenge. Several cases are reported on AOP infarction where initial CT was deemed normal , 13, 14.Finally, the treatment of AOP infarction should be focused on the pathophysiology of underlying disease. Long-term oral anticoagulant and antiplatelet therapy with Aspirin and Plavix could be debated and are generally prescribed by clinicians counting on the underlying disease process like cardioembolic events require long-term oral anticoagulants, whereas cryptogenic causes require antiplatelet therapy .Bilateral infarct being rare, can present with series of symptoms that vary from case to case. AOP should be kept in mind while managing patients with bilateral thalamic infarct having unusual symptoms as modifiable risk factors, if treated, can lead to better outcomes in patient care.


This paper presents the first described case of laparoscopy-assisted prepubic urethrostomy and laparoscopic resection of a tumor of the distal part of the urethra in a female dog as a palliative treatment.An intact, 11 -year-old, mixed breed female dog,weighing 15 kg, was admitted with signs of urinary obstruction and difficultywith catheterization. Vaginal, rectal, and endoscopic examinations revealed a firmmass in the pelvic cavity at the level of the pelvic urethra. Ultrasound andcomputed tomography examination showed enlargement of the urethral wall (5.5 cmwidth and 3 cm thick), which was significantly restricting the patency of theurethra. The lesion affected only the distal part of the urethra without thepresence of local or distant metastatic changes.The affected portion of the urethra was laparoscopically removed while performing pre-pubic urethrostomy with laparoscopy. The patient regained full consciousness immediately after the end of anesthesia, without signs of urinary incontinence. Histopathological examination of the removed urethra revealed an oncological margin only from the side of the bladder. In the period of 2.5 months after the procedure, the owner did not notice any symptoms that could indicate a postoperative recurrence, which was diagnosed three months after the procedure.Pre-pubic urethrostomy can be successfully performed with the assistance of laparoscopy. The use of minimally invasive surgery will allow, in selected cases, removal of the urethral tumor, and in inoperable cases, to perform a minimally invasive palliative pre-pubic urethrostomy. Transitional cell carcinoma (TCC) is the most common form of canine urinary tract cancer, accounting for up to 2 % of all malignancies of this species . UrethraTumors of the caudal/distal urethra in bitches often do not allow for their simultaneous removal and reattachment of the cut urethra using the end-to-end technique. In such cases, pre-pubic urethrostomy, vaginourethroplasty, or conservative management is suggested , 7. RegrPre-pubic urethrostomy has been described in animals, both in experimental  and clinLaparoscopic approach in the surgical treatment of tumors  of the urinary tract has been used in human medicine for many years –20. The The authors of this study presented the first case report with laparoscopically assisted pre-pubic urethrostomy and laparoscopic removal of the distal part of the urethra with the tumor in a female dog as a palliative treatment.An intact, 11 -year-old, mixed breed female dog, weighing 15 kg was admitted with signs of urinary obstruction and resistance to inserting a urinary catheter into the urethra. Signs of urinary obstruction had been recorded by the owner two weeks earlier. During this period, the patient was treated conservatively in another clinic, and after the clinical symptoms worsened, he was referred to the Department and Clinic of Surgery, Faculty of Veterinary Medicine of Wroclaw Environmental and Life Sciences. After admitting the patient to the clinic, vaginal and rectal examinations revealed a firm mass in the pelvic cavity at the level of the pelvic part of the urethra was perceptible. Abdominal palpation revealed a severely distended bladder. After a clinical examination and blood screening test, the patient was referred for ultrasound, CT, and endoscopy. The ultrasonographic examination revealed a strongly filled urine bladder, occupying almost the entire mid abdomen, and extending to the cranial abdomen. The ultrasound examination revealed only the initial, clearly extended (about 1.3 cm) section of the urethra, apart from the bladder. However, no cause of obstruction was visualized in the segment available for examination. The urethra and the wall of the entire bladder available for ultrasound examination did not show any hyperplastic changes.Computed tomography examination showed well-contrasting, heterodense enlargement of the urethral wall extending into the lumen. The growth was about 5.5 cm long (taking up about 3/5 of the length of the entire urethra). The lesion was about 3 cm thick, significantly restricting the patency of the urethra Fig. . The parPrior to surgery, vaginoscopy and an attempt of urethrocystoscopy was performed to localize the lesion that prevents the outflow of urine from the bladder . Endoscopic examination showed no macroscopic changes in the lumen of the vagina and in the external exit of the urethra. During the attempt of performing urethrocystoscopy, a mass occluding the lumen of the urethra  was found without the possibility of introducing the optics into the lumen of the bladder. During the same examination, a fine-needle biopsy was also performed for cytological evaluation of the examined lesion.Based on the results of the clinical trials and additional examinations , the owner of the animal was presented with possible options for conservative and surgical treatment. The owner of the animal did not consent for the removal of the tumor from the pathway of the pelvic symphysis osteotomy. At the same time, he accepted less invasive procedures with the possible risk of only palliative treatment. Therefore, it was decided to perform a pre-pubic urethrostomy and an attempt of removal of the altered part of the urethra by laparoscopy.Patient was pre-medicated by intramuscular injection of medetomidine  at a dose of 10 µg/kg with butorphanol  at a dose of 0.1 mg/kg. Endotracheal intubation was performed after induction of general anaesthesia with propofol at a dose of 1 mg/kg intravenously to effect. After intubation, the epidural anaesthesia was provided with a lidocaine at a dose of 4 mg/kg . General inhalation anaesthesia was maintained with isoflurane  in 100 % oxygen using a circle system (Mindary Wato-Ex 65 Pro). Before placing the patient on the operating table, a catheter with a diameter of 1 mm was inserted into the bladder through which the residual urine was removed. The patient was placed in dorsal recumbency for the procedure (Trendelenburg position). After the surgical field was prepared, the procedure was started with the introduction of a 5 mm diameter optical trocar using the Hasson method in the Linea alba cranially to the umbilicus. All endoscopic equipment used for the laparoscopic procedure with a 5mm 30˚ scope manufactured by Karl Storz SE & Co. KG . After the insufflation of the abdominal cavity with an insufflator (Storz) and reaching a pressure of 8 mm Hg, optics were inserted into the abdominal cavity. Subsequently, under the control of the endoscope, two consecutive 5 mm and 10 mm diameter trocars were inserted caudo-laterally to the optical trocar in a triangular fashion  were used alternately. Preparation began with cutting the median ligament of the bladder. The vesicogenital and pubovesical pouches were then opened and bluntly prepared using laparoscopic forceps. The fatty tissue present in this place, surrounding the urethra was dissected and cut off. The vessels were closed successively using the previously mentioned vessel-sealing devices. This procedure revealed a considerable length of the pelvic urethra  obtained during the alignment of its edges prior to the pre-pubic urethrostomy.Immediately after recovery from anaesthesia, the patient was able to get up and move without any problems. Controlled urination, without symptoms of incontinence, was found immediately after the anaesthesia subsided. The patient was discharged from the clinic the second day after surgery. Information about the dog’s health status was transferred to the clinic by the owner by phone, where no postoperative complications were noted for a period of the first 2 weeks. After this period, the authors had no possibility of direct supervision during treatment, despite the recommendations of regular monitoring in the clinic. Lack of contact with the owner was because he lived far away from the clinic and his advanced age. Unfortunately, it was only three months after the procedure that the owner returned to the clinic with the patient showing difficulty in moving and defecating, noting while for a period of 2.5 months he did not observe any negative changes in the dog’s behaviour. Another clinical (per rectum) examination showed the presence of a firm, strongly painful mass in the ventral part of the pelvis. Subsequent CT scan showed the presence of extensive recurrence in the form of a heterogeneous tumor covering the entire width of the medial and ventral pelvic cavity and extending to the posterior abdomen, ventral and right sided to the bladder Fig.  A. The eA fine-needle biopsy performed before the surgery did not give a definite answer as to the nature of the examined lesion. However, the cytological specimens showed mainly erythrocytes, weakly eosinophilic, amorphous necrotic masses, few neutrophils, and single cells showing features of anisocytosis and anisokaryosis.The microscopic examination of the histopathological specimens from both intraoperative specimens of the lesion, i.e., the fragment of the urethra from the side of the bladder together with the remaining removed tumor tissues, showed the weaving of a typical well-differentiated transitional cell carcinoma . Tumor cells were present in the incision line from the urethral opening to the vaginal vestibule. No neoplastic cells were observed in the connective tissue surrounding the urethral section in the incision line from the bladder side Fig.  A. The cAt the site of the urethrostomy, an irregular thickening of the skin and subcutis, about 1 cm thick, with no signs of neoplastic infiltration was found. The neoplastic tissue, however, comprised the urethra, circumscribed the bladder neck, and grew irregularly around these structures, reaching dimensions of approximately 12 × 7 × 7 cm. The tumor did not penetrate the lumen of the urethra and the bladder, growing exophytically Fig. B. FurtheAccording to the information available to the authors, only two papers are describing laparoscopic-assisted pre-pubic urethrostomy. Filho et al.  performeThe inability to restore the continuity of the urethra after resection of large tumors necessitates a pre-pubic urethrostomy or vaginourethroplasty to ensure urine outflow , 21. TheThe disadvantage of the presented laparoscopic technique may be the relatively long procedure time of two hours, which will probably be shorter as the number of procedures performed increases. Another limitation may be the lack of appropriate laparoscopic skills by surgeons performing only basic surgical procedures endoscopically. Where, according to the authors, the most difficult stage of the procedure is the dissection of the pelvic part of the urethra with its opening to the vaginal vestibule and sewing inside the abdominal cavity. The described difficulties probably can be solved by a slight modification of the described technique by combining it with the open technique. The effectiveness of the hybrid approach requires further study on similar clinical cases. The premise of the said hybrid modification is to perform an episiotomy after laparoscopic dissection of the urethra and performing a urethrostomy will allow the dissection of the opening of the urethra and suturing the resulting wound from the vaginal side using the open surgery technique. The laparoscopic technique presented in the article allowed for the removal of the tumor in the distal part of the urethra and the performance of a pre-pubic urethrostomy. At the same time, the short period of postoperative survival of the patient indicates that the procedure performed ultimately had the character of a palliative procedure. Therefore, when choosing a method of treating similar cases , the authors believe that other available palliative treatment methods should be considered. Among the palliative procedures enabling the outflow of urine from the bladder in the event of urethral obstruction, there are, among others, cystostomy and urethral stenting , 27, 28.The authors of this study are aware of the limitations of the objective evaluation of the presented surgical technique based on a single case, requiring further research. Especially considering the rarity of urethral tumor only in its distal part without local and distant metastatic changes present. According to the authors, the presented technique of laparoscopic removal of lesions in the distal part of the urethra may be considered, especially in the treatment of less invasive lesions of the urethra. A careful study is required for a hybrid technique, which, being a combination of the described laparoscopic technique with open surgery  would lead to maintain a clean oncological margin on both ends of the resected urethra. Additionally, only palliative pre-pubic urethrostomy  may be considered in inoperable cases.


Omental cysts are rare, predominantly occur in children, and often initially present with symptoms masquerading as other more common intra-abdominal pathologies. In this case report, we present the case of a child with an omental cyst that originated from the lesser sac. Due to the location of this cyst, resection presented unique technical challenges that have not been described in existing literature.A 4-year-old male patient presented with symptoms initially concerning for appendicitis. Ultrasound showed a normal appendix but a large volume of complex intraperitoneal fluid. Computed tomography subsequently demonstrated a large cystic structure spanning from the stomach to the bladder. The patient was taken to the operating room where a large omental cyst was found to originate from the lesser sac. The resection was difficult due to the thin wall of the cyst and the intimate association of the superior-most aspect of the cyst with the tail of the pancreas, but was ultimately successful.Omental cysts are rarely suspected before detection on abdominal imaging. Surgical resection is the treatment of choice, and complete resection can result in a recurrence-free postoperative course. Laparoscopic resection has been reported, but laparotomy is reasonable when a minimally invasive approach may not allow for a safe resection without rupture of the cyst. Anatomical characteristics of the cyst, as demonstrated in our case, can present challenges in the treatment of this otherwise benign entity. Omental cysts are rare intra-abdominal masses that occur primarily in children. They often present with symptoms similar to other more common abdominal pathologies and are discovered incidentally on imaging. Herein, we discuss the case of a 4-year-old male who presented with abdominal pain and was discovered to have a large primary omental cyst originating from within the lesser sac. The location of this cyst presented unique technical challenges during surgical resection that have not been described in existing literature.A 4-year-old male with no significant past medical history presented to our emergency department with one day of worsening abdominal pain. The pain was diffuse but greatest in his periumbilical area. His mother also noticed new-onset abdominal distention. He demonstrated decreased appetite but had no emesis. His last bowel movement was the previous evening and was normal. Upon presentation, the patient was febrile to 38.7 °C. On exam, the patient’s abdomen was soft but distended with tenderness to palpation around the umbilicus and in the left hemiabdomen. Labs were significant for leukocytosis (WBC 20.1) but otherwise unremarkable. The patient was tested for influenza A/B and respiratory syncytial virus (RSV)—all of which were negative.A transabdominal ultrasound was performed which demonstrated a normal appendix. Moderate volume complex ascites with particulate matter was also noted on this study. Given the unexplained presence of debris-containing intraperitoneal fluid, computed tomography (CT) of the abdomen and pelvis with intravenous contrast was obtained. This study showed a large cystic lesion in the left hemiabdomen, measuring 7.3 × 11.7 × 14.9 cm, which extended from the greater curvature of the stomach to the dome of the bladder . The superior-most attachment of the cyst was then explored Fig. . It appePostoperatively, the patient returned to the surgical floor. His subsequent course was unremarkable and he was discharged on postoperative day number two. The patient was seen in clinic four weeks after discharge and was doing well. His mother felt that his appetite had improved compared to his preoperative state, perhaps indicating that the cyst was causing some degree of subclinical early satiety prior to presentation.Omental and mesenteric cysts are rare entities, differentiated by the location in which they occur, with a reported incidence of one in twenty thousand admissions to a children’s hospital . The majTreatment is complete excision. While there have been multiple reports of laparoscopic resection of omental/mesenteric cysts , 9, 10, Our patient had a primary omental cyst. Like many patients who are ultimately found to have an omental or mesenteric cyst, the patient presented with abdominal pain and the initial clinical suspicion was for a more common abdominal pathology—in this case, the surgical team was consulted with concern for appendicitis—until subsequent imaging revealed the true diagnosis. In a previous series from our institution this was a typical sequence of events leading to the diagnosis of omental/mesenteric cyst . The acuThis 4-year-old child presented with abdominal pain, gradually increasing abdominal distention, and subclinical early satiety. He was found to have an omental cyst and underwent successful surgical resection. Though a benign mass with minimal chance of recurrence after complete excision, this cyst’s intimate relationship with the pancreas and the careful dissection required to separate those two structures highlights the occasionally challenging management of this rare finding.


Lymphangioma is a non-epithelial tumor marked by aggregates of abnormally dilated lymphatics. Mesenteric occurrences account for < 1% of all cases, and < 0.05% involve the gastrointestinal tract. Most are confined to children, rarely affecting adults.Herein, we describe an elderly Japanese woman with anemia, hypoalbuminemia, and episodic bleeding due to multiple intestinal lymphangiomas. Abdominal computed tomography revealed multiple low-density defects of mesentery, with areas of intermediate (T1 images) or high (T2 images) signal intensity similarly dispersed in magnetic resonance scanning sequences. Single-balloon enteroscopy was undertaken, enabling identification and tattooing of a small intestinal bleeding source. Laparoscopy-assisted resection at this site served to control related hemorrhage, removing a histologically confirmed hemolymphangioma. Having recovered uneventfully, the patient remained stable 2 months postoperatively.Although rare in adults, mesenteric or gastrointestinal lymphangiomas must be considered in a setting of anemia and hypoalbuminemia. Complete resection is advantageous to improve patient symptoms, but limited resection of multiple lesions may be equally effective. Lymphangioma is a non-epithelial growth composed of dilated lymphatic channels . MesenteA 77-year-old Japanese woman with chronic anemia (20 + years) had engaged elsewhere in supplementation for presumed iron deficiency. Her anemic condition seemed to abate until 6 years prior, at which point another episode prompted upper GI endoscopy and bone marrow examination. No abnormalities were apparent at the time, but fecal testing was positive for occult blood. Eventually, she was referred to our hospital in consultation. Subsequent colonoscopy and enteroscopy revealed numerous mesenteric and intestinal lymphangiomas in conjunction with bleeding. Given her fluctuating status during medical treatment, often reliant on transfusions, surgical control of blood loss was the therapeutic goal.2. Conjunctival pallor and lower leg edema were evident, but her abdomen was flat, soft, and non-tender. Other than very low hemoglobin (6.7 g/dL) and albumin (2.5 g/dL) levels, initial laboratory diagnostics were unremarkable. Her overall condition had been sustained through supportive measures, administering blood and albumin.Upon admission, the patient  had a body mass index (BMI) of 24 kg/mAbdominal computed tomography (CT) revealed multiple low-density mesenteric defects, devoid of contrast effect Fig. . Finding2 insufflation (10 mmHg) produced a pneumoperitoneum sufficient for viewing the abdominal cavity. Many yellowish, cystic growths and hemangiomatous nodules studded the small intestine and mesentery, accompanied by low-volume, grayish-white, and slightly cloudy ascites  are discovered at birth, and nearly all (90%) are reportedly diagnosed by age 2 . LymphanWhile generally benign in nature, such tumors may pervade mesenteric roots and peripheries  or invade surrounding organs, with potentially life-threatening complications. Traumatic rupture , ischemic tissue necrosis, intestinal gangrene , and intermittent intestinal obstruction are possible , 19. GI Ugwonali et al. have used intraoperative enteroscopy to identify and excise sources of hemorrhage in this setting, achieving good results . Morris-Complete resection of a localized lymphangioma is of course ideal , 24. HowHerein, we describe a patient with multiple mesenteric and intestinal lymphangiomas who experienced chronic episodic bleeding. The situation was resolved through enteroscopic tattoo and laparoscopic-assisted surgical resection. In adults, mesenteric and GI lymphangiomas are rare occurrences to bear in mind as underlying causes of anemia and hypoalbuminemia. Although complete resection is best for symptom improvement, partial resection of identified bleeding points may likewise enhance patient quality of life. Preliminary enteroscopic tattooing is a means of facilitating minimally invasive surgery in these circumstances.


Traumatic rupture of an ovarian endometrioma is extremely rare injury. We describe a case of a 63-year-old female presenting after a motor vehicle crash (MVC) with complex abdominal injuries requiring exploratory laparotomy that was complicated by delayed presentation of an ovarian endometrioma rupture on second look laparotomy. During the repeat exploration of the abdomen, multiple regions of small bowel and the pelvic floor were noted to be covered with a brown-colored material which was concerning for fecal matter from a missed enterotomy. The patient was kept open for an additional 24 h providing time for occult injuries to reveal themselves and for proper mechanical preparation of the rectum to perform rigid sigmoidoscopy, essential to definitively rule out a missed injury in this rare situation. Damage control surgery has been an established concept in management of traumatic injuries to the abdomen and is utilized as a tool to break the lethal triad of coagulopathy, acidosis, and hypothermia to which trauma patients are particularly susceptible in the initial stages after injury. This practice has become standard of care internationally in the management of trauma. World Society of Emergency Surgery (WSES) guidelines include persistent hypotension, acidosis, risk for compartment syndrome, or inability to definitively control contamination or necessity of reevaluating bowel viability as indications for damage control surgery in trauma patients A 63-year-old female retrained passenger was air-flighted from the highway to our level 1 trauma center after a motor vehicle collision (MVC). Patient was a restrained passenger with abdominal distention on initial physical exam but no obvious seat belt sign. Chest x-ray demonstrated bowel in the left chest field and a FAST examination demonstrated free fluid in the pelvis. It was initially difficult to obtain a blood pressure but the patient was noted to have bounding pedal pulses bilaterally with a heart rate of 86, and an oxygen saturation of 99% on 2 l nasal cannula oxygen and the patient was immediately transferred to the operating room for an emergent laparotomy. Examination of the left upper quadrant revealed traumatic rupture spanning the entire left hemi-diaphragm in the coronal plane and a mid-jejunal perforation with minimal contamination. The jejunal perforation was primary repaired and left hemi-diaphragm injury was closed with interrupted #1 Ethibond. It was noted that the patient had a previous gastric bypass with mesenteric tear near the jejunojejunostomy, but the anastomosis appeared viable. A left chest tube was placed and an ABTHERA was placed with the fascia open with the intention to perform a second look laparotomy the next day for to evaluate the jejunostomy anastomosis for viability. Approximately 24 h later the patient was taken back for abdominal re-exploration and at initial examination was found to have dark brown material similar in texture and consistency to feces staining the pelvis and the large and small intestine . A thoroThe patient remained in the ICU for 24 h and returned to the OR for a 3rd re-exploration in lithotomy position. Again, systematic examination was performed and there was no further staining of the pelvis. Rigid sigmoidoscopy was performed with insufflation of the rectum while submerged in saline. No bubbles were noted. There was no sign of injury and the patient's abdomen was closed. Her postoperative course was uncomplicated. She was discharged on hospital day 28 to an inpatient rehabilitation facility. Final pathology demonstrated normal right sided ovary and an endometriotic cyst.Second-look laparotomy after complex abdominal trauma allows discovery of delayed presenting devascularization injuries and missed enterotomies. The disadvantages, however, of temporary abdominal closure are numerous including the potential for loss of domain or development of an entero-atmospheric fistula, though more often seen in non-trauma patients Traumatic ovarian cyst rupture is an extremely rare occurrence and is usually associated with an ovarian dermoid cyst or teratoma Ruptured ovarian cysts can cause significant bleeding. Even ovarian artery ligation to control more significant bleeding is sometimes necessary This is the first case to our knowledge in the literature that describes discovery of a ruptured ovarian endometrial cyst during second look laparotomy. We propose that, especially in the acute setting of trauma when the risk of missed injury is particularly high, thorough examination of the abdomen during discovery of a ruptured endometrial (“chocolate”) cyst is not enough to rule out missed traumatic enterotomy. Proper rigid sigmoidoscopy in a prepped rectum after an additional 24 h with temporary abdominal closure we believe is essential to ruling out traumatic enterotomy in this context.Second-look laparotomy is a central component of trauma surgery management of acute abdominal injury. Traumatic ovarian rupture is extremely rare but can be associated with ovarian cysts. Presentation of a ruptured endometrioma of the ovary is extremely alarming in the context of abdominal trauma but a meticulous and measured approach by keeping the patient in the ICU with temporary abdominal closure, preparing the rectum with plans for re-exploration with rigid sigmoidoscopy and bubble test while insufflating the rectum are central to successfully treating these complex patients and achieving good outcomes.Nothing to disclose.


Abdominoscrotal hydrocele (ASH), a composite of scrotal and abdominal hydroceles connected through the inguinal canal, is rare and no consensus regarding its mechanisms and surgical treatments has been reached to date.We report a case of an 11-month-old boy with a large ASH. Ultrasonography and magnetic resonance imaging (MRI) revealed a huge hydrocele (maximum length: 8 cm). The patient underwent laparoscopic percutaneous extraperitoneal closure (LPEC) and the orifice of the processus vaginalis (PV) was completely closed. The postoperative course was uneventful. Follow-up ultrasonography and MRI in the first postoperative year showed no recurrence of ASH.An ASH with a length >8 cm is considered rare in pediatric patients. There is no consensus regarding its etiology and surgical intervention is selected according to the patient's condition and the characteristics of ASH. We opted to perform early surgical intervention considering the ASH size and the adverse effects on testicular development. LPEC helped identify the condition and location of the ASH and allowed safe and reliable operation of the large intrapelvic hydrocele. In patients with no PV patency, a change in approach from LPEC to an open anterior approach should be considered even if LPEC is feasible.This case provides valuable insight into successful LPEC of a large ASH without any complications, highlighting the importance of elucidating the morphological mechanisms and making an accurate diagnosis and the challenges associated with these processes. •A huge abdominoscrotal hydrocele (ASH) is a rare condition in a child.•ASH frequently exhibited a firm adhesion to the processus vaginalis.•Laparoscopic percutaneous extraperitoneal closure does not require the detachment.•Laparoscopic percutaneous extraperitoneal closure is a helpful and safe technique. He had no medical history. During the initial physical examination, there was a translucent mass in the left scrotum A. UltrasLPEC was performed as described previously 3Although childhood ASH was first reported in 1861 LPEC is a helpful and safe surgical technique for patients with ASH. However, there remains a technical problem wherein an internal inguinal ring cannot be confirmed when a swollen hydrocele overhanging the abdominal cavity covers the internal inguinal ring. In such cases, ultrasound-guided puncture from the inguinal region or scrotum to the hydrocele can be used to detect the internal inguinal ring. Nevertheless, if the ultrasound-guided puncture is insufficient, a puncture can be performed laparoscopically using a dissector or a needle. Subsequently, we can perform LPEC following the usual procedure without difficulty. In patients with ASH, severe adhesion is frequently observed between the peritoneum around the internal inguinal ring and the ASH wall. Importantly, LPEC does not require the detachment procedure and can achieve high ligation of the PV by ligating the peritoneum and the ASH wall concomitantly. In ASH patients with no PV patency, a change of approach from LPEC to an open anterior approach should be adopted considering the possibility of hypothesis (ii) described previously.4This case provides valuable insight into successful LPEC of a large ASH without any complications, highlighting the importance of elucidating the morphological mechanisms and making an accurate diagnosis and the challenges associated with these processes.Written consent was obtained from the patient's parents for writing this case report and accompanying images. Identifying details have been omitted.Ethical approval was not required for this case report in our institution.No funding.Dr. Toshifumi Hosoda.N/A .Dr. Toshifumi Hosoda — corresponding author; collecting the data, writing article, reviewing patient notes, writing articles, analyzing images, and approving final submission.The author declares no financial, personal, or other conflicts of interest that could induce a bias.


Invasive aspergillosis of the central nervous system is a rare but increasingly prevalent disease. We present the unusual case of an immunosuppressed patient suffering from unexpected superinfected invasive aspergillosis with cerebral, pulmonal, and adrenal manifestations, mimicking a metastasized bronchial carcinoma. This report reveals the importance of including aspergillosis in the differential diagnosis of a cerebral mass lesion in the light of unspecific clinical findings.A 58-year-old immunocompromised female presented to our emergency department with a single tonic-clonic seizure. Imaging showed a ring enhancing cerebral mass with perifocal edema and evidence of two smaller additional hemorrhagic cerebral lesions. In the setting of a mass lesion in the lung, and additional nodular lesions in the left adrenal gland the diagnosis of a metastasized bronchus carcinoma was suspected and the cerebral mass resected. However, histology did not reveal any evidence for a neoplastic lesion but septate hyphae consistent with aspergillus instead and microbiological cultures confirmed concomitant staphylococcal infection.A high index of suspicion for aspergillus infection should be maintained in the setting of immunosuppression. Clinical and radiological findings are often unspecific and even misleading. Definite confirmation usually relies on tissue diagnosis with histochemical stains. Surgical resection is crucial for establishing the diagnosis and guiding therapy with targeted antifungal medications. Invasive aspergillosis of the central nervous system is a rare disease, particularly in the Western World. However, in recent years this entity has become more frequently diagnosed, particularly in immunocompromised patients , 2. TherA 58-year-old female presented to our emergency department with new-onset, generalized tonic-clonic seizures controlled by the administration of midazolam and levetiracetam. Her past medical history included a kidney transplantation due to a focal-segmental glomerulosclerosis six months prior to admission, which was treated with immunosuppressive therapy . In addition, she received levothyroxine substitution after a total thyroidectomy for papillary thyroid cancer 3.5 years ago and she was treated with amlodipine and metoprolol for mild to moderate mitral insufficiency.On admission, her vital signs were within normal range. An initial aphasia resolved completely within a few hours, and she did not show any focal deficits on neurological examination. A computed tomography (CT) scan of her head revealed a space-occupying lesion in the left parietal lobe. Subsequent magnetic resonance imaging (MRI) tomography of the brain confirmed a ring enhancing mass with central diffusion restriction and perifocal edema in the inferior parietal lobule Fig. . In addiInterdisciplinary consensus was urgent resection of the symptomatic brain lesion, which would also enable a definitive diagnosis. A left parietal craniotomy was performed, and the superficial mass was completely resected. Macroscopically, the lesion appeared firm and indurated without any evidence of pus or necrosis. However, histology did not reveal any evidence for a neoplastic lesion. Instead, a collagenous abscess wall containing mixed inflammatory cells, including abundant neutrophils. The Grocott stain confirmed the presence of branched, septate hyphae consistent with aspergillus Fig. . PanfungThe postoperative course was uneventful. Therapeutically, voriconazole was initiated, and due to subtherapeutic drug values complemented by amphotericin B. However, the patient developed serious side effects  from amphotericin B whereupon the antifungal therapy was adapted to isavuconazole which was well tolerated. Initially, the patient received postoperative empiric antibiotics (ceftriaxone and metronidazole), which were adapted to flucloxacilline and metronidazole after microbiological cultures confirmed growth of staphylococcus warneri and pasteuri species. A positron emission tomography (PET)-CT scan showed metabolically active lesions in the right upper lung and left adrenal gland. Because of the yet unclear etiology, interdisciplinary board suggested a video-assisted thoracoscopic surgery (VATS) wedge resection of the right upper lung lobe for diagnostic and therapeutic reasons. Pathological analysis of this tissue confirmed the diagnosis of aspergillus fumigatus although microbiological cultures remained negative. Accordingly, a diagnosis of invasive aspergillosis with cerebral, pulmonal and adrenal manifestations was rendered. Over the course, antibiotics were deescalated to clindamycin, antifungal regime was continued with isavuconazole, and the patient discharged.We present the unusual case of an immunosuppressed patient suffering from unexpected superinfected invasive aspergillosis with cerebral, pulmonal, and adrenal manifestations, mimicking a metastasized bronchial carcinoma.Central nervous system (CNS) infections with aspergillus are rare and potentially fatal , 4. MicrThe presented patient was receiving immunosuppressive medications, including corticosteroids (after kidney transplantation). Thus, she harbored an increased risk for developing neuroaspergillosis. Her clinical findings were limited to a single tonic-clonic seizure and imaging features were nonspecific. The presented case illustrates that despite the unspecific clinical findings, it is important to include fungal infections in the differential diagnosis, especially in the setting of immunosuppression from whatever cause. Interestingly, the situation was complicated by a concomitant bacterial infection. The intraoperative findings were atypical in this regard and only microbiological cultures revealed streptococcus infection. Although superinfections are recognized in patients who are immunocompromised undergoing surgery, the detection of a bacterial infection may further confound establishing the definitive diagnosis, as in the presented case. Panfungal PCR from CSF (samples taken before starting the antibiotics) were negative. Although PCR from CSF is considered an experimental diagnostic methodology, it may prove helpful in certain cases. In the present case, however, the definitive diagnosis of aspergillus infection could only be established after histological examination of the resected mass, which is considered the gold standard.In conclusion, invasive aspergillosis of the CNS is a rare but increasingly prevalent disease, especially in immunocompromised patients. The infection may be isolated or combined with other infectious diseases. Accordingly, a high index of suspicion should be maintained in the setting of immunosuppression. Clinical and radiological findings are often unspecific and even misleading. Definite confirmation usually relies on tissue diagnosis with histochemical stains. Surgical resection is crucial for establishing the diagnosis and guiding therapy with targeted antifungal medications.


Posterior epidural migration of lumbar disc fragment (PEMLDF) is a very rare condition that may lead to a serious neurological deficit such as cauda equina syndrome. Magnetic resonance imaging (MRI) findings can often result in cases of PEMLDF being misdiagnosed as extradural masses of other origin or epidural hematomas. In this study, we reported four additional cases of PEMLDF and reviewed the relevant literature.We present four patients with PEMLDF. The mean age of the patients was 53.5 years. Two patients suffered from cauda equine syndrome, and the other two patients complained of radiculopathy.The MRI findings in each case showed masses with slightly high signal intensity in T2-weighted images, as well as heterogenous and peripheral rim enhancement after contrast enhancement. In some patients there was a tract-like enhancement extending from the outer aspect of the disc to the posterolateral epidural space. A definitive diagnosis was made intraoperatively.We performed laminectomy and discectomy in all patients.The PEMLDF patients with radiculopathy had no complaints of weakness or pain after surgery. Both patients with cauda equine syndrome showed a total recovery post-surgery.Early diagnosis and treatment via laminectomy and discectomy is critical to achieving the best postoperative outcomes. Understanding the patient's history, recognizing the similar signal intensity of the mass and intervertebral disc on MRI scans, and looking for peripheral rim enhancement, are the keys to the correct diagnosis of PEMLDF. Since Lombardi reported the first posterior epidural migration of a sequestrated lumbar intervertebral disc fragment case in 1973 approximately 120 cases have been reported in the literature.,3–6 The rarity of the condition has meant that the underlying cause of posterior disc fragment migration is not well understood. Moreover, while PEMLDF may lead to serious neurological deficit, the condition is difficult to diagnose and to treat. In this study, we report four additional cases of PEMLDF and reviewed the relevant literature. This case report has been approved by institutional review board of Jeonbuk National University Hospital, who waived the need for obtaining informed consent, because this study was retrospective.Intervertebral disc sequestration, in which an extruded disc migrates within the spinal canal, is responsible for up to 28.6% of all disc herniations.22.1A 45-year-old male presented with 1 week of progressive back pain radiating to his left leg and an acute onset of bilateral leg weakness. He had no history of trauma or surgery and no other medical illness. On the neurological examination, he was unable to dorsiflex his ankles and great toes against gravity . He also complained of voiding difficulty. Magnetic resonance imaging (MRI) of the lumbar spine indicated a somewhat heterogenous and T2-weighted hyperintense mass lesion in the left lateral and posterior epidural space at L3–4 , left lower extremity numbness, urinary incontinence and abnormal gait. The MRI demonstrated a posterior epidural mass lesion at the L4-5 level and an endplate degeneration adjacent to the L4-5 disc space Fig. . This ma2.3A 67-year-old female presented with radiating pain throughout her bilateral lower extremities that had lasted for 1 month. She showed no leg weakness. A lumbar MRI demonstrated a posterior epidural lesion at the L3-4 level with thecal sac compression . The MRI revealed a 1 cm X 2 cm sized posterior epidural mass lesion at the L3-4 level , possibly owing to the dynamics of spinal degeneration associated with aging.,9 Most commonly (40% of reported cases), posterior migration occurs at L3-L4, possibly due to the anatomical relationship between the nerve root and disc space in the horizontal plane, which appears to compromise the barrier role of the nerve root at this level.,9 In our case series, three among the four patients (75%) showed posterior migration at L3-L4.Only 120 cases of PEMLDF, including the present cases, are reported in the English-language literature. PEMLDF occurs infrequently because it requires passing through anatomical barriers such as the posterior longitudinal ligament, the peridural and lateral membrane, the epidural venous plexus, epidural fat, the nerve root, and the dura. CES is clinically rare in disc herniation cases, occurring in 1.8 per million persons within the general population. Notably, the incidence of CES is higher in PEMLDF cases. According to Elsharkawy et al approximately 50% of PEMLDF patients presented with CES and neurologic deficits. As an explanation, they suggested that the small size of the posterior epidural space is conducive to neural structure compression, increasing the chances of neurologic deficits. Among our case series, two patients (50%) presented with CES .,13 In the vast majority of cases (up to 80%), the sequestrated fragments exhibit high signal intensity on T2-weighted images relative to the degenerated disc of origin and low signal intensity on T1-weighted images. Inflammatory changes in the local environment cause an increase in fluid content in the extruded material, which is responsible for T2 hyperintensity. Chen et al suggested that high signal intensity on T2-weighted images could be explained as the result of herniated material possessing a higher water content than an intact disc. Contrast agent must be always used in order to rule out the most common topographical differential diagnosis. Most disc fragments show peripheral contrast enhancement, which may be attributed to an inflammatory response with granulation tissue and newly formed vessels around the sequestrated tissue, as shown in this report.The gold standard for diagnosis is a gadolinium enhanced lumbar spine MRI scan.MRI findings can be confounded by atypical images mimicking an epidural tumor, abscess, hematoma, and facet cyst, leading to diagnostic difficulty and uncertainly in management. Thus, clinicians should remain vigilant for the differential diagnosis of other diseases. Tumors usually enhance uniformly on gadolinium MR images. An epidural abscess could present as a mass with hypointensity on T1-weighted imaging, hyperintensity on T2-weighted imaging, and rim enhancement. Inflammatory involvement of the vertebral body, involvement of other intervertebral discs, as well as coherent laboratory findings may provide important clues in case of epidural abscess. A hematoma usually has isointensity or hyperintensity on T1-weighted imaging, no enhancement, and an associated trauma history. Synovial cysts have a characteristic MR imaging signal intensity, and are related to the facet joint. Takano et al used discography and disco-CT to distinguish PEMLDF from other spinal pathologies, such as malignancy, spontaneous hematoma, or epidural abscess, and make a definite diagnosis of PEMLDF. They also pointed out that discography allows surgeons to distinguish the L3-L4 lumbar disc herniation from other segments and to understand the entire aspect of the PEMLDF.Because the MRI appearances of PEMLDF are not specific and are similar to those of other posterior epidural lesions, anamnesis and laboratory findings are critical to preoperative diagnosis. A definitive diagnosis can at times be made intraoperatively. In most cases, surgery is the treatment of choice. Surgical management was carried out in 96% of the cases reviewed by Elshakawy et al, and in most cases the surgical intervention was satisfactory. Other authors have recommended that surgery should be performed without delay in patients with large sequestrated disc fragments and neurological deficits, and point out that this is particularly important in patients with CES. Laminectomy and decompression have been the surgical strategies predominantly used in cases of PEMLDF. Laminectomy ensures full exposure of the fragment and easier removal of the lesion, decreases the risk of incidental dural tear, minimizes the traction on the neural structures, and saves time, which is especially important in emergency situations. An extra discectomy may be called for, particularly when a rent is present in the posterior longitudinal ligament. Among the patients in our case series, the sequestrated disc fragment was removed either via laminectomy or hemi-laminectomy.  patients made a total recovery, 3 (4.17%) had a subtotal recovery, 15 (20.83%) showed improvement, and 1 (1.38%) had unchanged clinical condition.4PEMLDF is very rare. The condition may present with lower back pain, radicular compression, or CES. Preoperative diagnosis is difficult because of rim enhancement, which may mimic an intraspinal extradural tumor. The peripheral enhancement of the disc fragment on contrast-enhanced imaging studies is attributed to an inflammatory response with vascular granulation tissue around the disc mass. The patient history, the recognition of similar signal intensity between the mass and the intervertebral disc on MRI scans, and looking for peripheral rim enhancement are the keys to the correct diagnosis of PEMLDF.Conceptualization: Youngmin Oh.Funding acquisition: Jongpil Eun.Visualization: Youngmin Oh, Jongpil Eun.Writing – original draft: Jongpil Eun, Youngmin Oh.Writing – review & editing: Jongpil Eun, Youngmin Oh.


Spinal intradural arachnoid cysts (SAC) are non-neoplastic lesions that can cause spinal cord compression and present with myelopathy, radiculopathy, and/or back pain. Because these cysts typically span multiple levels, endoscopy could be a useful tool to avoid wide exposure. We present an 8-year-old patient with a history of gait imbalance and urinary incontinence who was found to have a SAC spanning C7 to T6 causing spinal cord compression. An osteoplastic laminoplasty was performed from T4 to T7 followed by ultrasonic verification of intracystic septations, dural opening, and cyst fenestration. A flexible endoscope was then introduced into the cystic cavity to guide complete rostral and caudal decompression of the arachnoid cyst. At six months follow-up, the patient was able to ambulate independently, but his urinary incontinence remained unchanged. Despite the combination of ultrasound and neuroendoscopy to minimize exposure, our patient suffered from worsening kyphosis from 36 degrees preoperative to 55 degrees postoperative and worsening scoliosis from 17 to 39 degrees which required treatment with a thoracolumbar sacral orthosis. Preoperative imaging demonstrated a reverse S-shaped scoliosis with the apex at T6 and T7 which were the levels included in the laminoplasty. This illustrates the need for careful preoperative risk stratification to avoid this postoperative complication. Spinal intradural arachnoid cysts (SACs) are expansile lesions of the arachnoid space which can cause spinal cord compression . They arSACs are most frequently present in the thoracic spine and are less commonly identified in the cervical and lumbar spine . They usWe present a pediatric patient with a multilevel cervicothoracic arachnoid cyst spanning C7 to T7, causing ataxia and urinary incontinence. We performed a fluoroscopic guided T4 to T7 osteoplastic laminoplasty, followed by ultrasound verification, and then flexible endoscopic-assisted cyst fenestration and confirmation.An 8-year-old male with a history of lumbosacral myelomeningocele and shunted hydrocephalus presented with two months of ataxic gait with inability to ambulate independently and worsening urinary incontinence with frequent and incomplete bladder voids despite botox and muscarinic agonist. An MRI of the spine demonstrated a non-enhancing cystic lesion extending from C7 to T7 with severe cord compression suggestive of an intradural arachnoid cyst which measured 9.2 cm in craniocaudal and 1.5 cm x 1.3 cm in the transverse dimensions  egressed under high pressure. Intracystic flexible endoscopy demonstrated additional caudal and rostral septations which prompted wider bony removal and cyst fenestration until a dark cavity and free-flowing CSF were visualized with the endoscope Figure .At one month follow-up, the patient’s gait had significantly improved. He was walking and running independently, but his urinary incontinence was unchanged from preoperative. An MRI at three months demonstrated worsening thoracic kyphosis without change in cystic mass Figure . Thus, sConventional treatment of SACs includes excision, fenestration, or cysto-peritoneal shunting via open laminectomy or laminoplasty. No surgical guidelines exist and specific treatment is tailored based on the location, size, and morphology of the SAC. All three techniques have shown efficacy in the literature ,6,7,10  fenestration despite minimal access surgery. Endoscopy and ultrasound are useful technologies to treat SACs that span multiple levels. Though these tools may help reduce surgical exposure, preoperative evaluation for kyphoscoliosis with clinical examination and/or scoliosis films should be done before performing multilevel laminectomy or laminoplasty in the pediatric population to reduce the risk of postoperative worsening spinal deformity.