Carotid body tumors (CBTs) are certainly unusual. They are vascular lesions originating from paraganglionic cells, located at the common carotid artery (CCA) bifurcation. They represent less than 0.5% of head and neck tumors, approximately 1-3 cases per million. Malignant CBTs are extremely rare; in the literature, published rates on average are < 10%. The diagnostic criteria for malignancy should be based on the finding of distant metastasis. Due to its unpredictable nature and its malignant potential, diagnosis before metastasis and complete surgical resection are the keys to a favorable prognosis.Given little experience in CBTs, its biology and treatment remain uncertain. We present the case of a 48-years-old patient, with a mass on the left side of the neck that was found to be a vast CBT with suspicious histopathology. Its size, rare location, pathologic findings, and management strategy applied for its treatment, illustrate an unusual case that highlights the importance of its publication.CBT is rare, but subject to cure lesion if resected without metastatic or residual disease. This is why surgery should be performed whenever possible and why it is so necessary to study this pathology thoroughly and to take it into account in the differential diagnosis. The carotid body is a small structure, located in the adventitia of the CCA bifurcation. Part of the sympathetic nervous system, is composed of chromaffin-negative glomus cells and works as a vascular chemoreceptor. CBTs are a rare group of non-functional, slow-growing, mostly benign tumors, originating from paraganglionic cells of the carotid body . They reShamblin III tumors or “Giant” CBTs are extremely rare and management of such highly vascular lesions could represent a complex challenge ,5. MaligA 48-year-old female patient, from Bolivia , consultA Magnetic Resonance Image (MRI) was requested to evaluate the extent of the lesion and its anatomic characteristics, to allow staging and surgical planning. It showed a voluminous expansive lesion centered in the left carotid space, compatible with paraganglioma of the carotid body with a maximum diameter of 100 mm .The left ICA, the ECA, as well as the left internal jugular vein (IJV) were displaced dorsally and compressed at the level of the proximal and middle section of the cervical segment (C1), with an absence of flow signal. The study also showed an alteration in the intracranial flow signal, linked to slow/absent antegrade flow due to the cervical compression of the ICA described above, possibly associated with arterial circle substitution. To clarify the case, a carotid angiography  was perfTo accurately predict the possible consequences of direct ICA ligation, a balloon occlusion test (BOT) was carried out. The patient tolerated the study adequately, without developing a neurologic deficit. There were no manifestations of hypo perfusion after measuring the cerebral blood flow, cerebral blood volume, and mean transit time. These results showed that an ICA sacrifice without the need for bypass could be performed. The case was discussed by a multidisciplinary committee and surgical treatment was decided. Due to the size of the lesion and vascular compromise, we performed a mandibular swing approach, to ensure an adequate surgical field. The mass was fixed to the sternocleidomastoid muscle and the external jugular vein. Dissection started at the CCA caudally and then progressed cranially towards the bifurcation. To attempt negative margins, the ICA and IJV had to be sacrificed. The vagus nerve was encased 360º by the tumor, above and below the carotid bifurcation, so it was resected. The hypoglossal, glossopharyngeal nerves, and the high cervical plexus were preserved.After the intervention, the patient was extubated and remained in the Intensive Care Unit for the first 48 hours postoperatively. Blood transfusions were not necessary during or after surgery, accounting for an approximate blood loss of 500 ml. Pathological analysis of the piece revealed a characteristic Zellballen pattern, suggestive of a CBT. Although atypical mitoses were not identified, we found confluent necrosis and infiltration of the capsule among the piece, characteristics highly associated with malignant behavior  Fig5)..Fig5).With the sacrifice of the vagus nerve, signs of its functional impairment were revealed. The patient presented dysphonia due to ipsilateral vocal cord paralysis, which was subsequently resolved with voice re-education by a speech therapist. She had no subjective difficulty swallowing. The patient did not manifest any ischemia-related symptoms.The aesthetic result was adequate and, in the year following the intervention, there were no signs or symptoms of disease recurrence.CBTs are an infrequent group of neuroendocrine neoplasms, originating from paraganglionic cells of the carotid body, located at the CCA bifurcation. The incidence of these tumors is around 1-3 cases per million inhabitants per year . They tyCase presentations can be sporadic or familial. Familial cases are usually bilateral, synchronous, or metachronous; and may be associated with other paragangliomas . In any Part of the sympathetic nervous system, they arise from chromaffin-negative glomus cells of the paraganglia . CloselyAlthough the gold standard of diagnosis for malignancy should be based on distant metastasis ,18, someTimely surgery is the optimal treatment and the key to a favorable prognosis. The reasons for performing surgical resection are a) malignant transformation; b) no reliable screening mechanism for monitoring tumor progression; c) eventually they could become symptomatic; d) the risk of vascular or neurological injury is acceptable in appropriate hands . The difBiopsy to confirm diagnosis should be avoided as it could represent a risk, due to the high vascularity of the lesion. Resection of these tumors requires an accurate preoperative assessment of vessel anatomy and probable consequences of interrupting blood flow. BOT and techniques to maintain vascular flow when a graft is required, have notoriously reduced surgical complications . In our In most cases, separation of the tumor from the carotid artery could be achieved by meticulous dissection in the subadventitial plane, as described by Gordon-Taylor . If resection of the ICA along with the tumor is necessary, intraluminal vascular shunts or vascular reconstructive techniques using autogenous vein grafts or prosthetic material could be performed . FortunaThe indications should, therefore, be limited to only unresectable tumors or non-operable patients. A wait-and-see policy has also been proposed, in some particular cases, since most paragangliomas grow slowly (33). If there is a risk of major postsurgical functional complications, it should be considered. Beyond the selected treatment, careful follow-up of all patients with CBTs is crucial considering the prolonged intervals between initial diagnosis and recurrence, as well as the infrequent but possible late metastasis.CBTs are unusual but treatable lesions if resected without metastatic or residual disease. This is why surgery should be performed whenever possible.


Pilonidal sinus is a common problem encountered in proctology clinics. It has a wide spectrum of clinical picture ranging from a single asymptomatic pit to a more complex disease with multiple sinuses and secondary openings. Hence, the treatment options could range from observation or simple excision to a more radical approach like flap surgeries. Ultrasonographic assessment could help in mapping the extent of the pilonidal sinus. It can also identify whether the sinus is infected or has formed an abscess. With the above-mentioned information provided by the point of care ultrasound, the surgeon can tailor the surgical approach to each individual case and improve the overall outcome. In this article, we are highlighting some examples of cases managed in our proctology unit where ultrasound was done preoperatively and guided the management. The term “pilonidal” was given by Richard Hodges as a description of the pilus and nidus, or hair and nest The ideal management and surgical treatment of pilonidal sinus disease is still debatable. Depending on the clinical presentation and surgeon’s assessment, the surgical approach can range from simple incision to flap surgeries. Ultrasound scanning is an undervalued non-invasive method of examination widely used in medicine. Endoluminal ultrasonography was first introduced in 1989 for the assessment of anal and rectal disorders by Law and Bartram, and has since become essential in coloproctological practice Ultrasonography is crucial in assessing different anorectal pathologies, mainly abscesses, fistulas, and sphincter defects. In our center, preoperative point of care ultrasound (POCUS) is performed by the same surgeon who will be operating on the patient. This practice, in comparison to departmental ultrasounds done by radiologists, yields better post-operative results and lower rates of recurrence. Here we present examples where bedside POCUS was done for pilonidal sinus disease cases and how it helped in guiding the operative management for optimal patients’ outcome.A 23-year-old female presented with a history of acute pain at the natal cleft area. POCUS revealed a small pilonidal cyst with no craniocaudal extension. The patient underwent localized excision .A 19-year-old male presented with a long-standing history of discharge from two openings at the upper part of the natal cleft. He had multiple pits at the midline. POCUS showed the sinus tract extending from the midline up to the secondary openings. A modified Lord Millar excision was done .A 21-year-old male with a past history of pilonidal sinus surgery presented with a history of swelling at the site of the previous operation. POCUS was done by the attending proctologist and showed a recurrent pilonidal sinus with abscess formation. An incision and drainage were done along with the removal of the single pit . It is commonly believed that complementary investigations are rarely needed because the diagnosis of pilonidal sinus disease is a clinical one. However, sonography is an important diagnostic tool that is cost-effective, time-efficient, and able to visualize superficial structures proficiently. Ultrasonography is particularly useful in the evaluation of pilonidal sinus disease as it provides the ability to perform a soft tissue exam of the natal cleft and visualize the track in any plane necessary at the level above the coccyx Ultrasonography can accurately evaluate the dimensions and shape of the pilonidal sinus pre-operatively and can therefore improve the management. Using ultrasonography, the surgeon can identify how far the tract is extending and the direction it is extending in, whether caudally or cranially. The surgeon can also identify whether the sinus is infected or has formed an abscess. With the information mentioned above provided by ultrasound imaging, the surgeon can tailor the surgical approach to each case and improve the overall outcome.A study done Mentes O et al.In brief, ultrasound in pilonidal sinus disease has a role in diagnosing, assessing the disease extent, presence or absence of abscess formation, and in detecting recurrent cases.Point of care ultrasound performed by surgeons is a useful non-invasive diagnostic tool in assessing pilonidal sinus. It can help tailor the surgical approach and map the extent of the disease preoperatively.This publication complies with the guidelines for human studies and conducted ethically in accordance with the World Medical Association Declaration of Helsinki. Ethical approval was not required for this case report in accordance with the Dubai Scientific Research Ethics Committee policies. Witten Informed Consent for publication of the case report and any accompanied images was obtained from the patients.There are no conflict of interests to declare.The authors did not receive any funding.All data generated or analyzed during this case report are included in this article. Further enquiries can be directed to the corresponding author.


Endosalpingiosis is occasionally incidentally found on histopathologic examination of gynecologic or gastrointestinal specimen, most commonly in the ovary, fallopian tube, omentum and uterus. Recently an association between endosalpingiosis and, ovarian and uterine cancer has been described. Here, we describe a rare case of appendiceal endosalpingiosis mimicking appendicitis. Further prospective studies are required to elucidate the clinical significance of appendiceal endosalpingiosis, the potential association with gynecologic malignancy and implications for management. Appendiceal endosalpingiosis is a reportedly rare entity with only few case reports in the literature . Endosal9 cells/L, neutrophils 2.5 × 10^9 cells/L, C-reactive protein of 9.5 mg/L, while creatinine was slightly elevated at 96 μmol/L and electrolytes were within normal limits. She was incidentally found to be COVID-19 positive, however, was asymptomatic and was fully vaccinated. As her abdominal symptoms continued, she was taken to the operating theatre for a laparoscopic appendicectomy. This was completed unremarkably, with intra-operative macroscopic appearance of a thickened appendix without other abnormality, and the specimen routinely sent for histopathology. She was subsequently discharged from hospital without complication with resolution of her pain. Histopathology demonstrated mild acute mucosal appendicitis with occasional endometrial type glands with no stroma nor hemosiderin-laden macrophages, in keeping with endosalpingiosis (A 56 year old woman presented to emergency with seven days of abdominal pain. Her pain was initially dull and within the peri-umbilical region before migrating to the right iliac fossa and becoming sharp and constant. The pain was associated with subjective fevers and anorexia. There were no bowel or urinary symptoms reported. The patient was post-menopausal and before presentation was previously well with no significant past medical history; her only surgical history included two lower segment caesarean sections. She was seen by her general practitioner who arranged for an outpatient CT of the abdomen and pelvis with oral and intravenous contrast, undertaken on day six of symptoms. CT findings demonstrated a thickened appendix measuring up to 11 mm, reported as consistent with acute appendicitis. There was no significant fat stranding, intraperitoneal free fluid, nor gas, and the CT was otherwise unremarkable . Upon pringiosis . There wEndosalpingiosis is typically considered the presence of ectopic benign glands lined by tubal-type epithelium in the peritoneum or subperitoneal tissues . It is mEndosalpingiosis of the appendix is much rarer, with only five case reports within the literature . A largeEndosalpingiosis has been associated with ovarian and uterine cancer. Hermens et al.  reviewedThere is scant literature regarding a potential association between appendiceal endosalpingiosis specifically and gynecologic malignancy. There are no reported rates of endosalpingiosis in series of patients undergoing appendicectomy for suspected appendicitis, as in the currently reported case. Esselen et al. did not present subgroup analysis of the association between their 20 cases of appendiceal endosalpingiosis and ovarian or uterine cancer. The association between endosalpingiosis and gynecologic malignancy may be clinically relevant to endosalpingiosis in acute appendicitis; however, future research is required to further explore this.In summary, we present a rare case of appendiceal endosalpingiosis as a mimic for appendicitis. Similar to the few reported cases in the literature, pain improved upon appendicectomy. There is limited data to extend the reported association between endosalpingiosis and gynecologic malignancy to appendiceal endosalpingiosis. It is therefore unclear whether patients with incidental appendiceal endosalpingiosis should be offered further investigation or closer monitoring for earlier detection of possible uterine or ovarian cancers. Further studies are required to more closely examine the relationship between appendiceal endosalpingiosis and gynecologic malignancies in order to assist surgeons who encounter this potentially under-reported mimic for appendicitis.The authors declare that there is no conflict of interest regarding the publication of this paper.None.


Anastomosing hemangioma (AH) is a rare vascular tumor and occurs in various organs. It is difficult to distinguish AH from malignant tumors even through multimodal imaging examination. AH located in the inguinal region is even rare. We present the diagnosis and treatment of a patient with spermatic cord AH in detail and conduct a literature review.An 84-year-old Chinese man had swelling pain in his right scrotum. A hard and fixed mass was palpable in the right inguinal region. Preoperative radiological examination considered it a neurogenic or vascular tumor. Malignant soft tissue sarcoma could not be excluded. He underwent radical inguinal right orchiectomy under intraspinal anesthesia. The diagnosis of spermatic cord AH was confirmed by pathological examination. The patient recovered uneventfully and remained disease-free during an 18-month follow-up.Spermatic cord AH is quite rare and could be misdiagnosed as a malignant tumor. Pathological evidence might be necessary. The optimal choice of treatment should be determined through a comprehensive assessment of both tumor and patient factors. Anastomosing hemangioma (AH) is a rare subtype of vascular tumor. Montgomery and Epstein reported the first AH case in 2009 . ThereafAn 84-year-old Chinese man came to our clinic complaining of swelling and pain in his right scrotum for 1 week. He could touch a mass in his right inguinal region. Upon physical examination (PE), a 3.0 × 1.5 cm hard and fixed mass could be touched in his right inguinal region. Droppler ultrasound (US) examination was performed initially. A 2.9 × 1.2 cm solid-cystic (predominantly solid) mass could be observed in the right inguinal region. There were abundant blood flow signals within the mass. The spermatic cord was swollen with a high echo. No obvious hernia contents or enlarged lymph nodes were observed when abdominal pressure increased . The radTo learn about the properties, blood supply, and anatomical position of the mass, an abdominal and pelvic contrast-enhanced computed tomography (CE-CT) scan was performed thereafter. A 2.3 × 1.3 cm heterogeneously enhanced mass with soft tissue density was seen inside the right inguinal canal . HypodenAfter intraspinal anesthesia, an oblique incision was made along a Langer line, 2 cm superior and parallel to the right inguinal ligament. The inguinal canal was exposed after incising the external oblique aponeurosis. We transected the cremasteric muscle and exposed the spermatic cord. The mass was palpable within the spermatic cord. The spermatic cord was then dissected bluntly from the mass toward the cephalad direction. Gonadal vessels and vas deferens were separately ligated with absorbable sutures at the deep inguinal ring level. Blunt dissection of the spermatic cord in the caudad direction was performed thereafter. The right testis along with its tunica vaginalis was retracted into the surgical area and completely resected. After careful hemostasis, the fascial layers and skin were sutured. The ilioinguinal nerve was well identified and preserved during the whole surgical procedure.Grossly, a 1.5 × 1 × 0.8 cm gray-white solid mass could be seen on the sagittal section of the resected specimen. The mass was 1 cm away from the cutting edge of the spermatic cord, 5.5 cm from the testis, and 5 cm from the epididymis. There was no clear boundary between the mass and its adjacent tissues. Microscopically, the mass showed typical features of a vascular tumor. It was composed of irregular, anastomosing capillary-sized vessels. The lumina of those vessels were lined by a monolayer of oval endothelial cells. Some of them showed a hobnail appearance. Those endothelial cells had a mild cellular morphology lacking nuclear atypia and mitoses. Focal short spindle stromal cell hyperplasia could be observed within the spermatic cord. Atrophy in adjacent seminiferous tubules was observed in the right testis. There was no obvious lesion in both resected testis and epididymis. The margin status was negative. Immunohistochemical (IHC) staining showed positive staining of endothelial markers—CD31, CD34, and ERG. Desmin, inhibin-α, S-100, and NSE were negative. The Ki-67 rate was low (approximately 2%) . SMA wasThe patient recovered uneventfully after surgery and was discharged 4 days later. During the 18-month follow-up, the patient reported no local discomfort. PE and abdominal US examination showed no disease recurrence. He expressed satisfaction over the treatment. The timeline of the presented case is summarized in To learn more about this rare subtype of vascular tumor, we searched PubMed, Web of Science, and EMBASE for all AH cases reported in English before September 1, 2021. Fifty-three publications , includiAH patients’ age varies from 1 to 85 years. There are more male patients than females. Most genitourinary AHs locate in the kidney, while the para-vertebral region is the most frequently involved region in non-genitourinary patients . The tumSupplementary Figure SCurrently, there is a lack of specific imaging features for a definite diagnosis of AH, but some common presentation is already confirmed. AHs usually show a hypoechoic or anechoic cystic lesion on US , 26, 57 Our patient showed a hypoechoic mass with a prominent blood circulation signal on US. The mass was peripherally isodense with centrally hypodense cystic components on non-contrast images and could be heterogeneously and avidly enhanced. Along with its characteristics on MRI , it showed similar imaging features to the previously reported AHs, while it lacked the typical filing pattern of hemangiomas on CE-CT. Radiologists from our center considered the initial diagnosis of neurogenic tumors such as schwannoma. Schwannoma is a benign peripheral nerve sheath tumor (PNST), which may also present as a hypoechoic cystic mass on US. On MRI, schwannoma shows hypo- or iso-intensity, compared with adjacent muscles on T1WI and high intensity on T2WI, especially on the periphery. Cystic degeneration may also exist on CT/MRI. However, typical characteristics, such as nerve entering or existing the mass, “fusiform” shape, “split-fat” sign, and “target” sign, were absent in our case , 59. MorThere exist controversial opinions on the optimal way to acquire pathological specimens in this circumstance. According to a literature review, all genitourinary AH cases underwent surgery, while some non-genitourinary cases chose relatively conservative treatment 2E. ImageAccording to the literature, the majority of AHs have a clear margin but lack a definite capsule and usually present a hemorrhagic “mahogany brown”  or “red-Our patient presented a gross gray-white appearance, which was distinct from the reported AHs. Rather than a neurogenic tumor, the microscopic histological features revealed typical features of an endothelial vascular tumor reminiscent of spleen sinusoids, and malignant morphologic signs of angiosarcoma were absent. CD31, CD34, and ERG were positive in IHC staining. ERG is also an endothelial marker, but it is more specific and sensitive than CD31 or CD34. ERG (+) has also been reported previously in AH patients , 44, 53.Overall, AHs have a benign course. In the literature review, follow-up time ranges from 0.5 to 156 months. Few instances of recurrence or metastasis were reported, except for two unique cases. One was an intracranial AH , and theThere exist some limitations in the current study. IHC staining of some markers like D2–40, GLUT-1, and HHV-8, which may help to exclude lymphatic tumors and other vascular tumors, was absent. The follow-up time is not so long to evaluate recurrence and tumor-specific survival.Spermatic cord AH is quite rare and could be misdiagnosed as a malignant inguinal tumor. Pathological examination is necessary when the diagnosis cannot be made through multi-modal radiology assessment. The optimal choice of treatment should be determined through a comprehensive assessment. If the mass has a high risk of malignancy and the patient may not benefit from percutaneous biopsy, a meticulously tailored surgery might be a reasonable choice.


Isolated endotracheal neurofibroma is very rare. The majority of neurofibromas are benign, but rarely, they can become cancerous. Furthermore, symptomatic neurofibroma is usually treated by surgical resection. Recently, several alternative options for surgical resection of this airway pathology have been suggested and developed, including bronchoscopic cryotherapy. Nevertheless, there has been no report on the application of repeated flexible bronchoscopic cryotherapy to remove an endotracheal neurofibroma.A 65-year-old woman presented with progressive dyspnea and productive cough. Chest computed tomography scans revealed a 1.5-cm polypoid-shaped mass with fat attenuation and mild enhancement in the distal trachea. Flexible bronchoscopic cryotherapy was performed to remove the mass and confirm the diagnosis.Pathologically, the mass was diagnosed as an endotracheal neurofibroma occupying the distal tracheal lumen.The endotracheal neurofibroma was completely removed with repeated flexible bronchoscopic cryotherapy instead of surgical resection.Follow-up flexible bronchoscopy also revealed that there was no regrowth of the neurofibroma. Up to 18 months after the completion of serial cryotherapy, the patient had no recurrent symptoms or complaints.Flexible bronchoscopic cryotherapy can be performed repeatedly for therapeutic purposes for airway tumors. It is recommended to consider flexible bronchoscopic cryotherapy as an alternative therapeutic option for patients with central airway obstruction due to tumorous lesions such as neurofibromas. Neurofibroma is generally associated with neurofibromatosis type I; however, solitary neurofibromas can develop. The majority of neurofibromas are benign, and rarely, they can become cancerous. It has been reported that up to approximately 10% of neurofibromas may undergo malignant change. In terms of treatment, neurofibromas usually need no treatment for a single, small  tumor in the skin. However, in the case of neurofibromas developing in particular organs, symptoms can be caused by the mass pressing on nearby tissues or by damaging organs. Although the type of surgery depends on the location of neurofibroma, surgical resection has been accepted as the standard treatment for symptomatic neurofibromas.Neurofibroma is a benign nerve sheath tumor usually located in the posterior mediastinum that originates from a proliferation of Schwann cells, fibroblasts, perineural cells, and mast cells. Cryotherapy causes the lesions to become dehydrated and damaged by deep-freezing-induced vascular injuries, including platelet aggregation, high blood viscosity, vasoconstriction, formation of microthrombi, and tissue ischemia. Based on this principle, cryotherapy has been used to freeze off cancer cells and to remove several types of neoplasms.Cryotherapy is a semi-invasive therapeutic tool for treatment of various pathologic lesions; it uses a cryoprobe at freezing or near-freezing temperatures. The principle of cryotherapy is that when a variety of pathologic lesions are exposed to very low temperatures, the tissues are frozen quickly at the same time and are fatally injured, resulting in cellular damage and local destruction of the target lesions. Since then, bronchoscopic cryotherapy has frequently been used to relieve endobronchial obstruction by extracting foreign bodies and reducing or removing malignant tumors. Despite the fact that bronchoscopic cryotherapy has been widely available and the related techniques and devices have been developed, currently, its use on benign masses of the central airway is unfamiliar to the majority of physicians. Moreover, the application of flexible bronchoscopic cryotherapy to treat tracheal obstructing masses is extremely rare.In 1968, the first bronchoscopic cryotherapy was performed on an endobronchial tumor by Gage et al.Here, we present an unusual case of a 65-year-old woman who reported shortness of breath due to an endotracheal neurofibroma; she was successfully treated with repeated flexible bronchoscopic cryotherapy.A 65-year-old woman was admitted to a tertiary hospital due to dyspnea of modified Medical Research Council Dyspnea Scale grade 2 and productive cough. According to her history, she had undergone choledochojejunostomy for a choledochal cyst type I 13 years ago. She also had been taking antihypertensive medications for 3 years. She was a nonsmoker and a social drinker. She had no specific family history. Physical examination revealed stridor at the substernal area, but no other remarkable findings such as skin lesions were observed. Pulmonary function test data revealed a forced vital capacity of 2.92 L (111% predicted), forced expiratory volume in 1 second of 2.16 L (114% predicted), forced expiratory volume in 1 second/forced vital capacity of 74%, and no bronchodilator response. Chest computed tomography scans revealed a 1.5-cm polypoid-shaped mass with fat attenuation and mild enhancement in the distal trachea (Fig. Flexible bronchoscopic cryotherapy was performed to remove the mass and confirm the diagnosis Fig. D–F. GrosWe recommended surgical resection or rigid bronchoscopic removal as the standard therapeutic option. The patient rejected surgical treatment and rigid bronchoscopy due to the fear of general anesthesia. Therefore, we decided to perform serial flexible bronchoscopic cryotherapies to remove remnants of the neurofibroma. A total of 6 flexible bronchoscopies were done at a 1-week interval. When each intervention was finished, the procedure site was observed to be covered by exudate and necrotic debris. As the procedure was repeated, the amount of exudate and necrotic debris decreased, and the cryotherapy-induced damaged lesions changed into fibrotic tissues (Fig. Follow-up examinations were performed 1 month after the completion of the final intervention. There was no evidence of recurrence of neurofibroma on computed tomography scans Fig. A, B. On  In the current case, symptomatic endotracheal neurofibroma was treated by repeated flexible bronchoscopic cryotherapy.Neurofibromas are usually associated with neurofibromatosis, especially type I. Isolated or solitary neurofibromas can occur without neurofibromatosis. The posterior mediastinum is the most common site of neurofibromas, and isolated endotracheal neurofibromas are rare pathologic conditions. Currently, the standard therapeutic option for neurofibromas causing clinically significant symptoms is surgery. For various airway pathologic conditions, interventional bronchoscopy has yielded clinical benefits as an alternative to surgery, thanks to the advancement of bronchoscopic technology. Recently, bronchoscopic cryotherapy has received attention from many physicians for its application to various types of endobronchial and endotracheal pathogenic conditions. Furthermore, the European Respiratory Society and American Thoracic Society guidelines recommend possible use of bronchoscopic cryotherapy for treatment of low-grade or noninvasive airway malignancies, foreign body removals, transbronchial biopsies, and endobronchial biopsies. Cryotherapy yields clinical benefits by reducing pathologic tissues induced by rapid freezing of tissues, resulting in cell destruction and death. Therefore, bronchoscopic cryotherapy must be performed with caution to avoid accidental freezing injury of tissues adjacent to the target pathologic lesions. Tissues containing high water content are more sensitive to cryotherapy and are more easily damaged. The freezing-sensitive tissues include tumors, granulation tissue, skin, mucous membranes, nerves, and endothelium; fat, cartilage, nerve sheath, connective tissue, and fibrosis are relatively freezing-resistant due to their low water content.Cryotherapy is a semi-invasive procedure with low risk of complications, although cryotherapy-associated complications include bleeding, cardiac arrhythmias, bronchospasm, and death.Given that neurofibroma is caused by proliferation of Schwann cells, fibroblasts, perineural cells, and others, neurofibroma appears to be less sensitive to cryotherapy. Very few case reports have shown the therapeutic efficacy of cryotherapy for neurofibromas in the central airway. In our current case, we performed repeated flexible bronchoscopic cryotherapies to remove an obstructing neurofibroma in the trachea. This strategy was appropriate to manage a tumor less that is sensitive to cryotherapy. The trachea is mostly composed of hyaline cartilage. Therefore, it may be hypothesized that the normal trachea structures were relatively tolerant and less likely to be damaged during cryotherapy. Based on these considerations, we could perform repeated bronchoscopic cryotherapy without any significant local complications such as tracheal stricture or perforation due to repetitive cryoinjuries of the adjacent normal tissues.In conclusion, this case report is the first to highlight the therapeutic effects of repeated flexible bronchoscopic cryotherapy for a symptomatic endotracheal neurofibroma. Because there has been little information regarding the safety and efficacy of repeated bronchoscopic cryotherapy on central airway obstruction, it is worth noting that flexible bronchoscopic cryotherapy can be performed repeatedly within short durations for therapeutic purposes. This case report is expected to provide physicians with an alternative for patients with central airway obstruction due to tumorous lesions such as neurofibromas.This study was performed under a project entitled “Medical school students training program: Dream of being a Nobel Prize Winner,” part of the Research Center for Pulmonary Disorders at the Jeonbuk National University Medical School and Research Institute of Clinical Medicine of the Jeonbuk National University, Biomedical Research Institute at the Jeonbuk National University Hospital.All authors have read and approved the article, and significantly contributed to this article.Conceptualization: Yong Chul Lee, So Ri Kim.Data curation: Ji Soo Yoo, So Ri Kim.Investigation: Yeong Hun Choe, Yong Chul Lee.Writing – original draft: Ji Soo Yoo, So Ri Kim.Writing – review & editing: So Ri Kim.


Mixed gonadal dysgenesis is a rare congenital and challenging condition, characterized mainly by 45,X/46,XY karyotype mosaicism, asymmetrical gonadal development and various internal and external genital anatomy. Because of frequent disorder of genital development and a higher risk of germ cell neoplasia, management of these patients is complex and requires multidisciplinary approach.We present a 45,X/46,XY mixed gonadal dysgenesis patient diagnosed with gonadoblastoma in both gonads after bilateral gonadectomy at 1 year of age.Because of high risk for malignant transformation, gonadectomy of a streak-like gonad and biopsy with orchidopexy or gonadectomy of a dysgenetic testicle is recommended at an early age. The index patient was born with ambiguous genitalia. Clinical examination revealed posterior penoscrotal hypospadia, unpalpable gonads and bilateral inguinal hernias. Transabdominal ultrasound (US) examination revealed 2.81 cm length uterus: 1.07 cm cervix, 1.74 cm fundus and 3.0 × 1.94 cm vagina. Cardiac US revealed atrial septal defect and bicuspid aortic valve. Abdomen and pelvic magnetic resonance imaging showed normal size horseshoe kidney, anteversion of uterus, minimal hydrocolpos: dilated vagina to 1.4 cm and persistent urogenital sinus. Moreover, on the left near the uterus, a 1.0 × 0,5 cm structure was seen that resembled an ovary. On the right near the bladder a 2.0 × 0.7 cm cystic structure was visualized that connected to the uterus like a fallopian tube. Serum hormone levels presented in Laparoscopic gonadectomy, cystovaginoscopy and bilateral inguinal hernia repair operations were performed at the age of 1 year and 2 months. A dysmorphic gonad resembling a dysgenetic testis was removed from the left and a streak-like gonad from the right. Gonads were sent for pathological evaluation and biopsies from the dysmorphic gonad and umbilical skin sent for genetic evaluation. Cytogenetic analysis of the cultured peripheral blood samples showed high-level Turner syndrome mosaicism with presence of Y chromosome – 45,X[32]/46,XY[3]. Karyotype result of skin fibroblasts was 45,X[24]/46,XY[6]. Predominant 45,X karyotype from peripheral blood and skin fibroblasts explains Turner syndrome phenotype: short stature (patient’s height at 1 year and 3 months was lower than 3rd percentile), left side heart anomaly  and horseshoe kidney. Because of short stature growth hormone therapy was planned from 4-6 years of age. Feminizing genitoplasty was performed at the age of 1 year and 11 months.Pathology of the left gonad: dysgenetic testis containing seminiferous tubules filled with Sertoli cells and a small number of spermatogonia; deficient stroma with poorly visualised Leydig cells; epididymis and fallopian tube tissue; small undifferentiated gonadal fragment with gonadoblastoma as an appendiceal outgrowth of testicular part. Pathology of the right gonad revealed streak-like gonad with gonadoblastoma and fallopian tube tissue. Tumor imunohistochemistry is shown in DSD are mainly classified according to Consensus statement of 2006, although some modifications and suggestions are already awaiting . The incGonadal dysgenesis (GD) is a rare congenital condition considered to be the least clearly classified subgroup of DSD characterized by underdeveloped gonads due to chromosomal abnormalities or gene mutations ,6. GenerMGD is a rare condition characterized by various karyotype mosaicisms, dysgenetic gonads, and diverse anatomical findings in internal and external genitalia ,8,9,10. GD with the presence of the Y chromosome is associated with higher risk for germ cell neoplasia ,6,13,18.TSPY) [TSPY markers may increase the chance of detecting neoplastic germ cells in dysgenetic gonads. Although, positive OCT3/4 in patients younger than 2 years old suggests delayed maturation, while placental-like alkaline phosphatase (PLAP) and stem cell factor receptor (c-Kit – CD117) staining may be demonstrated in normal boys undergoing puberty [The most common tumors found in MGD are germ cell tumors ,12. GonaTSPY) . Combini puberty . TherefoIn summary, multidisciplinary approach with involvement of parents and, if eligible, patients is a necessary requirement when managing DSD patients. In many cases DSD is recognized on the first objective evaluation. It should be followed by accurate history and physical examination . Guideli


Ganglion cysts arising from tendons are uncommon lesions with an unknown cause. We present a case report of a 38-year-old female was diagnosed with an intra-tendinous ganglion cyst of the peroneus longus. She complained of right ankle swelling for 1 year and associated with pain. MRI revealed a peroneus longus intra-tendinous ganglion below the lateral malleolus with a thin wall. The ganglion cyst was surgically excised while the structure of the peroneus longus tendon was preserved. The clinical and functional outcomes were satisfactory after 1 year without recurrence. Ganglion cysts are benign soft-tissue tumors found in the hand, wrist, ankle and foot . Althouget al. reported on a ganglion found in the muscle belly of Peroneus Longus [et al. have reported a recurrent finding of a similar presentation [Ganglions arising from the Peroneus Longus tendon are uncommon. Few case reports of ganglion cysts arising from the muscle belly were published. Both Graves and Marano s Longus , 5. Kumaentation . To our A 38-year-old female, not known to have any medical illness, presented to orthopedic outpatient clinic complaining of right ankle swelling with pain for 1 year. It was increasing with time & prolonged standing or walking. The swelling affected her footwear, and she tried changing them without success. She denied any prior trauma or similar lesions. She tried NSAIDs and ankle stabilization exercises with no significant improvement. Local examination of the swelling showed 3*3-cm tender, rubbery & mobile mass distally to lateral malleolus in her right ankle. It was not reducible or pulsatile. There was no sign of infection, and her distal neurovascular examination was normal.An AP, lateral & oblique X-ray views of her ankle were unremarkable for any boney or articular abnormalities. MRI with intravenous contrast showed a peroneus longus intra-tendinous ganglion cyst that measures 25*20 mm below the lateral malleolus with a thin wall . The cysThe patient was informed of her diagnosis and prognosis. To improve her condition, she required surgical excision of the cyst, which included surgical steps and if the lesion could be removed without affecting the integrity of the tendon or if it required reconstruction. She was also told about recurrence and peroneus tendon tear. She agreed to the surgery, and informed consent was obtained.She was assessed by our anesthesia team and admitted to the hospital. In the operating room, she received general anesthesia and antibiotic. She was in a supine position with a tourniquet applied on her right thigh and inflated to 270 mmHg. She was prepped and draped in the usual sterile manner. A 3-cm incision was distal to lateral malleolus over the course of the peroneus tendon and the swelling. A cystic mass measuring 25*20 cm from the peroneal tendon was seen . After tShe was instructed to mobilize as a non-weight for 2 weeks, then progressive weight bearing as tolerated for 4 weeks without any cast or support. She started ankle stabilization and proprioception exercises 6 weeks postoperatively. She was able to return to full activities without compromising her ankle eversion or plantarflexion and wear regular footwear. At 1 year follow-up, she did not show any sign of recurrence of the cyst.They can present within muscles, menisci and tendons . GanglioGanglion cysts can be resolved spontaneously at 52–58% without treatment . Surgicaet al. described a recurrent peroneus longus ganglion that did not affect the neurological structure of the affected limb. Initially, the ganglion was treated by incision and drainage of the cyst. A month later, the lesion recurred. The ganglion was removed entirely with no cyst recurrence [In 1956 Graves reported a ganglion cyst that occupied the muscle belly of the peroneus longus. Graves only mentioned X-ray examination as a preoperative assessment of the mass that showed ‘no involvement of the bone’. Fibrosarcoma or Rhabdomyosarcoma was thought to be a preoperative diagnosis due to limited diagnostic methods . Kumar eThe patient has provided written consent for the publishing of the report.The authors declare no conflict of interest regarding the publication of this article.The authors declare that the research was conducted independently of any commercial or financial relationships.


Ovarian and fallopian tube indirect inguinal hernias are rare hernias encountered on surgical floor. Herein, we are reporting a rare happening of obstructed ovarian and fallopian tube indirect inguinal hernia in an unmarried female.A 19 years old unmarried female presented to surgical emergency with complain of swelling in left inguinal region that was about 3 × 3 cm on visual inspection from last 4 days that was associated with menstruation. Abdominal ultrasound (USG) was showing left ovarian and fallopian tube indirect inguinal hernia with preserved internal follicles and intact vasculature. The diagnosis of obstructed ovarian and fallopian tube indirect inguinal hernia was made and diagnostic laparoscopy and left sided hernioplasty was performed. Ovary was retrieved back into abdominal cavity and stitched to lateral pelvic wall.Inguinal hernia itself is a rare happening in females and the presence of ovary and fallopian tube along with other hernial content can become a topic of discussion due to rarity of this case. It is of paramount significance to diagnose such cases with great expertise in order to avoid long term complications in terms of preserving fertility among females. Early utilization of radiological investigations like USG abdomen and laparoscopic retrieval of adnexal structures are standard approach in management of such cases.Presence of ovary and fallopian tube in indirect inguinal hernia is a rare happening that need to be diagnosed and treated at earliest to avoid infertility among females. •Presence of ovary and fallopian tube as content of indirect inguinal hernia is a rare happening.•Management of ovary and fallopian tube indirect inguinal hernia should be ascertained in timely manners.•Colour doppler USG is of great significance in determining the presence of blood flow to ovary and fallopian tube.•Laparoscopically diagnosis and retrieval of hernial contents is standard of care protocol. The presence of ovary, fallopian tube and uterus as contents of inguinal hernia is a rare happening 2A 19 years old unmarried female having no known comorbidities presented to surgical emergency with complain of swelling in left inguinal region that was about 3 × 3 cm on visual inspection from last 4 days. Patient also complaint of pain in the area of swelling that was gradual in onset, and progressive in nature and associated most of the time with menstruation and no other associated symptoms. The level of swelling also changes with menstruation. The patient was vitally stable otherwise. The swelling observed in left inguinal region is given in the .Fig. 1ShOn examination patient was vitally stable except slight tachycardia (pulse rate:102/min). On examination of the inguinal region a 3 × 3 cm swelling was noted that was tender to touch, immobile, irreducible with absent cough impulse, however no skin and temperature changes were observed at the swelling site. The laboratory investigations were performed that were within reference values. Patients past medical and surgical history was insignificant. However, patient's gynaecological history was showing irregular menstruation from 3 to 5 days, however; the flow was regular.Abdominal ultrasound (USG) was also performed that was showing left inguinal hernia containing left ovary with internal follicles and vascularity, and congenital agenesis of left kidney as shown in . SimilarThe hernial sac containing gut loops and mesenteric fat were also seen on USG abdomen and pelvis. However, no other congenital or genetic abnormality was detected. The diagnosis of obstructed ovarian inguinal hernia was made and patient was prepared for surgery. After complete anaesthesia fitness patient was shifted to operation theatre and diagnostic laparoscopy and left sided hernioplasty was performed. Ovary was retrieved back into abdominal cavity as shown in A and sti3Inguinal hernia is the defined as protrusion of abdominal viscera and preperitoneal fat into the inguinal canal. Inguinal hernias are the most frequently encountered benign surgical condition that accounted for about 75 % of the cases of abdominal hernias The diagnosis of inguinal hernias is based most commonly on clinical examination and sometimes patients sign and symptoms can also be the leading points towards the nature of diagnosis, as the patients with strangulated and obstructed inguinal hernias can be differentiated on the basis of nature and severity of pain at the mass region The purpose of highlighting this particular case was not only the rare happening of ovarian inguinal hernia in females that accounted for only 3 %, but also to highlight the delicate nature of the case as far as female fertility and hernia related complications are concerned and most importantly, the association of genetically or congenitally triggered anomalies can also be the hick in such cases that need to be addressed.4It is a rare case of inguinal hernia in an unmarried female having left ovary and fallopian tube along with part of colon and mesentery as content of inguinal canal. This is a rare happening to have adnexal contents in inguinal canal accounting for only 3 % of the cases of inguinal hernias. These cases of ovarian inguinal hernias require special attention in order to avoid complications like ovarian torsion, strangulation and loss of fertility among females. In our case the diagnosis of obstructed ovarian inguinal hernia was made and involved ovary and fallopian tube were also preserved.Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.Ethical approval has been exempted by our institution because this is a case report and no new technique were carried out.Not applicable.The Guarantor of this case report is Shahzaib Maqbool.Not commissioned, externally peer-reviewed.Shahzaib Maqbool: Writing-Original draft preparation & editing.Ayesha Huma: Writing-review & editing.Muhammad Atif Khan: Performed surgery & writing-review.Muhammad Idrees Anwar, Ka Yiu Lee: review.All authors read and approved the final manuscript.All the authors certify that there is no conflict of interest regarding the material discussed in the manuscript.


Inverted papillomas (IP) are rare benign neoplasms characterized by recurrence and local aggressiveness. They account for 0.5-4% of nasal tumorsF.M.A., male, 46, was seen in August of 2008 and complained of nasal obstruction, rhinorrhea and right mild epistaxis evolving for four months. He had been previously diagnosed with IP, as confirmed by histopathology tests. CT scans of his nose and sinuses revealed an IP staged as T2 according to Krouse's staging system Nine months later, the symptoms came back. Nasal endoscopic examination showed a relapsing tumor and CT scans revealed a then T3 neoplasm The patient had relapsing tumors another three times. The last time, on September of 2010, the tumor was protruding out of both nostrils, the patient had a painful, bulging right maxilla, hypacusis, otalgia, and ipsilateral purulent otorrhea. Examination with an otoscope showed a papillomatous lesion covered by purulent effusion occluding the outer ear canal.CT scans unveiled a tumor occupying the entire nasal fossa and invading the right mastoid, accompanied by intense bone lysis .Figure 1The nasal portion of the tumor was removed and, a week later, the patient underwent a radical mastoidectomy. Histopathology confirmed the subject had a non-malignant IP .The tumor relapsed once again into the nasal cavity, the right middle ear, and the right mastoid. The patient was referred to radiotherapy and was scheduled to receive a total dose of 5000 cGy divided in 20 sessions. The tumor regressed promptly, but the patient abandoned treatment and died two months later of an unknown cause.The lateral nasal wall is the preferential primary site for inverted papillomas. Tumors of this type may invade the paranasal sinuses, the orbit, and the anterior portion of the skull baseThe signs and signals of nose and sinus disease are non-specific. There may be unilateral nasal obstruction, epistaxis, hyposmia, rhinorrhea, and repetition rhinosinusitisNose and sinus IP occurs predominantly in males, at a ratio of 4:1Differential diagnosis must consider para-ganglioma, middle ear adenoma, and endolympha-tic sac adenocarcinomaThe treatment of choice is surgical resection leaving disease-free margins. When there is temporal bone involvement, tympanomastoidectomy is an excellent choice for initial treatmentPostoperative radiotherapy (RT) is not routinely indicated due to the risk of introducing malignant disease and osteoradionecrosisDespite the rarity of inverted papillomas, they must be included in the differential diagnosis of middle ear tumors. The occurrence of otitis media in patients with a history of sinonasal IP should serve as a red flag for the possibility of temporal bone involvement


Uterine leiomyomas are rare in the pediatric population with less than 20 cases in adolescences reported in the literature. Furthermore, these masses represent a common presentation of gynecologic tumors with increasing age. We report a case of a 14-year-old female who presented with abdominal pain and increasing abdominal girth. Workup with ultrasound, CT and MRI demonstrated a large pelvic mass. Complete resection by median laparotomy was performed. The mass weighed 5,596 g and was 29.5 cm × 27 cm × 19 cm; the pathological examination confirmed the hypothesis of leiomyoma. The patient remained asymptomatic at 3 months follow up. Uterine leiomyomas are frequent benign tumors in adult women and they represent the most common indication for hysterectomy. However, leiomyomas are extremely rare at pediatric age, with less than 15 adolescent cases reported in the literature . We repoA 14-year-old Caucasian gravida 0 presented to the emergency department complaining of abdominal pain and increasing abdominal girth. Abdominal exam revealed a soft abdomen with a voluminous, partially mobile, pelvic mass extending to the level of the xiphoid process.Pelvic ultrasound revealed a voluminous mass, displacing the uterus and the ovaries and measuring approximately 20 cm. Subsequently, the patient underwent Computed Tomography (CT) scan, which confirmed the presence of an abdominal solid lesion (with size 25 cm × 18 cm), intensively vascularized, with multiple areas of impaired signals, ranging from the pelvis up to the right hypochondrium; the mass made contact with the fundus of the uterus and caused pelvic varicocele.After multidisciplinary meeting, the patient underwent percutaneous biopsy of the tumor, which showed a proliferation of bland and homogeneous spindle cells without atypia or mitosis. The cells were positive for smooth muscle actin and negative for HMB45. Considering the size of the lesion, only a morphological diagnosis of spindle cell neoplasm was rendered.Magnetic Resonance Imaging (MRI) was then performed in order to better characterized tumor's contact with nearby structures: the lesion, widely inhomogeneous, presented a large central areas inhomogeneously hypointense in the T2-weighted sequences and showed an inhomogeneous post-contrast enhancement, more evident at the periphery, and inhomogeneous restriction of diffusivity. The lower portion tightly adhered to the anterior portion of the uterine fundus, without a clear cleavage plan. The mass contacted superiorly the liver, anteriorly the rectus abdominals and posteriorly the spine (causing marked compression on the inferior vena cava); the ovaries, located medially and characterized by the presence of multiple follicles, were not involved by the tumor. Tumor markers, including Beta-human chorionic gonadotropin (β-HCG), Alfa-fetoprotein (α-FP), CA 19-9, CA-125 and CEA, were within normal limits.After multidisciplinary meeting, surgical excision of the mass was indicated. Median laparotomy was performed; upon opening, the abdomen was widely occupied from the lesion, arising from the fondus of the uterus. The left and right ovaries were inspected and found to be grossly normal . No pathGrossly the resected specimen weighed 5,596 g  and measShe did well postoperatively; the patient presented regular, painless menstrual cycles. Follow-up ultrasound three months later showed no recurrence of the lesion.Uterine leiomyomas are benign tumors that arise from the uterus' smooth muscle cells and extracellular matrix. Leiomyomas are reported in 4%–11% of the female population, and their prevalence rises with age, reaching approximately 40% by the age of 50 . These tPediatric patients with leiomyoma typically present with significant symptoms, such as abdominal pain or distensions, back pain, irregular vaginal bleeding or urine retention. These tumors produce symptoms referable to their size and location: the submucous lesions produce metrorrhagia , the intramural ones result in menorrhagia , and the subserosal ones usually remain asymptomatic. They may also become large enough to block the ureters, interfere with pregnancy, or cause inflammatory complications. Occasionally, the initial clinical scenario may include life-threatening conditions such as uremia and hemorrhagic shock –11, 15. Leiomyomas are benign masses arising, subserosally, intramurally or submucosally, from the smooth muscle of the uterus and enclosed by a thin pseudocapsule of areolar tissue, according to pathological investigation. Leiomyomas displace and compress surrounding structures rather than invading them. There are histological features in the teenage population that appear to signal malignancy: enhanced cellularity, increased mitotic activity, and cellular atypia. Malignant transformation is a concern in this population due to these histological traits, fast growth, and the very large size of the leiomyomas themselves. In the first description of a leiomyoma in a teenage girl, Wisot documented a 13-year-old girl who appeared with irregular vaginal bleeding and a growing abdominal mass and was found to have a 12 cm uterine leiomyoma . A uteriLeiomyomas are treated with observation, medical therapy, and/or surgery. Observation may be adequate if the leiomyoma is asymptomatic or medically managed with hormone therapy. Medical treatment with progestational drugs has been reported in the literature to reduce myoma growth and control hemorrhage; however, well-documented controlled studies confirming their effectiveness are missing . The oneFollow-up is crucial, especially in situations where histology was doubtful, to watch for symptom relief and probable regrowth. These patients should have their symptoms resolved while maintaining their fertility with correct surgical technique and follow-up. In the presented case, the surgical excision of the lesion involving the fallopian tubes entry may necessitate tubal patency testing in the future to confirm the likelihood of spontaneous pregnancy or to indicate medically aided procreation.


Granular cell tumors are rare tumors of Schwann cell origin that present in any anatomic location, age or sex. We present a case of a granular cell tumor in the scrotum of a prepubescent male. The tumor was excised, with histology revealing abundant eosinophilic cytoplasm and positive S-100 staining. No stigmata of malignancy were identified and no recurrence has been reported during follow-up. Most commonly they are found in subcutaneous tissue and the gastrointestinal tract.2A 7 year-old male was referred for a solitary scrotal nodule that had developed over the past year. There was no associated pain, drainage, antecedent trauma or prior history of surgery. He had no stigmata of underlying syndromic conditions.Physical examination revealed a normal, circumcised phallus with bilaterally descended testicles of normal size and consistency for his age. The lesion in question was a 1.5 × 1 cm superficial, epithelialized, firm mass just off midline in the mid-scrotum. The epithelium differed from the scrotal skin with a more pale, smooth surface, giving the lesion the appearance similar to a sebaceous cyst A. An ultIndications for excision were discussed with the family who elected to proceed. The patient underwent excision of the scrotal lesion, which was confined to the skin without deeper extension. An elliptical incision was made around the base of the lesion and incised sharply. Complete excision was carried out with blunt dissection and cautery. The skin defect was then closed in a multi-layer fashion.On gross examination, the lesion showed a firm white cut surface A. The le3This case presentation highlights a rare clinical entity requiring a high index of suspicion to diagnose. Available literature regarding GCTs has largely come from small retrospective reviews, case series and case reports, though a recent systematic review by Mobarki et al. highlighted the variable clinical and histopathologic characteristics of these tumors.Granular cell tumors tend to present in women in the 4th to 6th decade in life but can occur at any age. Most present as solitary lesions, but approximately 12.5% are associated with trauma or chronic inflammation and 7.1% involve multiple lesions.Our patient had no clinical or histopathologic findings concerning for malignancy and is disease-free. GCT of the scrotum is rare, with few cases reported in the literature.4Granular cell tumor of the scrotum in a child is rare, but clinical suspicion should be present in the evaluation of a genital lesion in pediatric males. Diagnosis of these tumors should prompt a thorough physical examination for multi-focal tumors, and if found, work-up for underlying genetic syndromes should be considered. Complete excision of the tumor should be considered given the malignant potential, especially in large tumors, followed by thorough histologic assessment geared towards the identification of risk factors for malignancy. In the absence of malignancy, the prognosis is very good with complete local excision.Caleb Ashbrook: Conceptualization, Writing – original draft Shane F Batie: Conceptualization, Writing – review/editing Anita Sengupta: Visualization, Writing – review/editing Crag A Peters: Supervision, Writing – review/editing.None.


Vascular anomalies of the pediatric orbit represent a heterogeneous group that include both vascular tumors and vascular malformations. The disorder may initially be silent and then associated with symptoms and/or function damage, depending on the type of vascular anomaly and its extension. Vascular tumors include benign, locally aggressive (or borderline) and malignant forms while vascular malformations are divided into “simple”, “combined” and syndromic, or “low flow” or “high flow”. Both entities can arise in isolation or as part of syndromes. In this review, we describe the imaging findings of the vascular lesions of the orbit in the pediatric population, which are key to obtain a correct diagnosis and to guide the appropriate treatment in the light of the new genetic and molecular discoveries, and the role of the radiologist in their multidisciplinary management. We will also touch upon the main syndromes associated with orbital vascular abnormalities. Vascular anomalies of the pediatric orbit represent a heterogeneous group of diseases caused by an abnormal embryological development of vascular structures or by a clonal proliferation of endothelial cells, due to a sporadic or hereditary genetic “error”. This group of pathologies is characterized by (i) morphological and/or hemodynamic alterations, (ii) of blood or lymphatic vessels, (iii) of varying severity and (iv) of any anatomical district , includiThe reported Incidence of vascular orbital lesions in the pediatric population ranges from 5.5% to 22%  presents itself as a valid starting point to provide a meaningful and universally accepted classification of vascular anomalies.These issues have mostly been addressed by the original ISSVA classification and its iterations , 6 whichHowever, despite the many efforts, it still has some drawbacks to consider, such as its lack of anatomical specificity. Indeed, it still does not account for some lesions specific to peculiar anatomical sites such as the orbit, while other lesions listed in the classification cannot technically exist in the same location .The aim of this manuscript is to report the main radiological features of orbital vascular anomalies in the pediatric population using the proposed nomenclature of the latest iteration of the ISSVA classification . The radiologist’s role is pivotal in the multidisciplinary team for the proper management of these lesions, in order to obtain a correct diagnosis and to guide the appropriate treatment in the light of the new genetic and molecular discoveries.Successful management of orbital vascular lesions depends on the clinical presentation, site and extension of the lesion, patient age, symptoms and functional and esthetical damage. In addition, since the genetic and molecular background of both inherited and sporadic vascular malformations are currently being elucidated, genetic testing should be performed (i) to confirm the diagnosis in some cases, (ii) in view of a target therapy, and (iii) to perform genetic counselling. Thus, the diagnostic management of a vascular lesion requires an integrated and multidisciplinary approach involving multiple specialists. Radiologists are key part of this team, combining both the diagnostic expertise in imaging and their involvement in their endovascular treatment.Imaging evaluation represents an important clue within the diagnostic management of vascular anomalies, and cannot overlook orbital anatomy. For this reason, detailed schemes of the orbital spaces and of the vascular supply of the orbit is provided in Imaging, other than recognizing the lesion in the first place, contributes to determine lesion extent, organ involvement and potential complications especially in a complex and functionally critical anatomic location as the orbit, and to rule out other entities. Moreover, imaging is paramount for proper treatment planning and for establishing a baseline before treatment.Mainstay imaging modalities in the pediatric population include Ultrasound (US) and magnetic resonance imaging (MRI), also with angiographic techniques.•the anatomical location and the involved layers •mono vs. multifocality•the presence of a parenchymal component•the echogenicity and architecture •the degree of compressibility•dynamic changes •distribution, density of vascularization, type of vessels  and flow dynamics (high flow vs. low flow) at Doppler study and Spectral analysis•the status of surrounding tissues•secondary effects on surrounding structures and organs.The choice of the initial imaging modality varies based on the clinical scenario and specific lesion. Its wide availability, the lack of radiation exposure, little costs and no need for sedation all make US an appropriate initial screening modality after clinical examination in children ; high-frAlthough it usually follows US in the diagnostic work-up, MRI is the preferred imaging modality due to its higher spatial, contrast and temporal resolution. Particularly, it is obviously indicated (i) in the assessment of large and deeper lesions, (ii) when they are part of complex or syndromic vascular anomalies and/or (iii) prior to invasive treatment. Not secondarily, it allows defining their extension and their anatomic relationship to adjacent structures.*-weighted images can be added to demonstrate calcification or hemosiderin deposits; on GRE images, generally, low-flow vessels appear as flow-voids, whereas high-flow vessels have high signal intensity. Diffusion Weighted images can be included in the protocol so to help in the differential diagnosis with malignant entities. Contrast–enhanced MR angiography, performed with a 3D T1w fast gradient-echo (GRE) sequence is also needed to evaluate the enhancement pattern of the lesion: usually, imaging is performed in the arterial phase and several venous phases. Images are also obtained before contrast material administration for posterior subtraction of contrast-enhanced images (MRI (preferably at high field strengths) can be performed both with head coils (preferably a 32-channel phase-array) and orbital surface coils before and after contrast administration, tailoring the specific protocol to the type of vascular anomaly suspected and its location. The recommended slice thickness is 2–3 mm with a 512 × 512 matrix and no interslice gap. Mandatory sequences should include multiplanar T2 weighted (T2w) fat-suppressed images and pre and post contrast T1 weighted (T1w) images, with or without fat suppression, in at least two orthogonal planes. GRE T2d images . The comd images . VasculaDSA or venography are mostly used as therapeutic modalities. DSA is most critical for evaluating high-flow vascular malformations  and offeVascular tumors are formed by the proliferation of vascular tissue and are still divided into benign, locally aggressive and malignant based on their nature , with maHemangiomas – are the most frequent orbital vascular lesions, taking the “lion’s share” among vascular tumors. The most commonly involved location is the head and neck region (60%) with the orbit being the most frequent . HemangiInfantile hemangiomas (IHs) are usually not visible at birth, but present within the first several weeks of infancy . Their aThe presence of the immunological marker glucose transporter one (GLUT-1) differentiates IHs from vascular malformations in tissue biopsies .Congenital hemangiomas (CHs) are rare entities  that have long believed not to arise in the orbit. Although even more uncommon, some reports have demonstrated the possibility of CH also arising in this location .in utero), lack positive staining for GLUT-1 and show GNAQ/GNA11 genetic changes. In addition, they either involute (more or less rapidly) or never spontaneously involute; according to their involution they are further categorized into Rapidly Involuting Infantile Hemangioma (RICH), Non-Involuting Infantile Hemangioma (NICH) and the newly recognized Partially Involuting Infantile Hemangioma (PICH)  , 18.Their clinical presentation depends on the depth of cutaneous involvement, their size and either the evolutionary phase. Generally, they present as soft masses: visible lesions that are within or near the dermis appear as bright red or pink (“strawberry hemangiomas”), whereas deeper lesions may be blue or purple, therein the name as they have long been known “cavernous hemangiomas” . ComplicAlthough hemangiomas can be suspected clinically in the majority of cases, imaging evaluation is indicated either in the diagnosis of profound hidden hemangiomas to estimate their extension or in masses which are minacious to visual function. The diagnostic workup is primarily based on US. Sometimes MRI (eg in deep lesions) and CT (in a few of cases) are required.Despite the different pathogenesis, clinical presentation and genetics, CH and IH have almost the same imaging characteristics, particularly during the proliferative phase. However, CHs are more likely to have aneurysms, larger venous components, intravascular thrombi and even high flow velocity at birth, compared to their infantile counterpart , ancillaOn the other hand, it is MRI that provides the best insights on the architecture and the best accuracy on the extension and spatial relationships of the lesion. Indeed, it may show the tumor involving and enlarging the eyelid and obstructing vision, displacing or distorting the globe or the extra- ocular muscles. On T2w images hemangiomas appear as a well-defined, lobulated and hyperintense masses with flow-voids and thin, dark septa between lobules . These fCT is rarely indicated. However, it is especially useful in (i) suspected skeletal involvement, (ii) contraindication to sedation in pediatric patients, (iii) situations requiring urgent imaging, and (iv) view of surgical treatment in some conditions. At CT, proliferating IHs appear as well-demarcated masses that are isoattenuating to muscle and demonstrate early, uniform, intense enhancement with intravenous contrast. Calcifications are rarely seen. In involuting and involuted IHs fat deposition increases, and enhancement becomes less homogeneous. In case of rapidly growing lesions, CT may demonstrate bony orbital expansion or scalloping.Although the majority of IHs represent an isolated finding, at least 20% of children will have multifocal lesions. In the case of more than 5 IHs (in any body part), the child should be screened with an abdominal US to rule out hepatic hemangiomas . MoreoveFirst off, they are more prone to complications, such as ulceration.PHACES syndrome: PHACES is present in up to 2% of children with facial hemangiomas and 20% of children with “segmental” facial hemangiomas  , Eye defects and Sternal abnormalities (It includes: angioma) , 6, Hemamalities , Cardiacmalities . Importamalities  and theymalities . Hence, malities , althougLastly, the finding of a segmental orbital or, generally facial, IH should prompt a multidisciplinary evaluation in all infants .In the case of orbital location, large intra-orbital hemangiomas with retro-orbital extension have been reported. Moreover, intracranial locations of the hemangiomas, with a keen predilection for the cerebellopontine angle, have also been described  Figure .The rare tufted angiomas (TAs) and kaposiform hendoteliomas (KHEs) have been sporadically reported in the infantile orbit .GNA14 lead to the constitutional activation of MAPK pathway in both  deep lesions that usually have no surface manifestations and are entirely retrobulbar, (iii) combined lesions that have both superficial and deep components and (iv) complex lesions that involve the orbit and peri- orbital and intracranial tissues, and may be seen in multifocal sites .GNA11 have also been identified as a cause of both sporadic and syndromic CMs  are superficial cutaneous lesions that consist of very small, dilated capillary-like channels and manifest clinically at birth as “port wine stain” macules . In the omic CMs , 48. Theomic CMs , 50. Altomic CMs  and ParkHB4 gene , MacroceHB4 gene  and KlipCMs are superficial, therefore their imaging findings - when present - are often subtle and not specific: on US, they are usually isoechoic and confined to the dermis, showing occasionally Doppler flow . On MRI Venous Malformations (VMs) are composed of an abnormal venous network of varying size and the most common low-flow vascular malformations . They caSuperficial lesions present as a bluish skin discoloration and are soft, compressible and non-pulsatile lesions that gradually refill when pressure is released  while deOn US, venous malformations often present as compressible, well-marginated masses with a spongiform appearance from the presence of hypoechoic ectatic venous spaces separated by hyperechoic septa; they are generally heterogeneous and mostly hypoechoic when compared with the adjacent subcutaneous soft tissues, although occasionally they appear isoechoic or hyperechoic  Figure . On coloLymphatic malformations  and may present with abrupt pain, swelling, proptosis, ocular dysmotility or visual loss.On gray-scale US, LMs appear as ill-defined and mostly anechoic lesions; echogenicity can be more heterogenous in the setting of recent bleeding or infection, even with the formation of possible fluid-fluid levels. The macrocystic lymphatic malformations appear as lesions containing numerous cystic formations of variable dimensions with liquid content separated by thin hyperechogenic septa ; the lesArteriovenous malformations (AVMs) are defined by the presence of an abnormal vascular network (nidus) connecting the arterial and venous system, without an intervening normal capillary bed. They are rare and even rarer in the extra-cranial compartments, although they are the most frequent high-flow vascular malformations in the head and neck region accounting for 70% of high-flow lesions.AVMs are always present at birth. Signs and symptoms of the AVMs vary depending on location, degree of arteriovenous shunting, venous hypertension , stage o•Stage I AVMs: simple skin staining with redness and warmth. With time they will progressively grow•Stage II: pulsations, bruits and tortuous dilated veins become apparent.•Stage III: local complications such as ulceration, bleeding, infection and pain.•Stage IV: general complications. The AVM will produce a flow-steal syndrome with chronic fatigue and heart failure that may eventually be fatal.The clinical evolution of AVMs is described by the Schöbinger classification :•Stage Noninvasive imaging is mandatory: it allows proper confirmation of diagnosis, sets a baseline for the patient and helps define the architecture of the malformation . The AVMLike other vascular anomalies, AVMs can occur in isolation or as part of syndromes. Endothelial cells of the cephalic region have a regionalized origin from the paraxial mesoderm, which will finally provide the blood vessels to specific regions of the face and brain in a metameric fashion –74. AccoVascular anomalies of the orbit must be distinguished from other lesions sharing common clinical and radiological features. Indeed, the risk of high morbidity in such a complex anatomical location from mismanagement requires a systemic and multidisciplinary approach to facilitate an accurate diagnosis between the different entities based on clinical and imaging examination. With respect to imaging, the understanding of orbital anatomy and blood flow patterns and the knowledge on how to obtain the best spatial and contrast resolution by US and especially MRI permit confident evaluation of the subtle structures of the orbit and increase diagnostic accuracy .−3 mm2/s represents an optimal threshold for predicting malignancy with a sensitivity of 95%, specificity of 91% and accuracy of 93% /extracellular signal-regulated kinase (ERK) and the phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) , both reThese discoveries led to repurpose several target therapies available in oncology for the treatment of complex vascular malformations.Rapamycin (or Sirolimus) has been the first developed targeting agent. Once reserved for tumors, this drug reduced the proliferation of endothelial cells and the growth of venous malformations in murine models  by inhibVascular anomalies are among the most frequent lesions of the pediatric orbit. The orbit relative small space and its complex anatomy pose specific considerations to be addressed, such as the difficulties to perform a biopsy, the high risk of complications both intrinsic to their evolution and relative to treatment that can lead to permanent functional deficits, not to mention the risk of cosmetic disfigurement. Thus, an early correct diagnosis allows an appropriate management. For this reason, pediatric patients with suspected vascular abnormalities should be evaluated by an expert multidisciplinary team including clinicians, radiologists, surgeons, pathologists, and geneticists. The role of the reference Centre is crucial for (i) diagnosis, (ii) patient follow-up, (iii) to guide and accompany the patient and family during the chronic and frequently disabling disorder, and (iv) to participate to research in the field, and (v) to recruit patients in clinical trial for emerging targeted therapies , 94.Multimodal imaging is key in this process : US is nIn addition, some vascular syndromes are associated with other characteristic congenital anomalies, and affected patients have an increased risk of developing various malignancies. Patients with BWS are at increased risk of developing several embryonal malignancies including Wilms tumor, hepatoblastoma, rhabdomyosarcoma, and neuroblastoma , 99, whiWith new developing of new imaging techniques and endovascular treatment strategies not to mention artificial intelligence widely making is way, the role of radiologists will grow even more in the future.Vascular anomalies are among the most frequent lesions of the orbit in the pediatric population and necessarily require a multidisciplinary team evaluation for their adequate management, including clinicians, radiologists, surgeons and geneticists. Multimodality imaging allows their accurate classification into tumors or malformations according to the latest ISSVA classification and their anatomical definition in order to guide appropriate treatment. Moreover, the multidisciplinary team should be aware of the possibility that although the majority of these lesions are isolated, syndromic association do occur.


Parasitic fibroids or leiomyomas are rare extrauterine benign tumors in women of reproductive age. Often, they are named wandering fibroids or ectopic fibroids. They lack any myometrial connection and obtain their nourishment from other abdominopelvic structures to which they are attached. Clinicians often find it difficult to diagnose these fibroids preoperatively due to their atypical presentations and locations. Recent studies have suggested that the development of parasitic fibroids is iatrogenic. Inadvertent seeding of fibroid fragments during the morcellation procedure in a previous laparoscopic myomectomy surgery could be the pathogenesis. However, in rare scenarios, they may develop spontaneously with no history of surgery or a coexistent uterine fibroid. In this report, we present a case of parasitic fibroid in a 75-year-old postmenopausal woman. She had no surgical history, and she had a normal uterus. Radiological investigations had initially suggested the mass to be a subserous fibroid. However, it was diagnosed as parasitic fibroid intraoperatively, confirmed later by histopathological examination. Uterine fibroid or leiomyoma is one of the common benign tumors of women in the reproductive age group, with an estimated prevalence ranging from 4.5% to 68.6% . They arParasitic fibroids can be primary, secondary, or iatrogenic. Primary variants are presumed to be the detached pedunculated subserous fibroid. They subsequently get adhered to the nearby extrauterine structures and lose any vascular connection with the uterus. Literature regarding primary parasitic fibroids is scarce ,6. InsteUterine fibroids are slow-growing tumors, and they usually shrink after menopause due to the lack of estrogen and progesterone. Therefore, parasitic fibroids are highly unusual in postmenopausal women. This case report discusses the preoperative diagnostic conundrum of an abdominal mass in a postmenopausal woman who presented with abdominal discomfort. It was diagnosed intraoperatively as parasitic fibroid and later confirmed by histopathological examination. She had no history of any abdominal surgery.A 75-year-old postmenopausal woman was evaluated at the gynecology clinic for pain and heaviness in the lower abdomen for four months. She was para four, live four, and all her deliveries were vaginal; the last childbirth was 35 years back. She did not have any known comorbidity and had no history of surgery. She had no family history of malignancy or any significant comorbidity. There was no history of any abnormal vaginal discharge or bleeding.On examination, her vitals were found to be stable. The abdomen was slightly distended, and on palpation, a firm non-tender mass was felt occupying the right iliac fossa and suprapubic area. The mass had a smooth surface, and its movement was restricted from side to side. The liver and the spleen were palpated as normal. There were no perceivable ascites. On per speculum examination, the cervix and the vagina were found to be healthy. The per vaginal examination revealed a mass corresponding to a 20-week size uterus, which felt like a right adnexal mass. The right fornix felt shallow, and the left fornix was normal.The hemogram, serum electrolytes, urea, creatinine, liver function tests, and urinalysis were all within normal limits. The serum cancer antigen 125 was 9.4 IU/ml. The chest X-ray and electrocardiogram were normal. Abdominopelvic ultrasonography showed a large heteroechoic solid lesion measuring 11 cm × 7 cm seen involving the posterior myometrium with calcification. The impression was of a large, calcified fibroid in the uterus. The ovaries could not be visualized, and other abdominal organs appeared normal. There were no ascites. Magnetic resonance imaging (MRI) of the abdomen and pelvis revealed a large well-defined encapsulated heterogenous lesion measuring 10.7 cm × 9.5 cm × 9.4 cm noted in the subserous plane of the uterus, displacing it to the left anterolateral aspect Figures . The masShe underwent an exploratory laparotomy. Intraoperatively, a mass measuring approximately 10 cm × 10 cm × 8 cm with cystic and solid areas was observed. It was filling up the pouch of Douglas and extending up to the right iliac fossa. The mass was completely free from the uterus and was found to have adhered to the right infundibulopelvic ligament. It was also attached to the sigmoid colon and lateral pelvic wall with flimsy adhesions. The uterus was approximately 10 weeks in size, and the fallopian tubes and ovaries appeared normal. All the adhesions were removed, and the mass was excised, followed by total abdominal hysterectomy and bilateral salpingo-oophorectomy Figure .The patient had an uneventful postoperative course. The histopathology report later confirmed the mass to be a fibroid.The first reference to parasitic fibroid was by Kelly and Cullens in 1909. They described it as a “myoma that has for some reason become partially or almost completely detached from the uterus and receive their main blood supply from another source” -12.A retrospective analysis of 12 patients with parasitic fibroids by Kho and Nezhat revealed that 10 out of 12 cases had prior abdominal surgeries. They also found that in eight cases morcellation procedure was performed during myomectomy . Lu et aTheories of de novo development of fibroids have also been described in some rare variants of extrauterine fibroids, such as in leiomyomatosis peritonealis disseminata (LPD) and benign metastasizing leiomyomatosis. LPD is a benign condition characterized by the development of multiple fibroid nodules on peritoneal surfaces. There are multiple theories behind the pathogenesis of LPD. One of them is the estrogen-induced metaplasia and differentiation of subperitoneal mesenchymal stem cells to smooth muscle cells. Similarly, in cases of metastasizing leiomyomatosis, embolization of fibroid tissue from the uterus is implicated as one of the etiopathogeneses .The most likely location of parasitic fibroids is in the pelvis which is the area close to the uterus. Nevertheless, they are seen all over the abdominal cavity. Unusual locations such as the lungs, bladder, urethra, and sigmoid colon have also been reported ,14,17. TUterine fibroids are tumors of the reproductive age group as their development and proliferation depend on ovarian hormones. As expected, parasitic fibroids are commonly reported in premenopausal women and are extremely unusual in postmenopausal women. In the literature, there were reports of only two cases of parasitic fibroid in postmenopausal women, and in both cases, there were coincident uterine fibroids ,18. In tManagement of parasitic fibroids is usually surgical either by laparoscopy or open surgery. Medical treatment with gonadotropin-releasing hormone analog was attempted in a few cases with good results but needs further investigation as a treatment modality .Multiple pathological descriptions of extrauterine fibroids or parasitic fibroids have been reported, including LPD, metastasizing leiomyomatosis, ectopic fibroid, etc. The FIGO leiomyoma classification system has added a separate category, type 8, to include all extrauterine fibroids that do not relate to the myometrium, such as cervical fibroids, broad ligament fibroids, and other parasitic lesions . HoweverParasitic fibroids are extrauterine fibroids with no myometrial connection. Clinicians often encounter difficulty in diagnosing these fibroids preoperatively due to their rarity, aberrant locations, and unusual presentations. Parasitic fibroids are primarily thought to be a derivative of uterine fibroids. Recent evidence has suggested a higher risk of occurrence after laparoscopic myomectomy using a power morcellator. Rarely, as witnessed in the current case, it may be encountered isolated without any history of myomectomy or coexistent uterine fibroid. This report also demonstrated the persistence of fibroid even after menopause which is uncommon and needs further research.Clinicians should be highly suspicious of parasitic fibroids due to their tendency to mimic other pelvic tumors. It is rational to keep this rare condition as a differential diagnosis of unusual abdominopelvic mass.


Immediate appendectomy for acute appendicitis with abscess has a high frequency of ileocecal resection and postoperative complications compared with interval appendectomy after conservative treatment. The optimal approach to acute appendicitis with abscess remains controversial.A 69-year-old woman was referred to our hospital for abdominal pain. A computed tomography scan revealed an enlarged abscess around the cecum. The diagnosis was perforated appendicitis with abscess, and conservative treatment was performed. Percutaneous drainage was difficult because the abscess was near the intestinal tract. Because of the persistence of symptoms on the fourth day of hospitalization, laparotomy drainage was performed, and the patient's condition improved afterwards. Colonoscopy was performed on an outpatient follow-up to rule out malignant tumors of the colon. Interval laparoscopic appendectomy was performed 3 months after discharge to prevent appendicitis. The postoperative course was uneventful.For this case of acute appendicitis with abscess, conservative treatment such as antibiotic therapy and laparotomy drainage was performed. Laparotomy drainage enabled us to approach the abscess directly and minimized the risk of its spread into the abdominal cavity compared to the laparoscopic approach. Interval laparoscopic appendectomy was more effective and easier for this case of appendectomy, wherein adhesions to the abdominal wall were expected compared to laparotomy.Conservative treatment approaches, such as drainage and antibiotic therapy, can be first-line for appendicitis with abscesses. Interval laparoscopic appendectomy can be useful to resect the appendix and observe the abdominal cavity. •For appendicitis with abscess, drainage and antibiotics are the first-line approach.•Laparotomy drainage is an effective alternative to percutaneous drainage.•Colonoscopy should be done after conservative treatment to rule out tumors.•Interval laparoscopic appendectomy is effective for appendicitis with abscess. This report aims to provide information regarding the treatment for appendicitis with abscess. This case report has been reported in line with the SCARE 2020 criteria 2A 69-year-old woman sought consultation at our institution for decreased appetite and lower abdominal pain. The patient was noted to have a fever 10 days ago, which eventually resolved at the time of consultation (Body temperature: 36.1 °C). Lower abdominal pain and tenderness were noted, but there was no rigidity or rebound tenderness. Laboratory tests revealed a white blood cell (WBC) count of 20,790/μl and C-reactive protein (CRP) of 37.6 mg/dL. Computed tomography (CT) scan revealed an abscess around the cecum and ascites in the pelvis . The preColonoscopy was performed one month after discharge to rule out malignant tumors of the colon. An endoscopic mucosal resection was performed because of a polyp in the cecum. A pathologic examination revealed an inflammatory polyp , and there were no malignant findings.On the follow-up, WBC and CRP values were within the normal range. On CT scan detected abscess around the cecum disappearing and appendix with gas A–B. The 3The proper management of perforated appendicitis with abscess is a clinically important issue In some cases of appendicitis with abscess, antibiotic therapy alone is not sufficient and case drainage may be effective Interval appendectomy after successful conservative treatment for appendicitis with abscess remains controversial. The rate of recurrence after conservative treatment for perforated acute appendicitis and phlegmon ranges from 12 % to 24 % Laparoscopic surgery was chosen in order to avoid adhesions at the incision site of the first laparotomy drainage. In fact, the abdominal wall and cecum were highly adherent at the site of the previous incision A. It is Low postoperative complications are one of the reasons for choosing interval surgery over immediate surgery. Immediate surgery in acute appendicitis with abscess is prone to postoperative ileus and residual abscess due to the presence of the abscess. Fortunately, no complications occurred after interval laparoscopic appendectomy in this case. Treatment of the abscess via antibiotic therapy or drainage followed by surgery may prevent complications related to the abscess and extended resection, such as ileocecal resection.Interval surgery was also chosen because it can be performed alongside a colonoscopy while waiting. Renteria et al. reported that the rate of unexpected malignancy was 3 % in of elderly (mean age: 66 years) and 1.5 % of young (mean age: 39 years) patients who underwent appendectomy as primary treatment for acute appendicitis In this case, laparotomy drainage and interval laparoscopic appendectomy were performed, suggesting a risk of postoperative complications associated with two surgical procedures. However, no postoperative complications were observed. The proper choice of surgical approach can minimize postoperative complications. Thus, even two surgical procedures can be acceptable even for old age patients, such as this case.4Immediate appendectomy for acute appendicitis with abscess is associated with higher morbidity. Thus, conservative treatment by laparotomy drainage and antibiotic therapy should be performed in such cases. Subsequent colonoscopy should also be performed because of the possibility of malignant findings in patients aged >40 years. Interval laparoscopic appendectomy is effective to easily resect the appendix and observe the abdominal cavity.Patient consent form was signed by the patient. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.All authors do not have any conflicts of interest.