The cancer of the splenic flexure of the colon is a rare medical entity with severe morbidity because of its insidious onset.We present the case of a 59-year-old male patient with dull left upper quadrant pain, leukocytosis, and anemia. A splenic abscess described as an air-fluid level with splenocolic fistula was found on CT scan imaging. Surgery was done for splenic pus drainage. He was again admitted 2 months later for intestinal obstruction.TM Colostomy bag placed. We also reviewed the literature-linking colon cancer and splenic abscess with specific attention to the carcinoma of the splenic flexure. As the latter invades through the spleen matter, there is the creation of a splenocolic fistula, which allows the migration of normal gut flora into the spleen. This leads to the formation of the splenic abscess.An exploratory laparotomy showed multiple hard, gray liver nodules as well as a hard mass in the small bowel. Owing to extensive adhesions and a late stage of cancer involvement, the splenic flexure tumor was not resected. A loop transverse colostomy was done and a Coloplastth case report pertaining to invading colonic cancer causing a splenic abscess. Although the treatment for splenic abscesses is shifting from splenectomy to image-guided percutaneous pus drainage, the few reported cases make the proper management of such complication still unclear.This is the 13 The rise in parasitic abscesses and fungal abscesses is because of increased international travel, whereas increase in immunosuppression is because of the increasing number of AIDS patients, as well as subjects undergoing organ transplant or affected by neoplastic diseases.,9 Direct invasion of the spleen by colon cancer of the splenic flexure of the colon is not a common occurrence. We report the case of a cancer of the splenic flexure of the colon, which created a splenocolic fistula to cause an abscess in the spleen. To have an initial presentation of colon cancer as splenic abscess is not common in daily practice and young surgeons should again be remembered to consider all surrounding organs while consulting a complaint, especially in the abdomen. After the case report, the various literature reports of cases of similar nature are exposed for a better understanding for this uncommon but yet, morbid complication of colon cancer.The spleen is one of the usually forgotten organs to be considered in the work-up of a differential diagnosis during clinical evaluation. Splenic abscess can be seen as that rare entity that has or hides disastrous underlying pathology. With autopsy studies revealing 0.14% to 0.7% of splenic abscess,2We present the unfortunate case of a 59-year-old Chinese man  with no relevant medical history. He initially presented to our department in the beginning of March 2015, complaining of intermittent dull left upper quadrant pain, exacerbated with exertion, with no radiation and intermittent low-grade fever not exceeding 37.6°C over the last month, but which have aggravated over the 2 days before admission. During the 1 month, he sought help in primary-level health care facilities, but he was given only anti-inflammatory drugs and sent home, without further investigations.3Upon initial examination, his vitals were stable except a low-grade fever. Cachexic in nature, his physical examination was also significant for tenderness in the left upper quadrant region with no organomegaly felt.4The timeline of events is as shown in Figure 5He had leukocytosis with a left shift, hemoglobin level of 104 g/L and hematocrit (HCT) of 31.30%. Computed tomography (CT) scan Figure  revealed6An exploratory laparotomy with a 40-cm left anterolateral incision revealed a 5-cm hard immovable mass in the region of the splenic flexure of the colon with a spleen of size 12 cm. The whole compound was surrounded by extensive adhesions to the stomach, tail of pancreas, and diaphragm. Three hundred microliters of pus was drained intraoperatively from the spleen with copious amount of necrotic debris from the spleen and the splenocolic fistula was closed. Examination of the liver, gall bladder, stomach, mesentery, and abdominal aorta was not significant, with no lymph nodes nor nodules felt.As the surgeon decided that a splenectomy would not have been beneficial to the patient already cachexic in nature, the spleen was not removed. However, a colonoscopy was ordered to be done after the patient recovers from the surgery. Three drainage tubes were placed in situ before standard technique layer-by-layer closure of the abdomen. The patient recovered well postoperatively with no complications up to his discharge from the hospital. One drainage tube was removed after 1 week as there was no drainage and the others were kept until the follow-up visit at the end of April, as they were still draining.Unfortunately, the patient did not attend his follow-up visit and the colonoscopy was not performed. However, 2 months later, he came again to the department complaining of 1-day history of colicky, intermittent abdominal pain, with heaviness in the umbilical area, having vomited 3 times undigested food and mucous, and not passing stools for 1 day, with no improvement after the use of self-administered laxatives. He has no fever and no other complaints. An anterior-posterior erect abdominal x-ray in the Emergency Department showed step-ladder formation of the bowels with the presence of 4 air-fluid level bubbles. He was primarily admitted for incomplete intestinal obstruction. His vitals were stable and abdominal examination did not reveal any abnormal finding except for abdominal distention and mild tenderness around the scar from the previous operation. Upon admission, his blood parameters showed a leukocytosis with a left shift, whereas his hemoglobin and hematocrit values were improving. A colonoscopy was ordered and the relevant findings were chronic inflammation in the region of the hepatic flexure, with nothing noted at the splenic flexure. Biopsies of the relevant region were sent for pathological studies, which later confirmed a chronic inflammatory process. CT scan , CA 125 117.90 KU/L , CA 199 265.94 KU/L , and CA 242 65.54 .TM Colostomy bag placed.Surgery was chosen. A 20-cm upper median incision was done for the exploratory laparotomy. Within the peritoneal cavity, around 500 mL of yellow fluid was drained with a sample sent to the laboratory. The bowels were dilated with thick edematous walls with the external diameter of the dilated small intestines being around 4 cm. The greater omentum was adherent to the left side of the peritoneal cavity, covering the transverse colon and part of the small intestines. Within the mesentery of the small intestine and greater omentum, multiple hard nodules were felt. Ten centimeters after the Treitz's ligament, the small intestine had a hard consistency. The liver was felt and hard grayish nodules were found, with the largest being 3 cm in the inferior border of the liver, with no abnormality found in the stomach, duodenum, spleen, kidney, gall bladder as well as no metastatic involvement of the peri-aortic lymph nodes. However, the pelvic floor had metastatic seedlings. The intraoperative diagnosis was sT4NxM1. Adhesiolysis between the small intestines was performed and the small intestines were decompressed with a lot of gas and yellow stools being evacuated at an incision 20 cm before the ileocecal valve, which was sutured closed hereafter. The invaded small bowel was not resected and a side-to-side intestinal tension-free anastomosis with the jejunum was done. A right partial hepatectomy with nodule resection was performed and frozen section sent for pathology, which revealed a moderately differentiated adenocarcinoma and stain positive for CK 19 and Villin. Owing to extensive adhesions and a late stage of cancer involvement, the tumor felt at the splenic flexure of the colon was not resected. A loop transverse colostomy was done and a Coloplast7Postoperatively, the patient recovered without complications with timely dressing. With the sad occurrence of liver metastatic, there is nothing more that surgery can do and he was then referred to the Oncology Center.88.1 Bacon et al in 1952 and Popper in 1968 reported the incidence of carcinoma of the splenic flexure to account for 2% to 3% of all colorectal cancer. In 143,747 patients studied between 1995 and 2009, the incidence of carcinoma of the splenic flexure ranged between 2.80% and 3.11% with respect to age groups and sex. Taking into consideration the time intervals mentioned in the studies,–12 the incidence of colon cancer of the splenic flexure has remained stable in the region of 2% to 3% of total colon cancers.As compared in Table  However, specific data about the involvement of the splenic flexure in malignancy were not available.Colorectal cancer had a prevalence of 16.3% in males and 12.2% in females, being the fifth cancer with the highest incidence in both sex groups. It is attached to the tail of the pancreas by the left end of the transverse mesocolon. Above and to the left, the lower border of the spleen is supported by the phrenocolic ligament, which connects the splenic flexure to the diaphragm. It is supplied by the left branches of the midcolic vessels and the upper branches of the left colic vessels. Lymphatic drainage of the splenic flexure is through to the hilum of the spleen and along the tail of the pancreas. Based on this, the appropriate treatment of the carcinoma of the splenic flexure should include splenectomy with distal pancreatectomy.The splenic flexure is the part of the colon that is most inaccessible to proper exposure during operations. It lacks a posterior peritoneal investment where it lies on the perirenal fat and fascia on the outer border of the left kidney.8.28.2.1,17–19 Direct invasion from neighboring neoplasms to the spleen is a rare entity. In our patient, Enterobacter cloacae was the organism cultured from the pus that was drained during the surgical intervention. The pus formation was because of to the direct invasion of the gut flora through the splenocolic fistula. There are 5 distinct predisposing factors in descending order: metastatic infections; trauma; contiguous infections; hematological disorders; immunodeficiency states (including AIDS).The mortality rate of splenic abscesses ranges between 13% and 25%. The most common organisms involved in the formation of splenic abscesses, in most series, were aerobic microbes, especially staphylococci, streptococci, Salmonella, and Escherichia coli.,21,22 Furthermore, the cultures of organisms can reflect the pathogenesis of the original causative insult.S aureus and S bovis were associated with endocarditis, K pneumoniae with respiratory infection or liver abscess, E coli with urinary tract and abdominal infection, and Bacteroides spp and Clostridium spp with abdominal infection.,23 While considering the microorganism of the initial insult that can lead to splenic abscess, one should also remember the geographical distribution of the causative agents. In one of the largest series of splenic abscess reported in the literature by Chang et al in 2006 in Taiwan, analyzing 67 cases over 19 years, K pneumoniae was the most common pathogen, which was similar to other Asian countries. Splenic trauma causes a physical breach that increases risk of infection in the spleen leading to splenic abscess. An interrupted splenic capsule may complicate the catheterization during ultrasound-guided percutaneous drainage. In the English literature for splenic abscess owing to M tuberculosis, older American studies reported at most 0.8% of incidence compared to 1.5% and 7.8% in the more modern Southern Asian reports. This may be because of the increased prevalence of the disease caused by M tuberculosis in those countries. Fungal infections causing splenic abscess are also on the rise, with Candida being the most common, especially in the immunocompromised patients. Hemoglobinopathies, especially sickle cell disease, leukemia, polycythemia, or vasculitis, can cause splenic infarction, which can be infected and evolve into splenic abscesses. Owing to the increase in the number of AIDS and organ transplant patients,,24 the advent of splenic abscess because of immunosuppression has increased; 33.5% of patients in a review involving 287 patients had an immunosuppressed state with nearly half of the 287 patients being intravenous drug abusers and afflicted by AIDS.Metastatic infection accounts for approximately two-thirds of all splenic abscesses reported in the literature, with endocarditis and secondary bacterial seeding of the spleen constituting the most common 2 etiologies.8.2.2Our patient complained of intermittent dull left upper quadrant pain, exacerbated with exertion, with no radiation and intermittent low-grade fever not exceeding 37.6°C over the last month, but these symptoms have aggravated over the 2 days before admission.,22,25 and the triad of fever, left upper quadrant pain, and a tender mass for the diagnosis of splenic abscess by Sarr and Zuidema were not present in our patient. This nonspecificity of symptoms unfortunately prolongs the delay in diagnosis,,25 with the average time between the onset of symptoms and the diagnosis exceeding 2 weeks.,27The clinical presentation of splenic abscess is always vague,24,28,29 Left hypochondriac pain and/or tenderness was/were not reliable signs because they were present in 50% to 70% of cases only, and splenomegaly present in 30% only.,7,29 Atypical signs such as digestive problems, vomiting or left-sided pulmonary symptoms were rare in occurrence.,7,9,28Splenic abscess should always be suspected in a patient with pyrexia of unknown origin (PUO), which is the main symptom in 90% of cases in previous reported series.,29,30 On both admissions, our patient had raised leukocytosis with increased neutrophil count. This is in accordance with the infective process within the spleen over the month that he has harbored the disease.Leukocytosis was noted in 60% to 100% of cases.Roentogram of the chest may show left pleural effusion, raised left hemi-diaphragm or atelectasis of the left lung lower lobe.,31 The combination of ultrasound with CT scan approximates the success of diagnosis to nearly 100%.,29,32 Our patient presented with low-grade fever and left upper quadrant pain only while no mass was felt. However, the diagnosis was made with the help of CT scan imaging, which revealed the unifocal splenic abscess with the presence of an air-fluid level and left pleural effusion upon his first admission.The definitive diagnosis is through the use of imaging modalities. Bacterial lesions can be solitary, multiple, or multiloculated. Multiple lesions are usually centrally located, circular, or irregular in shape with low attenuation centers of fluid/necrosis. When a capsule has developed, there can be minimal peripheral enhancement. The presence of gas is diagnostic, even though it is rarely found. In our case, the air fluid level was present together with the splenocolic fistula, thus establishing a straight-forward diagnosis. However, the interpretation of imaging studies of the spleen remains tricky and Table Infectious and inflammatory diseases form the major part of cases with multifocal splenic lesions.,6 but can drop to below 30% when the population consists of patients with tuberculosis and AIDS.,27,35Blood cultures are mandatory in patients in PUO. In cases of splenic abscess, blood cultures are positive in 48.2% to 71.8% of cases, In the immunocompromised, fine needle aspiration may also help in differentiating splenic abscess from other splenic lesions that have a similar radiographic interpretation, such as lymphoma, metastasis, infarction, or hematoma. Unfortunately, this was not performed in our patient. The pus was collected intraoperatively and thereafter revealed a monomocrobial culture of Enterobacter Cloacae.Together with blood cultures, which are usually monomicrobial in nature, a fine needle aspiration of the pus from the splenic abscess for culture is essential. Diagnostic fine needle aspiration is important to identify the proper course of antibiotics to follow. Usually, this sample is polymicrobial in almost half of cases.8.2.3,37 Ultrasound-guided or CT-guided percutaneous drainage is advised for unilocular or bilocular abscesses that have a discrete wall and no internal septations with its liquid content being thin enough to be drained, whereas splenectomy for multiple abscesses is reported as a safe and effective treatment choice. However, our patient was not consenting with the use of ultrasound-guided pus drainage upon his first admission to our institution. The authors believe that the reason why the patient did not consent for the ultrasound-guided intervention is perhaps because of the lack of awareness of the general population about the new management modalities that interventional radiology offers. This lack of knowledge will decrease their probability of choosing interventional radiology as part of the initial management in this case.Antibiotics and splenectomy were traditionally considered as the treatment of choice. However, nowadays, spleen-preserving management with percutaneous image-guided drainage is favored.M tuberculosis and Candida, medical treatment is more suitable.,22,39 Failure of medical treatment will ultimately lead to surgical intervention. It is also important to note that in the chronic course of Brucella infections, abscesses should be managed with the combination of both medical and surgical treatment.Abscesses owing to Percutaneous drainage is more advantageous than surgical drainage as it spares the risks associated with a splenectomy. It is also cheaper and has a low risk of intra-abdominal spreading, the absence of postoperative complications, including those owing to anesthesia and wound infection, a shorter length of hospital stay, and better compliance of patients. into adjacent organs, pneumothorax, pleural effusion, and colonic injury.The most common complications following percutaneous drainage are hemorrhage,43 especially because of intra-abdominal perforation of the abscess or rupture of the spleen during the surgery. The suspicion of neoplasm arising from the splenic flexure of the colon invading the spleen was not considered as a possibility at the first surgery but rather, the splenic abscess caused an inflammation of the splenic flexure of the colon. Thus, cancer resection was not performed. A colonoscopy was recommended to him after the first intervention, and scheduled as appropriate but the patient did not attend that appointment. Unfortunately, the patient presented again within 48 days with liver metastases and during the second surgery, performed 115 days after the first intervention, the cancer was staged sT4NxM1 with a mass in the small intestines as well as liver metastasis and pelvic floor seedlings.Splenectomy is the treatment of choice for many surgeons. However, as in many cases of splenic abscesses, parasplenic inflammation together with extensive adhesions makes it challenging even to the experienced surgeon to perform a proper splenectomy. This is without forgetting that the mortality rate after surgery for splenic abscess varies from 13% to 30%, with the most common pathogen being Streptococcus pneumoniae, Haemophilius influenzae, and Neisseria meningitidis. Most infections happen within 2 years post-splenectomy with also one-third of cases occurring up to 5 years post-splenectomy. Moreover, 38% to 69% of post-splenectomy patients who develop sepsis will die, despite the administration of pneumococcal vaccine and antimicrobial prophylaxis.Successful splenectomy is also a case to warrant care as it entails the great risk of fulminant infections with incidence being 3.2% and mortality rate being 1.4%,8.3th case report pertaining to invading colonic cancer causing a splenic abscess with respect to a PubMed search with key words “EXACT (splenic abscess) AND colonic cancer” accessed on July 30th, 2015. Relevant articles were those published in English and French or had abstracts in English or French, even though the articles were in any language other than French or English. This yielded the following relevant results, as shown in Table –57In the case of an invading neoplasm, the formation of a splenocolic fistula is not impossible, which will lead to the formation of a splenic abscess with an air-fluid level as seen in our case. Including our case report, this will be the 13 reported a similar case as ours, with no metastases, which underwent a left hemicolectomy with splenectomy. Their histological diagnosis of mucinous adenocarcinoma was made with the pathological findings of pT4b, pN1, cM0, fStage IIIa. They recommended an en-block resection including lymph node resection.In 2014, Oneda et al,59 Cabanas et al proposed that mucus-producing epithelial cells are entrapped within the trabeculae of the splenic capsule, in congenital clefts of the spleen and microfissures caused by trauma. From thereon, the mucinous tumor will expand into the soft splenic parenchyma rather than in the peritoneal cavity.Mucinous gastrointestinal tumors can cause perforation and infiltration into the full thickness of the bowel wall extending to the pericolic fat.,55 whereas there was a Polish article of splenic cancer complicated by perirenal abscess and 2 Spanish reports about intra-abdominal abscess from a nonspecified colon cancer lesion and 7 cases of cancer of the splenic flexure with 1 case re-operated for retroperitoneal abscess.Two particular case reports mentioned the presence of gas in the portal vein system with synchronous splenic abscess owing to local invasion of colon cancer,8.4–64Apart from the direct neoplastic invasion into the spleen, one should not forget the metastasis of cancerous cells to the spleen, although the spleen is an infrequent site despite its high vascularity. To attempt the explanation of the spleen being an infrequent site, there are various proposed hypotheses including the anatomical placement of structures, the rhythmic parenchymal sinusoidal contractions, and the absence of afferent lymphatic vessels in the parenchyma, among others.,63 In addition, the splenic parenchyma contains no afferent lymphatic vessels, although they are present in the subcapsular, capsular, and trabecular regions. Yet, tumor cells can still reach the spleen through the lymphatic system, which explains the typical subcapsular isolated splenic metastases. Also, Indudhara et al, in 1997, proposed that neoplastic cells can reach the splenic vein and parenchyma by retrograde diffusion through the inferior mesenteric vein.The spleen is the second largest organ of the reticuloendothelial system, which firstly blocks metastasis thanks to the anti-neoplastic properties of the lymphoid-rich splenic parenchyma. On an anatomical point of view, the sharp angle of the splenic artery with the celiac axis and the rhythmic contraction by the sinusoidal splenic architecture may limit the propagation of metastasis into the spleen. Splenic metastasis can be seen in 2% to 9% of untreated cancer patients but systemic chemotherapy has led to an increase in the incidence of splenic metastasis.–67 Forty-one cases of splenic metastases with primary colon cancer were studied in a literature review by Pisanu et al in 2007, which included only 3 cases of synchronous colon cancer and splenic metastasis. Splenic abscess was also present in 2 cases, which had synchronous splenic metastasis with colon cancer in this review.Splenic metastatic lesions can be solitary, multiple, or diffused and may vary in number and size. When present, it is not uncommon to find other metastatic sites such as lung, liver, and lymph nodes with common primary cancer sites being breast, lung, liver, stomach, pancreas, ovary, melanoma, and colon cancer.Enterobacter cloacae was the organism cultured from the pus drained intraoperatively from our patient. Coupled with the presence of the splenocolic fistula seen on CT scan, the presence of Enterobacter cloacae, which is part of the normal human gut flora in many humans, supports the pathological mechanism of direct invasion of the neoplastic splenic flexure into the spleen, into which the bacteria of the normal gut flora proliferated leading to abscess formation. The limitation of this case report was the missed appointment of the patient which could have resulted in, perhaps, more effective results to have been achieved. Furthermore, the diagnostic colonoscopy performed during his second admission did not point toward an overt splenocolic fistula, which again emphasizes the importance of user-operated imaging tools. This report is the 13th of similar nature to increasing cases of similar nature with the hope to keep the physician aware of this rare, but yet tragic incident that can occur. The oncological timeline has not been included in this report as it, according to the authors’ perspective, goes beyond the essential diagnostic message that we wish to pass through.The incidence of such a complication does not occur on a daily basis and the ability of the clinician to correlate the different signs and symptoms together with relevant diagnostic tools comes with experience. With the increasing popularity in the Western world of interventional radiology, the Chinese population are still sceptic in accepting and understanding these new methods. However, given in our case, it is still debatable as to whether or not, depending on the clinical care setting, it was possible to employ the interventional radiology in contrast to the radical surgical approach. 9The incidence of splenic flexure of the colon causing splenic abscess is a rare feat that has a growing number of reported literature over the years. With the advent of increasing immunosuppressed patients such as post-transplant, undergoing chemotherapy and AIDS, its incidence is increasing over the years. The splenic flexure of the colon still remains the least frequent site of occurrence of colonic neoplasm. Direct invasion into adjacent organs will cause atypical presentation of this condition, which will usually happen at an advanced stage of the disease. CT scan and ultrasound imaging modalities are pillars of diagnosis and are becoming the favorite approach for the initial step of treatment with image-guided percutaneous drainage over open surgery. The micro-organisms cultured in blood or pus samples in suspected splenic abscesses can hint toward the site of the primary insult. When surgery becomes the ultimate recourse for carcinoma of the splenic flexure, an en-block resection with splenectomy with or without lymph node resection, depending on the stage of the disease, is advised. However, there is not enough evidence to support or reject this approach because of the limited number of cases available in the literature. It is of utmost importance that any splenectomy should have the proper follow-up with respect to vaccination and warning against fulminant infections. The young and inexperienced surgeon must always keep in mind the probability, no matter how minimal, of the occurrence of a splenocolic fistula before it is too late. Again, emphasis cannot be put enough on the use of a multidisciplinary team for the proper detection and management of such cases.


Many normal variants of bones on plain radiographs have been reported.In the current report, a 14-year-old Asian girl noticed an occasional slight elbow pain. She had no traumatic episode. Plain radiographs showed a well-defined osteolytic lesion with a sclerotic rim, which was continuous with the normal subarticular bone in the distal humerus. Magnetic resonance imaging revealed that the defect area seen on the plain radiograph showed low-signal to iso-signal intensity on T1-weighted images and slightly high-signal intensity on T2-weighted fat suppression images. Bone edema was not observed. The association between her elbow pain and the lesion was not conclusive.The findings from the images suggested that the lesion was a normal variant rather than osteochondritis dissecans or a neoplastic lesion, and possibly an anatomical counterpart of a dorsal defect of the patella. Atlas of Normal Roentgen Variants That May Simulate Disease [Normal variants can be defined for lesions with atypical findings, and are normally found in some percentage of the population. Normal skeletal variants identified from plain radiographs have been listed in the well-known book  Disease .The current report describes a characteristic osteolytic lesion with a clear osteosclerotic rim at the distal humerus. This lesion, previously unreported, may be an anatomical counterpart of a dorsal defect of the patella. A distal defect of the humerus is a normal variant, and the discussion about the current case was made in light of a dorsal defect of the patella .A 14-year-old Asian girl had no pain in daily life, but occasionally had a slight pain in her left elbow. She looked normally developed, and was not obese. There was no past medical, surgical, or family history of factors that might contribute to bone disease. She had no tenderness over the elbow. She was not an active athlete, but belonged to a basketball club in school. There was no history of trauma. Plain radiographs showed a well-defined osteolytic lesion with an osteosclerotic rim in the distal humerus. The osteosclerotic rim was absent at the joint periphery, but continued to the subarticular bone. The osteosclerotic rim had no irregularity. Periosteal reaction was not seen. Her right elbow was normal  revealed that the osteolytic lesion was solid, and was next to the surrounding joint cartilage. The lesion had low-signal to iso-signal intensity on T1-weighted images, slightly high-signal intensity on T2-weighted fat suppression images, and high-signal intensity on short tau inversion recovery (STIR) images (Fig. The osteolytic lesion had a differential diagnosis of osteochondrosis dissecans as an osteocartilaginous defect. In the current case, the osteolytic area was rather deep and the osteosclerotic rim was clear. Our patient had no traumatic episode, and a clinical symptom of rocking at the elbow was not observed. No free body was detected in her elbow joint space on MRI. These image and clinical findings did not meet the diagnostic criteria for osteochondrosis dissecans.A neoplastic lesion was also a differential diagnosis in the current case. Osteolytic bone tumors that involve the epiphysis include chondroblastoma, chondromyxoid fibroma, and giant cell tumor of bone. An osteosclerotic rim is not usually seen in giant cell tumor of bone. Although chondroblastoma and chondromyxoid fibroma may have an osteosclerotic rim, the osteosclerotic rim would not be as clear as that in the current case. Furthermore, the absence of bone marrow edema suggested a lower probability of a neoplastic lesion.After excluding the possible differential diagnoses of traumatic and neoplastic lesions, a normal variant condition was considered. Biopsy was not performed for the diagnosis. The plain radiograph at follow-up at 2 years had not changed, and pain was not noticed at that time.The current lesion of a so-called distal defect of the humerus was considered to be a normal variant, but this variant is not listed in the text book . The plaThe diagnosis of dorsal defect of the patella can be made from a plain radiograph, and invasive diagnostic procedures including a biopsy should be avoided . In the Most cases with dorsal defect of the patella cause no pain, and the lesions are usually found incidentally. However, dorsal defect of the patella causing knee pain has been reported –11. In tThe characteristic imaging findings at the distal humerus suggest that this lesion is a normal variant and possibly an anatomical counterpart of dorsal defect of the patella.


Hyperlordosis is common in facioscapulohumeral muscular dystrophy (FSHD), which cannot be controlled by bracing. While the surgical treatment is neither reported nor recommended in previous studies, we report the first corrective surgery for hyperlordosis in one wheelchair-dependent FSHD patient.A 15-year-old, wheelchair-dependent girl complaining of hyperlordosis and lower extremity weakness was diagnosed as FSHD. Preoperative examination showed hyperlordosis of 116° with scoliosis of 44°. Posterior correction and bone graft fusion was performed. Postoperatively, the hyperlordosis was corrected to 72° and better sitting posture was gotten. 12 months’ follow-up showed favorable correction with improvement in SF-36 and ODI score.The correction for hyperlordosis in FSHD is controversial. We report the first successful case of operative treatment by corrective spine surgery in these rare and demanding patient collective. Corrective surgery for spinal deformity, such as hyperlordosis and scoliosis, could do some help in posture and improve the quality of life especially in wheelchair-dependent patients. Althougith FSHD .Hyperlordosis is common in FSHD, which results in weakness of pelvic extensor and paraspinal muscles , 6. BracWe report the first corrective surgery for hyperlordosis in one wheelchair-dependent FSHD patient, who shows improvement in posture, Medical Outcomes Study Short Form-36 (SF-36), and Oswestry Disability Index (ODI) postoperatively, indicating that correction for hyperlordosis can help to improve posture and quality of life for wheelchair-dependent FSHD patients.A 15-year-old girl was admitted into our spine center in November 2015 with complaint of gradually aggravated hyperlordosis for 4 years and lower extremities weakness for 1 year. She had been wearing the brace for more than 4 years (20 h/day) without controlling the hyperlordosis. She was dependent in the wheelchair and couldn’t stand without any support. Medical history included pectus excavatum at birth, and corrective operation was performed 4 years ago. Physical examination found weakness of facial expression muscles , winged scapula of both sides and decreased strength in back, proximal upper and lower extremities . The Gower sign was positive due to the weakness of abdominal and iliopsoas muscles, while her intelligence, vision and hearing acuity were all normal. Her mother also had weakness of expression muscles without spinal deformity. Anterior-posterior (AP) and lateral standing X-ray of whole spine revealed thoracolumbar hyperlordosis , scoliosis , and horizontally positioned sacrum (Fig. FSHD was diagnosed on the basis of classic clinical presentations . In DeceHyperlordosis is common in FSHD, which results in weakness of pelvic extensor and paraspinal muscles , 6. The Unlike the patient reported by Lee, the back extensor muscles of this girl are weaker due to the deterioration of FSHD, and fail in maintaining compensatory mechanism. So, the girl is wheelchair-dependent and in bent posture when sitting. The involvement of paraspinal and pelvic extensors muscles in MRI can prove this. It can be expected that, hyperlordosis and bent posture will be worse and worse with weakness of paraspinal muscles, which has obvious influence on the daily life. So, the correction is necessary because the rigid internal fixation system could hold the upright sitting posture, while the paraspinal muscles were weak.The changes in SF-36 and ODI scores can also prove the improvement in quality of life after correction of hyperlordosis.FSHD is one of the most common forms of muscular dystrophy, and many patients accompanies with spinal deformity including hyperlordosis or scoliosis. The spinal deformity influences the posture, even ability of movement. The correction for hyperlordosis in FSHD is controversial. We report the first successful case of operative treatment by corrective spine surgery in these rare and demanding patient collective. Corrective surgery for spinal deformity, such as hyperlordosis and scoliosis, could do some help in posture and improve the quality of life especially in wheelchair-dependent patients.


Right lower quadrant pain is a symptom with an exceptionally broad differential diagnosis. Intussusception of the appendix is a very uncommon condition with many manifestations. Additionally, the pathologic finding of ectopic presence of a mixture of at least two mullerian-derived tissue components is rare. This report presents the case of a 49-year-old woman who presented twice with acute right lower abdominal pain. Diagnosis of appendiceal inversion was made surgically. Pathologic examination of the specimen identified extensive endometriosis, endosalpingiosis and endocervicosis of the colon wall. Appendiceal intussusception and colonic mullerianosis, present together, are discussed, and recommendations for the diagnosis and treatment of appendiceal intussusception are discussed. Intussusception of the appendix is a rare condition with an estimated incidence of 0.01% . The incOn the other hand, mullerianosis is a highly infrequent lesion diagnosed histologically by the presence of a mixture of at least two mullerian-derived tissue components . LesionsA low-population incidence, combined with poor diagnostic study options, in the setting of a disease characterized by a variety of clinical presentations make the diagnosis and appropriate treatment of appendix intussusception and mullerianosis difficult. Therefore, the purpose of this report is to present a case of appendiceal intussusception, analyze the diagnosis and treatment of this patient, examine the diagnostic options and discuss the appropriate management of the condition.This report presents the case of a 49-year-old Caucasian female with a past medical and surgical history significant for acute cholecystitis, for which she underwent a laparoscopic cholecystectomy in 2009, and symptomatic uterine fibroids, for which she underwent a laparoscopic supracervical hysterectomy and bilateral salpingectomy in 2012. At that time, evidence was noted of endometriosis at the left pelvic sidewall and posterior cul-de-sac. The patient also underwent colonoscopy in 2010, where a prominent appendiceal orifice was described. No additional medical conditions are reported.The patient presented to the emergency department complaining of a 5-day history of intermittent throbbing abdominal pain, initially periumbilical, but migrating to the right lower quadrant on initial presentation, which was associated with nausea and increased stool frequency. Physical exam was significant for moderate tenderness to palpation in the right lower quadrant and positive Rovsing sign. Laboratory studies were all within normal limits. Contrast CT identified lobulated tubular soft tissue and inflammation adjacent to the terminal ileum/ileocecal valve did not identify an appendix  and quesFor this diagnosis, the patient was started on broad-spectrum antibiotics and underwent diagnostic laparoscopy. Mild inflammatory changes of the terminal ileum and adhesions involving the cecum, right ovary, and abdominal wall were observed without evidence of Crohn’s disease, but no appendix was identified despite full mobilization of the cecum and a thorough running of the small bowel. A biopsy of the inflamed areas was taken and revealed acute inflammatory changes surrounding the fallopian tubes as well as focuses of endometriosis. Intraoperative consultation with the colorectal surgery team was performed, and it was decided at that time to avoid further surgical interventions and continue course with intravenous antibiotics. Postoperatively, the patient began to tolerate a solid diet and was discharged on postoperative day 2, with plans for interval diagnostic colonoscopy. The patient returned to the emergency department within two hours of discharge, complaining of sharp right lower quadrant pain, nausea and vomiting. Repeat labs were significant for a white blood cell count of 13.23. Repeat CT of the abdomen and pelvis was consistent with small bowel obstruction focused at the level of the terminal ileum, likely secondary to an adjacent pericecal soft tissue mass . DiffereGiven the negative findings on prior diagnostic laparoscopy, a laparoscopic ileocecectomy with primary anastomosis was performed. Intraoperative inspection on the back table revealed a large inverted appendix. Gross pathologic examination identified an area of induration and fibrosis having a dark brown nodular appearance and located between the cecum and the terminal ileum. Within the bowel, an intussuscepted portion of appendix measuring 2.2 cm in length and up to 1.4 cm in diameter was identified; the appendix was not inflamed . Cut secThe patient recovered after a short ileus and was successfully discharged home on a regular diet and having normal bowel function on postoperative day 7 from the second surgery.Intussusception of the appendix is rare, affecting an estimated 0.01% of the population . AdditioSurgical management differs between these diagnoses. Obviously, the cases of clear appendicitis are treated surgically via appendectomy. Intussusception tends not to respond permanently to non-surgical management, and simple appendectomy may not be adequate treatment. Removal of a “cecal cuff” with the appendix is reasonable as this technique reduces the probability of recurrent intussusception of the appendix stump and creates a surgical margin for possible tumors at the base of the appendix . FinallyInversion of the appendix represents a significant diagnostic challenge. Preoperative identification can be obtained by double-contrast barium enema (“coiled spring sign” with non-filling of the appendix), ultrasound (“doughnut sign”/”target lesion”), CT, endoscopy, and laparoscopy . Our casBased on the published cases in the literature, comparable proportions of patients treated with surgical therapy undergo appendectomy versus partial colectomy. Improving diagnostic algorithms and imaging may increase the rate of appropriate surgical treatment and decrease unnecessary resections. Therefore, this report reminds clinicians of this diagnosis and draws attention to the need for an accurate and precise diagnostic test to serve as the gold standard of diagnosis.Mullerianosis is a rare lesion diagnosed histologically by the presence of a mixture of at least two Mullerian-derived tissue components . LesionsEndocervicosis is defined by the presence of benign ectopic endocervical-type glands. It is rarer than endometriosis and endosalpingiosis. It has been reported to involve the pelvic structures, but only one case of involvement of the small bowel has been reported . One casEndocervicosis and endosalpingitis findings tend to be incidental, contrary to the more common endometriosis. The management of endocervicosis and endosalpingitis includes analgesics, hormonal therapy, surgical intervention or a combined approach . The appAny commentary on inversion of the appendix is limited by the overall low incidence and diagnosis of the condition. Additionally, it is possible that not all cases are reported in the literature. Our case highlights the importance of reporting diagnosed events, such that practicing clinicians can diagnose and properly treat this patient population. Further studies on diagnosis of appendiceal intussusception may prove beneficial.This case reports a rare diagnosis of appendiceal intussusception, with pathology findings remarkable for the unique presence of endocervicosis and mullerianosis of the colon wall. This report adds data to the currently small body of literature for each finding. Additionally, diagnostic and treatment considerations for appendiceal intussusception were discussed, with the goal of educating the practicing clinician and reducing patient morbidity.Consent: 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.Conflict of interest statement: none declared.


Sinonasal teratocarcinosarcoma is a rare and aggressive malignancy with histological features of both carcinosarcoma and teratoma. The optimal management of this malignancy is unclear, with most patients being managed by a combination of surgery and radiotherapy.We describe an 83-year-old white woman with sinonasal teratocarcinosarcoma of her left nasal cavity treated with surgical debulking initially with radiological evidence of residual disease which was treated with radiotherapy (60 Gy in 30 fractions). A follow-up examination at 2 years showed no evidence of recurrence.In cases of sinonasal teratocarcinosarcoma with residual disease post-surgery, radiotherapy alone can be an effective option. Sinonasal teratocarcinosarcoma (SNTCS) is an extremely rare malignant neoplasm of uncertain histogenesis . It is hAn 83-year-old white woman presented to her general practitioner initially with 1 month of nasal obstruction, intermittent epistaxis, and anosmia. This is on the background of atrial fibrillation, hypertension, and osteoarthritis. Her regular medications were apixaban, digoxin, amlodipine/valsartan, frusemide, metoprolol, and paracetamol with no known drug allergies. She lived with her son, mobilized independently with a walking stick, and was independent with all activities of daily living (ADLs) with an Eastern Cooperative Oncology Group (ECOG) score of one. She did not smoke tobacco and drank three to four standard units of alcohol per day.On examination, her vital signs were within normal range and the rest of the physical and neurological examinations were normal. Her blood pressure was within normal range at 120/70 mmHg. A nasal speculum examination found a large tissue growth in her left nasal cavity and a subsequent computed tomography (CT) scan revealed a large soft tissue mass opacifying the left maxillary, ethmoidal, frontal, and sphenoid sinuses – there was no intracranial extension  scan revealed some ongoing soft tissue thickening in her left nasal cavity and her maxillary, ethmoid, and frontal sinuses with no evidence of distal fluorodeoxyglucose (FDG)-avid disease Fig. . She recSNTCS is a highly aggressive and rare malignant tumor with epithelial, mesenchymal, and neuroepithelial origins. The term was first used by Heffner and Hyams based on a case series with 20 patients with SNTCS . This isOnly after formal examination of the whole specimen was it recognized both histologically and on immunohistochemistry that the tumor was a heterogeneous mixture of components from all three germ cell layers at varying degrees of differentiation. These included both mature benign glandular and stromal components Fig.  along wiOn clinical examination, patients often present with nasal obstruction and epistaxis; however, they can also present with anosmia, headache, visual changes, and neurological symptoms .The prognosis in SNTCS remains unclear, however, it is an aggressive tumor and recurrence and metastasis are common, with a recent systematic review of 71 cases quoting figures of approximately one-quarter having recurrence and 10% having metastasis . Howeveret al. consisting of 86 patients showed that the most common treatment modality was surgical resection followed by radiation therapy, with 51 cases out of 86 utilizing this approach [et al. and Peng et al. have utilized IMRT with good effect, with no recurrence at 2 and 3.5 years respectively [The optimal approach to treatment remains unclear in this condition due to the lack of large-scale studies given the rarity of the disease. A systematic review by Misra approach . The aveectively , 11. Ouret al. reported an 88.8% survival rate at follow-up after an average of 32 months for those who received adjuvant chemotherapy in addition to surgery and radiation, as compared to 56.5% at 45 months for those who received surgery and radiation only [The role of adjuvant chemotherapy remains unclear; there is some suggestion that adjuvant chemotherapy can lead to better survival outcomes. Misra ion only , 12. HowThis case demonstrates that radiotherapy alone can be an effective and well-tolerated treatment modality in patients with SNTCS who have residual disease post-surgery. Further larger scale studies should be conducted to clarify if there is a role for adjuvant chemotherapy.


Background. Submandibular oncocytomas are rare benign salivary gland neoplasms. They are typically found in Caucasian patients aged 50–70 years with no gender preference. Due to the overlapping histological and clinical features of head and neck tumors, they are often misdiagnosed. Methods. We report a case of unilateral submandibular gland oncocytoma in a 63-year-old Caucasian man. Results. The patient underwent unilateral submandibular gland resection and histopathologic analysis of the tumor specimen. On follow-up at 2 weeks and 1 year, no recurrence was identified. Conclusion. Submandibular oncocytomas are best diagnosed with preoperative FNA and CT imaging and have distinctive findings on cytology and histology. CT followed by fine-needle aspiration cytology would be the preferred diagnostic modalities. Due to its low rate of malignant transformation and recurrence, the best treatment is local resection with follow-up as necessary. Oncocytomas are rare benign neoplasms composed of oncocytes or polyhedral cells with eosinophilic cytoplasm made up of abundant mitochondria and dark centrally located nuclei –3. HürthSalivary gland oncocytomas are primarily found in the parotid gland and rarely found in the submandibular glands . To the Submandibular oncocytomas can present asymptomatically or as tender, enlarging neck masses over weeks to years. Typical patients are Caucasians 50–70 years of age with no gender preference. There are no clear etiologies for the development of submandibular oncocytomas, although there have been cases associated with radiation exposure .This report aims to evaluate the clinical and histopathological features of submandibular oncocytomas through a single case report at St. Louis University hospital and will include a review of previous literature with an emphasis on diagnostic criteria and future treatment of such cases.A 63-year-old Caucasian male presented with a 3-year history of tender right neck mass. He denied other symptoms and his past medical history was noncontributory. He denied cigarette smoking and tobacco use and reported 15 alcoholic drinks per week. Past surgical surgery included an osteotomy of the clavicle. On physical exam, a 1.5 cm solid nodule was palpated in the right submandibular region above the tip of the hyoid. The presence of the mass was confirmed on CT imaging, which showed a well-defined, homogeneously enhancing 1.6 × 1.3 cm mass in the inferior pole of the submandibular salivary gland .A fine-needle aspiration (FNA) of the lesion was performed. In cytopathology Figures , there wFor definitive treatment and pathologic diagnosis, a right submandibular gland resection was performed. Gross examination revealed a weeping tan/yellow mass. The cut surface was coarsely lobulated with focal hemorrhage. Microscopically, the tumor showed a well-circumscribed mass with a thin capsule . The tumOncocytomas of the salivary gland are rare benign neoplasms that comprise 3-4% of head and neck tumors , 20. TheOncocytosis, marked by increased number of mitochondria, is frequently reported in aged, reactive, inflamed, hyperplastic salivary glands . HoweverThe differential diagnosis for benign submandibular tumors includes pleomorphic adenoma and Warthin's tumor. Each tumor can be distinguished based on its histopathological characteristics. Oncocytomas are characterized by the presence of monomorphic oncocytes without mitoses and necrosis . Unlike Due to the similarities in clinical presentation between benign and malignant submandibular oncocytomas, radiologic imaging and fine-needle aspiration cytology (FNAC) are essential in distinguishing between the two entities. Ultrasound is recommended for initial assessment of a mass, but is insufficient because it does not provide information about surrounding structures. Recently, F-18 FDG PET/CT has shown promise in detecting features of salivary gland malignancies. Subramanian and colleagues described the utility of PET/CT in the initial staging and histologic grading of salivary gland malignancies . Fine-neTo date, the first-line treatment for submandibular oncocytomas is surgical excision. Of the cases in In summary, we present a case of submandibular oncocytoma, which is a rare benign salivary gland neoplasm. Distinguishing features of oncocytomas are best seen on preoperative FNA cytology and histology, which include the presence of monotonous oncocytes with low N/C ratio and lack of mitoses and necrosis. The malignant potential of a benign oncocytoma is extremely low at around 3%, with only one previously reported case in literature. CT followed by fine-needle aspiration cytology would be the preferred diagnostic modalities. Treatment is local excision of the tumor with appropriate follow-up as needed.


Cardiac papillary fibroelastomas (CPF) are rare cardiac tumors, mostly found on the valvular surfaces in the heart. These tumors are frond like in nature and are benign, intracardiac masses, rarely causing any hemodynamic disturbances. However, excision of these masses is indicated due to their propensity to embolize. We present a case report of the tumor found on the coumadin ridge, causing transient ischemic attacks in a patient. We performed complete excision of the tumor via median sternotomy on cardiopulmonary bypass support with cardiac arrest. The diagnosis was confirmed by histological examination. The patient had an uneventful postoperative course and was discharghed on postoperative day 4. She has had complete resolution of her symptoms post excision. The diagnosis of the mass was confirmed on histological examination. She was found to have a CPF arising from the so-called coumadin ridge  that underwent surgical resection.A 71-year-old female presented to her primary care physician with complaints of lightheadedness. She had no other symptoms and her physical examination was unremarkable. A non-contrast head computed tomography scan was negative for any abnormalities. This prompted a cardiac work up for her symptoms. An electrocardiogram revealed premature ventricular contractions that led to a transthoracic echocardiogram (TTE). This showed a 1 cm mass within the left atrium, concerning for a thrombus. A transesophageal echocardiogram  with subThe procedure was performed via median sternotomy with the aid of cardiopulmonary bypass. Central aortic arterial cannulation with bicaval venous cannulation was performed. The heart was arrested with aid of antegrade cardioplegia. For surgical exposure, Sondergaard’s groove was dissected and a left atriotomy performed. A 1 cm mobile, gelatinous mass on the left atrial wall was found . This arOn gross examination, the tumor was soft and grey-white, that appeared frond-like and translucent when submerged in liquid. Histologically, it was composed of branching avascular papillae with variable amount collagen and myxoid change consistent with papillary fibroelastoma, with no evidence of extension into the left atrial wall .3 Since greater than 95% of CPF are located on the left side, these usually present with symptoms of systemic embolism, with reports of tumors fragments embolizing to the cerebral, coronary and even mesenteric circulation.3 Nevertheless, there have been reports of right sided tumors embolizing to the pulmonary circulation.4 It has been suggested that that the tumor location may influence the potential for thromboembolic events, in particular in the vicinity of the left atrial appendage. Thrombus formation and subsequent embolization may be more susceptible due to low flow in the area of the left atrial appendage.2CPF are rare tumors that are usually asymptomatic and often discovered incidentally. A large retrospective analysis of 725 patients revealed the valvular surfaces as the most common location of these tumors, with only ten arising from the left atrial wall.3 A survey of recent literature revealed less than 20 reports of CPF arising from the left atrium.8 The presenting symptoms were transient ischemic attacks in most cases. Rarely, these tumors may present with chest pain, angina or even myocardial infarction, if embolism to the coronary arteries occurs.7Although CPF are the second most common benign tumors of cardiac origin, the left atrium is a very unusual location for these tumors.1 More recently, cardiac magnetic resonance imaging has helped differentiate these tumors from other cardiac masses.9 Electrocardiographic findings are usually non specific, but may present with atrial arrhythmias. Due to the risk of embolism with these tumors, surgical excision is the recommend therapy.Diagnosis is usually made by echocardiography, either transthoracic or transesophageal, with images confirming a pedunculated and mobile mass. This may appear speckled, with a stippled pattern near the edges.6 This structure has often been mistaken as a thrombus, resulting in life long anticoagulation for the patient. In these situations, contrast magnetic resonance imaging is helpful, and aids in diagnosis.5The coumadin ridge has been described as a ridge of atrial tissue separating the left atrial appendage from the left pulmonary vein. It can appear as a mass that protrudes into the left atrium and can appear similar to a tumor or thrombus.In conclusion, left atrial papillary fibroelastomas are rare benign cardiac tumors, with propensity to cause thromboembolic events. In patients with unexplained neurological symptoms, echocardiographic imaging should be performed. Surgical excision is warranted in these cases since these small, seemingly harmless tumors have the potential to cause significant systemic and neurologic complications.This study is in compliance with the Ohio State University Internal Review Board Committee Rules and Regulations.None.


Introduction. Gallbladder volvulus is a rare, potentially fatal condition unless diagnosed and treated early. Choledochal cysts are rare congenital malformations of the biliary tree predisposing to different pathologies and posing the risk of degradation into cholangiocarcinoma and gallbladder cancer. Dealing with both diseases at once has not been published yet in the literature. Presentation of Case. We report a case of gallbladder volvulus in an elderly female who happened to have a concomitant type I choledochal cyst. Treatment was achieved with a cholecystectomy and observation and follow-up of the choledochal cyst. Discussion. Prompt diagnosis and surgical management of gallbladder volvulus is important to avoid the morbidity and mortality of gangrenous cholecystitis and biliary peritonitis in a frail old population of patients. Precise clinical diagnosis, supplemented with specific imaging clues, helps in the diagnosis. Management of choledochal cysts is also surgical; however the timing of surgery is still a matter of debate. Conclusion. We describe in this report the first case of gallbladder volvulus in a patient with a choledochal cyst and propose a management algorithm of a very rare biliary tree pathology combination. Gallbladder volvulus is a rare, difficult-to-diagnose clinical condition that presents as acute abdomen and often leads to significant morbidity due to the delay in diagnosis and surgical treatment. Since first reported by Wendel in 1898 as a “floating gallbladder,” more than five hundred cases have been reported in the literature with an incidence of approximately 1 in 365,000 hospital admissions . Volvulu3/μL. After reviewing of previous CT scans spanning several years, the gallbladder was noted to be located in several different locations adding suspicion for gallbladder torsion to the differential diagnosis  scan demonstrated a markedly dilated extrahepatic biliary ductal system (intrapancreatic common bile duct > 2.5 cm) and a markedly distended gallbladder . The patiagnosis . The patAt laparotomy, a gangrenous, necrotic gallbladder was identified in the right lower quadrant and was nonadherent to the liver bed. The gallbladder was completely torsed (360 degrees) around the cystic duct and cystic artery. The gallbladder was so mobile that it could be brought out onto the abdominal wall and detorsed; a blood clot was visible in the gallbladder mesentery at the point of torsion. The gallbladder was readily removed following simple ligation of the cystic artery and duct . The choGallbladder volvulus or torsion occurs when the gallbladder rotates either clockwise or counterclockwise around its mesentery along the axis of the cystic duct and cystic artery causing complete obstruction of blood flow and biliary drainage resulting in acute gangrenous cholecystitis . This coThe etiology of gallbladder torsion is unknown. Anatomic anomalies, such as an abnormally long mesentery or abnormal fixation of the gallbladder to the liver, can result in a suspended gallbladder allowing it to freely float from the liver bed . It is tPatients with gallbladder torsion present with symptoms similar to biliary colic or acute cholecystitis including acute onset of right upper quadrant pain. The acuteness of the presentation depends on whether the volvulus is partial or complete; a partial torsion is followed by spontaneous detorsion and resolution of symptoms, thus presenting like biliary colic, whereas a complete torsion  presents with acute cholecystitis-type symptoms with worsening over the ensuing hours to days . As in oIn the past, gallbladder torsion was typically diagnosed intraoperatively. However, advancements in diagnostic imaging as well as the increased use of imaging in the workup of patients with acute abdomen have led to an increase in preoperative diagnosis . UltrasoEarly diagnosis and prompt surgical intervention with detorsion and cholecystectomy are important to avoid complications of perforation and bilious peritonitis . The useTo our knowledge, this is the first report in the literature that describes the presence of gallbladder torsion in a patient with a choledochal cyst. Choledochal cysts have been associated with other anomalies within the pancreaticobiliary tree including multiseptated gallbladder, heterotopic pancreas, and pancreatic divisum, but they have not been reported to predispose to volvulus of the gallbladder , 25. ChoDue to the rarity of this combination of gallbladder torsion and choledochal cyst, a hepatobiliary surgeon should be involved from the outset. Prompt gallbladder detorsion and cholecystectomy is the standard of care for gallbladder volvulus regardless of the timing of diagnosis (pre- or intraoperatively). Extrapolation from common surgical practice precludes excision of the choledochal cyst and construction of a hepaticoenterostomy in the setting of an acutely inflamed and potentially infected field; thus laparoscopic cholecystectomy should be done first. The patient can then be brought back electively for choledochal cyst resection. In cases of acute cholecystitis without gallbladder torsion, conservative management of cholecystitis can be attempted with antibiotics with or without percutaneous cholecystostomy drainage which may then allow for a one-stage procedure . We suggest an algorithm extrapolated from literature data suggesting a plan of action when a gallbladder volvulus is encountered in a patient with choledochal cysts . It is bGallbladder volvulus and choledochal cysts are two very rare entities of the biliary tree. Volvulus should be considered in the elderly female patients with symptoms suggestive of sudden onset of acute acalculous cholecystitis with imaging characteristics pointing towards a free-floating gallbladder. While gallbladder volvulus requires a high index of suspicion and early surgical intervention to avoid significant morbidity and mortality in a frail patient population, choledochal cysts can be dealt with electively taking into account their symptoms and risk for malignancy relative to age.


Lymphangioma circumscriptum is a superficially localized variant of lymphangioma. The characteristic clinical presentation is a “frogspawn” grouping of vesicles or papulovesicles on the proximal limb or limb girdle areas. Though most lymphangiomas develop congenitally, the lymphangioma circumscriptum subtype is known to present in adults. We report a case of lymphangioma circumscriptum on the left inframammary area of an African American female with an unusual supernumerary nipple-like clinical presentation. Our patient presented with a firm, smooth, hypopigmented papule, and the clinical diagnosis of keloid was made initially. However, she returned reporting growth of the lesion and was noted to have a firm, exophytic, lobulated, pink to skin-colored nodule. Histopathological examination demonstrated dilated lymphatic vessels, consistent with the diagnosis of lymphangioma. The presentation as a firm, hypopigmented papule and later exophytic, lobulated, skin-colored nodule in our case represents a clinical presentation of lymphangioma circumscriptum not previously described in the literature. Correct diagnosis in lymphangioma circumscriptum is vital, as recurrence following surgical resection and secondary development of lymphangiosarcoma and squamous cell carcinoma following treatment with radiation have been reported. Thus, it is important to consider lymphangioma circumscriptum in the differential of similar lesions in the future to allow appropriate diagnosis, treatment, and monitoring. Lymphangiomas are malformations of lymphatic tissue characterized by distended channels. They are most frequently seen in children, with up to 90% of cases occurring within the first 2 years of life . One theA 42-year-old African American female initially presented with a several month history of an asymptomatic lesion on the left inframammary area. She denied any antecedent trauma to the area or any other predisposing factors. The patient had a history of breast cancer that was being treated with tamoxifen at that time; however, she had not received radiation to the area as part of her treatment regimen. Physical exam revealed a 3-mm, firm, smooth, hypopigmented papule on the left inframammary area. The lesion was diagnosed as a keloid, and the patient was reassured and asked to return to the clinic for treatment if the area became irritated.The patient presented 1.5 years later because the lesion had been growing and rubbing on clothing. She denied any associated bleeding, pruritus, or pain. On exam, the left inframammary area was noted to have a 1.5-cm, firm, exophytic, lobulated, pink to skin-colored nodule with a surrounding hyperpigmented patch . The cliLiterature search reveals several cases of LC arising on the abdomen, breast, and inframammary region; however, these cases manifested clinically with papulovesicular lesions , 6. The Additionally, adult-onset or acquired cases of LC in the literature usually report some history of antecedent trauma, particularly in areas that are subject to friction or previous radiation therapy or in the setting of chronic lymphedema , 7, 8. THistologically, lymphangiomas are characterized by dilated lymphatic vessels present in the papillary dermis, positivity of the lymphatic channels to the lymphatic endothelial marker D2-40, atrophy of the overlying epidermis, and elongation of the rete ridges , 9. The The importance of the correct diagnosis in cases of LC is multifold; risks associated with this diagnosis include recurrence and the secondary development of malignancy. One study reports that the risk of recurrence in surgically resected cases of LC is 11% , 13. The


A four-year-old female was admitted to a university-based children's hospital with a newly-diagnosed posterior fossa tumor. She was started on famotidine and high-dose dexamethasone and underwent gross total resection of a medulloblastoma. She was continued on dexamethasone and famotidine. She exhibited postoperative posterior fossa syndrome and was started on enteral feeds via the nasoduodenal tube. She had small gastrointestinal bleeds on postoperative days eight, 11, and 18, and was found to have a well-circumscribed posterior duodenal ulcer. On postoperative day 19, she suffered a massive life-threatening gastrointestinal bleed requiring aggressive resuscitation with blood products. She required an emergent laparotomy due to ongoing blood loss and she was found to have posterior duodenal wall erosion into her gastroduodenal artery. She recovered and subsequently began delayed chemotherapy. This case demonstrates a rare and life-threatening complication of high-dose dexamethasone therapy in the setting of posterior fossa pathology despite stress ulcer prophylaxis. We present a historical perspective with the review of the association between duodenal and intracranial pathology and the usage of high-dose dexamethasone in such cases. In 1932, Dr. Harvey Cushing reported a series of patients found to have gastroduodenal ulcers after the initial presentation for brain tumors [Gastroduodenal ulceration secondary to intracranial pathology has now been termed a Cushing’s ulcer, but reports of severe sequelae in the pediatric population remain infrequent, attributed to the advent of acid suppression . We presA four-year-old female with a history of prematurity (31 weeks gestation), atrial septal defect, and neonatal tachycardia requiring digoxin for the first year of life was admitted to a university-based children’s hospital following evaluation in an emergency department for one month of progressive ataxia, several days of headache, and two days of emesis. Brain magnetic resonance imaging (MRI) at the outside hospital revealed ventriculomegaly and a posterior fossa mass. She initially received 7.5 mg (0.5 mg/kg) dexamethasone, followed by 4 mg dexamethasone every six hours (one mg/kg/day) and standard–dose IV famotidine 0.25 mg/kg BID for the first three days of admission. On hospital day two, she underwent intraoperative external ventricular drain (EVD) placement and a suboccipital craniotomy with gross total resection of her tumor which was ultimately found to be a grade four, C-myc amplified (group three) medulloblastoma, initially staged M0. She received 6 mg dexamethasone at the beginning of the case and the tumor was noted to be invasive into the floor of the fourth ventricle and the bilateral middle cerebellar peduncles. Postoperative magnetic resonance imaging (MRI) demonstrated no residual tumor or stroke, though there was some indeterminate enhancement in the infundibular recess of the third ventricle. Her immediate postoperative course was notable for mutism and lethargy, which would continue as a severe case of transient posterior fossa syndrome. She was continued on dexamethasone 2 mg every six hours, which was lowered to 1 mg every six hours on the postoperative day five with twice daily ranitidine (2 mg/kg/dose) continued throughout. Enteral feeds were initiated on postoperative day one via the nasoduodenal tube.On the postoperative day eight, she passed bright red blood per rectum with sudden onset of tachycardia to over 220 beats per minute and anemia with hemoglobin 4.3 g/dL. She stabilized with red blood cell transfusions, pantoprazole infusion, and initiating a rapid two-day dexamethasone wean. Despite treatment with a proton pump inhibitor (PPI), she had repeat hematochezia on postoperative day 11, which required additional red blood cell transfusion. Esophagogastroduodenoscopy showed a large, well-circumscribed posterior duodenal ulcer with no active bleeding  remained stable. On postoperative day 19, massive gastrointestinal bleed and hemorrhagic shock were signaled by sudden tachycardia to 210, progression to diffuse pallor, poor responsiveness, and hypotension within several seconds, with estimated blood loss of 1.8 liters per rectum was found. Her airway was secured and she required emergent resuscitation with three liters of blood products and vasoactive infusions. Upon emergent laparotomy, the stomach and duodenum were filled with arterial blood. Duodenotomy revealed active pulsatile bleeding from her gastroduodenal artery due to erosion from a posterior duodenal ulcer. Hemostasis was achieved by ligating the gastroduodenal artery and overseeing the duodenal ulcer. Due to diffuse bowel edema secondary to massive fluid resuscitation, her abdomen was left open with a temporary abdominal silastic dressing. Over the next four days, she underwent abdominal wall silo closure until the fascia was able to be closed.Individualized chemotherapy as per clinical study ID SJYC07 was started on postoperative day 38, and she was found to have probable metastasis in the infundibular recess of the third ventricle on repeat brain MRI. The remainder of her postoperative course was complicated by Enterobacter cloacae bacteremia (E. cloacae)  requiring removal of her port and further delay in chemotherapy. Her posterior fossa syndrome was largely resolved at her three-month postoperative follow-up and she is now talking and walking with no focal neurologic deficit and MRI at one year demonstrated no residual or recurrent tumor. She was continued on pantoprazole for the first six months and is now 12 months postoperative with no further evidence of bleeding.Although neurogenic gastroduodenal ulcers are often eponymously associated with Cushing, recognition of a connection between central nervous system disease and gastrointestinal disease extends as far back as 1772, when John Hunter published postmortem findings of gastromalacia in the patients who suffered fatal head trauma . RokitanIn the era prior to the routine administration of gastrointestinal prophylaxis with H2 blockers, the incidence of massive GI hemorrhage in pediatric patients with brain tumors was reported more commonly than expected. Lewis reported 10 cases of massive GI hemorrhage secondary to duodenal ulcers in approximately 100 pediatric patients with brain tumors during a five-year period . SimilarOur case is similar to those presented by others in that it involves posterior duodenal bulb ulceration in the setting of a posterior fossa tumor with brainstem invasion. The patient’s immediate onset of mutism and lethargy postoperatively is consistent with Lewis’ description of ‘embarrassment of brain-stem function.’ Ross presents a strikingly similar four-year-old with medulloblastoma who suffered hemorrhagic shock from erosion of an ulcer into his gastroduodenal artery following craniotomy. However, our case differs in two key ways. First, our patient received ulcer prophylaxis with appropriately-dosed H2 blocker and proton pump inhibitors (PPI) per standard of care in keeping with the lessons learned from prior similar cases, but this was insufficient to prevent massive gastrointestinal bleed. Second, although she evidenced smaller gastrointestinal bleeds in the common seven to 10-day postoperative time period, her massive life-threatening hemorrhage did not occur until postoperative day 19. If she had not had her early bleeding episodes or if they went under-recognized, she would have been home or in the acute care ward at the time of her massive hemorrhage. In either case, it is quite unlikely that her resuscitation could have been rapid enough to preserve her life, similar to a recently reported case where a 10-year-old male who suffered massive GI bleeding in the clinic and subsequently died despite ranitidine prophylaxis [This case supports the association between posterior fossa tumors and posterior duodenal ulceration but suggests that the current standard of acid suppression may not be sufficient to prevent life-threatening sequelae. Our experience emphasizes the need for prolonged vigilant observation, particularly in patients with known ulcerations, as continued ulceration may result in quite delayed hemorrhagic events. Given the preponderance of duodenal ulcers in this population, we suggest avoiding nasoduodenal feeding tubes to avoid any contribution of local inflammation from the feeding tube tip. Additionally, gastric pH monitoring may help guide acid suppressive therapy, with possible early dual prophylaxis with proton pump inhibitors (PPI) and H2 blocker. While we recognize the paucity of data on the ideal dosing of dexamethasone in this population, strong consideration of the increased risk of gastrointestinal (GI) bleeding associated with higher doses of dexamethasone should be given. Early endoscopy can be useful in localizing bleeding and for potential intervention. However, given the limitations of therapeutic endoscopy in small children along with its associated risks, aggressive early surgical management of hemorrhagic ulcers in children with posterior fossa tumors may be warranted.


Imaging modalities (computed tomography (CT), ultrasonography, and magnetic resonance imaging (MRI)) have only limited ability to distinguish liver focal nodular hyperplasia (FNH) from metastatic liver tumors. Here, we report a patient who underwent surgery for benign FNH that mimicked a liver metastasis from soft tissue sarcoma (STS).A 23-year-old man with a history of several surgeries for metastatic abdominal STS, developed a hepatic tumor accompanying peritoneal STS recurrence. He was diagnosed with a metastatic liver tumor from the STS, based on imaging studies for the hepatic tumor that showed a growing hypervascular lesion and hypo-intensity in hepatic phase on dynamic CT and MRI. However, when the liver and peritoneal tumors were resected, histological diagnosis showed the hepatic tumor to be benign liver FNH.Although FNH should be considered as a differential diagnosis for hypervascular hepatic tumors, it has few typical findings, and its appropriate management is controversial. A lesion strongly suspected of being a metastatic liver tumor might require surgical resection. Soft tissue sarcomas (STS) comprise a heterogeneous group of rare solid tumors. Although only a resection is needed for cure, intra-abdominal STS frequently recurs in the liver and peritoneum even after curative resection , 2. For In contrast, surgery is not indicated for liver focal nodular hyperplasia (FNH) because it is a common and benign focal liver lesion , 5, and Here, we describe a patient with peritoneal recurrence of spindle cell sarcoma (SCS)—an unclassified STS—and FNH that was misdiagnosed as an STS metastasis to the liver.A 23-year-old man had a history of two resections of SCS as the following clinical course.At the initial resection at the age of 13, although the tumor was curatively resected, the SCS located on posterior layer of the rectus abdominis sheath was injured with the abdominal cavity exposed  were not detected on polymerase chain reaction-based method (data not shown).At the age of 22, he was suffering from recurrence of the SCS besides the small intestine and was given curative resection Fig. b. HistolDuring the follow-up period, a solitary tumor in the lateral segment of the liver and two other tumors that are located beside the right kidney and on left anterior layer of the rectus abdominis sheath were newly diagnosed through contrast-enhanced computed tomography (CECT; Fig. Surgical resection can provide the potential for cure in patients with recurrence of STS. The local control rate at 5 years after resection was 85% . In contAs this patient had both recurrent SCS—an unclassified STS—and liver FNH, distinguishing the FNH from a hepatic metastasis was difficult. Other literature also reported some FNHs that were diagnosed as metastases in patients with concurrent malignancies, who therefore underwent resections, including two patients with insulinomas and one with renal cell carcinoma Table  8, 12, , 12, 13.FNH typically shows a characteristic enhancement pattern on CT or MRI –16: earlIn the present case, a characteristic finding, such as a “central scar,” was not present. Also, in the MRI hepatobiliary phase, some atypical hemodynamic aberrations (such as the hypo-intense lesion with ring-like hyperintensity; Fig. Because the guideline offers no recommendation for preoperative histological diagnosis of resectable STS , 3, histConsequently, in the present case, surgical resection for liver tumors might be unnecessary according to the guideline . RetrospIn conclusion, decisions for surgical resection should depend on details of the clinical situation, such as coexistence of malignancy or enlargement of FNH over time. However, a conclusive method for diagnosing FNH should be developed to avoid unnecessary surgery.


Endosalpingiosis is a benign and rare entity whose pathophysiology remains unknown. It has been described in pelvic organs, the abdomen, or axillar lymph nodes. Its underrecognition has occasionally led to its misinterpretation for an adenocarcinoma. This case reports the treatment and follow-up of vaginal endosalpingiosis, presenting as a vaginal polyp in a premenopausal women with intermenstrual bleeding. To our knowledge this is the first reported case of vaginal endosalpingiosis and the second mucosal localization after bladder endosalpingiosis. Endosalpingiosis is a benign condition defined by the presence of ectopic fallopian tube-type epithelium. Histologically it corresponds to ciliated tubal-like epithelium lining glandular cysts  Figure .The Mullerianosis theory defends that endosalpingiosis arises from embryonic Müllerian tissue, misplaced during organogenesis. According to this theory adenomyosis, endometriosis, and endocervicosis, which frequently coexist , originaEndosalpingiosis is influenced by the hormonal status and is most often identified in premenopausal women (similar to endometriosis). However it has also been described in postmenopausal elderly women  and in mIntraoperatively, endosalpingiosis has often been taken by endometriosis, even if they frequently coexist . FulguraThe finding of this pathological diagnosis is usually incidental , though  lamina propria and the muscularis mucosa and therefore be misinterpreted for well differentiated, invasive adenocarcinoma [Although endosalpingiosis is a benign condition, it can invade thearcinoma , 6. Whenarcinoma ; biopsiearcinoma ; and perarcinoma . The misarcinoma . The difarcinoma , 10.While endometriosis frequently affects the vaginal cuff and endocervicosis has previously been recognized in the vagina , to our A 46-year-old woman presented with intermenstrual bleeding since several months before. She had 2 previous cesareans and no other abdominal or pelvic surgery. With no active sexual life, this patient had not been taking hormonal contraception for years and she used to have regular menses with normal bleeding before the present situation.This woman had no history of infertility (with 2 pregnancies at 19 and 21 years old) and denied present or past symptoms of dysmenorrhea or dyspareunia.Her clinical evaluation revealed a polypoid neoplasm, in the posterior vaginal cuff, about 2 cm. It had a soft consistence and was bleeding easily with touch. The uterine cervix or vaginal walls were otherwise completely normal to macroscopy .Her cervical smear was negative for intraepithelial lesion or malignancy, and the gynecological ultrasound revealed only small uterine myomas, with normal adnexa, and no signs of endometriosis.This patient was electively admitted for ambulatory polypectomy with electrocoagulation of the bleeding insertion pedicle .Pathology examination identified a stratified squamous epithelium with submucosal endosalpingiosis and signs of recent bleeding Figures  and 3.At subsequent follow-ups she was asymptomatic and the vaginal cuff cicatrized easily with no sequel. After 1 completed year, the patient remains asymptomatic and the vagina is macroscopically unremarkable.Endosalpingiosis' origin, risk factors, prognosis, and follow-up recommendations remain unestablished. In the presented case either the embryonic remnant theory, the implantation theory, or the metaplastic theory is valid hypothesis. The only relevant fact in our patient personal history was the 2 previous cesareans; however, the longtime interval between this surgical insult and the diagnosis of endosalpingiosis is against the establishment of a causal relation.Intermenstrual bleeding was the only symptom of our patient. Even without hormonal contraception, she had no complaint of dysmenorrhea, for instance. In fact this lesion could have gone undetected if it would have been smaller, in an inattentive observation.Considering the appearance of this easy bleeding polypoid lesion, we opted for elective complete polypectomy with subsequent electrocoagulation, avoiding a potential bleeding complication. Also, the polypectomy specimen was more representative than a biopsy sample for pathological evaluation, avoiding misdiagnosis. On the other hand, a surgical excision with healthy margins could have represented an overtreatment, with more probabilities of a defective scar, or other comorbidities.As mentioned above, to the authors' best knowledge, this is the first reported case of vaginal endosalpingiosis. While representing a diagnostic challenge for the pathologist, maybe the most important concerns for the surgeon would be to provide enough and undeteriorated specimen for a correct pathological diagnosis and avoid overtreatment.


Dear Editor,A 69-year-old male patient sought outpatient treatment with a 10-year history of fattymasses in the lateral corners of his eyes, best characterized as retropulsion of theglobes. He underwent computed tomography (CT) of the orbits, which revealed intraconalfat proliferation in the lateral corners of the eyes, from the orbits to the epibulbarregion . Given t. It is more common in obese men between the 7th and 8thdecades of life and manifests clinically as a yellowish mass in the lateral corner ofthe eye, which becomes more evident with retropulsion of the globe.Subconjunctival fat prolapse is an acquired, typically bilateral, condition characterizedby herniation of the intraconal fat, resulting from weakness of the eyeball andintermuscular septum due to aging, trauma, or surgeryThe imaging tests that can facilitate the diagnosis of subconjunctival fat prolapse areCT and magnetic resonance imaging (MRI) of the orbits, the most important radiologicalfinding being that of a mass with fat density or fat-like signal intensity,respectively, located in the temporal aspect of the orbits, contiguous with intraconalfat..The treatment consists of transconjunctival excision, a simple, safe and effectivesurgical procedure. The rate of recurrence after transconjunctival excision is reportedto be approximately 9%. The main differential diagnosis is conjunctival dermolipoma, whichconsists of a benign lesion, usually present at birth, that affects young women, the mean age of suchpatients being 22 years. Althoughthe clinical presentation of conjunctival dermolipoma is similar to that of thesubconjunctival fat prolapse, the former is typically unilateral and fairly immobile. OnCT and MRI, conjunctival dermolipoma presents as a crescent-shaped fatty mass in thetemporal aspect of the orbit, not in communication with the intraconal fat.Making a clinical diagnosis of subconjunctival fat prolapse is relatively easy. However,due to its rarity, it can be misdiagnosed as conjunctival dermolipoma, lymphoma,epidermoid cyst, or lacrimal gland prolapse. Although resection of a conjunctival dermolipoma is a simpleprocedure, there can be severe complications, including blepharoptosis, diplopia, andkeratoconjunctivitis sicca. Therefore, a number of different surgical techniques aimedat a lowering the rate of complications and improving the aesthetic results have beendescribed, including resection with conjunctival flap rotation.In conjunctival dermolipoma, surgical resection is indicated mainly for aestheticpurposes and tends to be more conservativeSubconjunctival fat prolapse and dermolipoma present clinically as a fatty epibulbarmasses in the lateral corners of the orbits, and in some cases their differentiation byclinical aspects can be difficult. The subject is little known among radiologists, andthere have been few reports of related cases. Therefore, given the difference betweenthese two entities in terms of treatment, it is necessary that radiologists be familiarwith both, in order to recognize them promptly and make the differential diagnosisthrough the use of imaging tests.


Appendiceal mucinous adenocarcinoma is an extremely rare disease in clinical practice. Here, we report a case of unprecedented size that occupied the entire abdomen of a man.A 49-year-old Chinese Han man presented with symptoms of abdominal distension. During a computed tomography imaging examination, a cystic-solid mass that occupied his entire abdominal cavity was detected. During exploratory laparotomy, an appendiceal tumor in his abdominal-pelvic cavity measuring 27.6 × 14.2 cm was found, and he underwent tumor resection. The pathology of the tumor identified a well-differentiated appendiceal mucinous adenocarcinoma with mucin infiltrating into the soft tissue of the lump edge and omentum tissue. After surgery, our patient accepted intraperitoneal infusion chemotherapy. At present, he has had no recurrence for 15 months.To the best of our knowledge, the present case is the largest appendiceal mucinous adenocarcinoma reported. Surgical tumor resection is the preferred treatment for appendiceal mucinous adenocarcinoma. This is supplemented by chemotherapy which can further prolong survival. Primary neoplasms of the appendix are very rare and histologically diverse. Tumors are broadly classified as colonic-type or mucinous adenocarcinoma, goblet cell adenocarcinoma, or neuroendocrine carcinoma . AdenocaA 49-year-old Chinese Han man presented with abdominal distension of ten years’ duration. He stated that he did not experience abdominal pain, fever, chills, nausea, vomiting, constipation, or other discomfort symptoms. A systemic examination was within normal limits but an abdominal examination revealed a distended abdomen. Blood tests for tumor markers indicated increased ferritin  and increased carbohydrate antigen 724 . A blood biochemistry test indicated decreased albumin , decreased total protein , decreased albumin to globulins ratio , decreased alanine aminotransferase , decreased aspartate aminotransferase , decreased AST/ALT , and decreased lactate dehydrogenase . Other routine laboratory tests were within normal range. He received an abdominal computed tomography (CT) scan which indicated a cystic-solid mass in his abdominal-pelvic cavity measuring 27.6 × 14.2 cm, and multi-node shadows in his omentum and partial mesenterium . A simple appendectomy can also achieve the same effect as a right hemicolectomy. If the tumor cells have infiltrated through to the submucosa or the whole layer and become associated with regional lymph node metastasis, then a right hemicolectomy combined with omentectomy are often performed. If a histological examination shows the presence of mucinous peritoneal carcinomatosis, the patient should undergo cytoreductive surgery and intraperitoneal chemotherapy [The treatment of choice is often surgical resection combined with adjuvant chemotherapy. The surgical approach for treating MAA depends on the specific circumstances of the tumor, such as tumor size, tumor location, histology of the tumor, and whether it is perforated or not, as well as the clinical presentation . If the otherapy . The mosotherapy . Once thOnly very few cases of MAA have been reported and the present case is the largest MAA. Diagnosis of the disease is difficult due to its lack of specific symptoms and signs. Diagnosis is mainly achieved through the results of a CT scan. In our case, a frozen biopsy as a rapid pathological examination during surgery was helpful to guide further treatment. The appropriate surgical approach was chosen according to the histological type and differentiation degree of the specimen. Mucinous adenocarcinoma has a high risk of cavity planting; therefore, we should pay attention to protect the operative field and wound. Surgical resection plus adjuvant chemotherapy are currently an effective treatment with the aim of improving long-term survival.


We describe our experience with what is, to our knowledge, the first case of robotic assisted ex vivo partial splenectomy with auto-transplantation for a benign non parasitic cyst.The patient is a 32 year-old female with a giant, benign splenic cyst causing persistent abdominal pain. Preoperative imaging showed a cystic lesion measuring 8.3 × 7.6 cm, in the middle portion of the spleen. Due to the central location of the bulky lesion a partial splenectomy was not feasible. As an alternative to a total splenectomy, a possible reimplantation of hemi-spleen after bench surgery was offered. We proceeded with a robotic total splenectomy and bench hemisplenectomy, preserving the lower pole and a portion of the middle segment of the organ. A robotic reconstruction of the splenic vessels was then performed intra-abdominally. The reperfusion was optimal.The total operative time was 305 min, with 78 min of robotic time. Postoperative ultrasound confirmed a patent arterial and venous flow. The postoperative course was uneventful and the patient was discharged on postoperative day 4. The pathology report was consistent with epithelial cyst of the spleen. The patient is doing well at 6-month follow-up.The optimized vision and dexterity provided by the robotic system allowed a safe and precise reconstruction of the splenic vessels, even in a deep and narrow operative field. Partial splenectomy with autotransplantation of the organ was thus achieved, avoiding a total splenectomy in a young patient. The treatment of benign splenic lesions has evolved over time. While total open splenectomy for non-parasitic splenic cysts is still considered a surgical option, the risk of overwhelming post splenectomy infections (OPSI), especially in younger patients, has prompted the development of newer, less invasive approaches . The bes2, with a history of endometriosis and appendectomy who presented for persistent abdominal pain, requiring opioids for relief. The pain was referred as dull and achy in nature, concentrated in the upper abdomen and had no link to diet or bowel habits. She had no other complaint. Physical examination did not reveal any specific findings. CT-scan of the abdomen was performed and revealed an 8.3 × 7.6 cm splenic cyst with normal splenic vascularization. Abdominal MRA confirmed these findings  of 30 kg/mngs Fig. .Fig. 1Pr®  was installed through a small midline incision below the umbilicus. The splenic artery and vein were clamped with Bulldogs and divided using the robotic scissors, taking care to leave a long proximal stump for the reconstruction. At this point, the spleen was placed in an endobag and retrieved through the GelPort®.After discussing all possible options an informed consent was obtained and the patient was scheduled for surgery. All necessary vaccinations were performed prior to the operation. She was informed of the possibility of ex vivo surgery and, in case of failure, total splenectomy. The patient was placed in a supine position and the table was slightly titled to the right. A 5 mm scope was first inserted to assess the peritoneal cavity. There were no signs of portal hypertension or any contraindications to proceed with the surgery. A 10 mm trocar was placed in the left upper quadrant, at the intersection with the left mammillary line, 3 inches above the transverse umbilical line. Two 8 mm trocars were placed in the right upper quadrant, one 8 mm in the left lateral quadrant and one periumbilical assistant trocar. The patient was then placed in reverse Trendelenburg and the robot was docked, coming from the patient’s head. The third robotic arm was used to retract the stomach to the left. The gastrocolic ligament was divided allowing access to the lesser sac. The left colonic flexure was mobilized using a combination of robotic hook, ultrasonic shears and bipolar coagulation. The splenocolic ligaments were gently detached. The cyst appeared to occupy the central portion of the spleen and it was felt that standard in vivo partial splenectomy would be impossible. Dissection and vascular control of the proximal splenic artery and vein were carefully achieved. A GelPort®. Arterial and venous reconstructions were performed robotically, using running 6-0 Gore-Tex suturing. After vascular reconstruction, indocyanine green fluorescence was used to assess splenic perfusion which was considered to be optimal (Fig. The spleen was cooled with infusions at 4 degrees Celsius and flushed with approximately 1.5 L of custodiol solution through the splenic artery until there was a clear flow from the splenic vein. The bench procedure started with the preparation of the hilum. Segmental arteries from the main splenic artery to the upper splenic pole containing most of the cyst were divided. The parenchymal transection was gradually performed until complete resection of the cyst. Hemostasis of the parenchymal transection plane was obtained with multiple prolene 4-0 and 5-0 sutures. Finally, a row of 3/0 interrupted U-stitches with pledgets were placed on the transected capsule Fig. . A leak The total operative time was 305 min, with 78 min of robotic time and an estimated blood loss of 150 mL. No intra- or postoperative blood transfusions were necessary. Postoperative ultrasound confirmed a patent arterial and venous flow. The postoperative course was uneventful and the patient was discharged on postoperative day 4. Final pathology report was consistent with benign epithelial splenic cyst. At the 6-month follow-up the patient was doing well. A CT was performed and showed no evidence of perisplenic fluid collection, with a splenic vein that appeared patent and a good size spleen that enhanced homogenously (Fig. Surgical resection is the mainstay of treatment for larger non parasitic splenic cysts . For manThere have been reports of total splenectomy and splenic tissue re-implantation, especially in cases of trauma –12. WhilThe field of organ transplantation has provided new and innovative approaches to resection of tumors initially deemed unresectable. While still investigational, there are now several reports of ex vivo resections of a variety of lesions with re-implantation of the affected organ , 14. BecTo our knowledge, there is only one described case of open ex vivo partial splenectomy and re-implantation for non parasitic splenic cyst . We descIn conclusion, we believe this case provides evidence that the robotic approach may be an asset in ex vivo surgery and that a large splenic cyst involving the splenic hilum is not an absolute contraindication to partial splenectomy.