Trichilemmal cysts (TCs) are common benign cysts that form from the hair follicles in the skin. Proliferating trichilemmal cysts (PTCs) are rare types of TCs characterized by rapid cellular proliferation. Malignant transformation of PTC (MPTC) is a rare adnexal tumor that account for <0.1% of all skin cancers. TCs and PTCs are benign tumors; however, MPTCs grow rapidly and are prone to metastasis.A 77-year-old man was referred to our hospital with a solitary pinkish mass on his left elbow. Trichilemmal carcinoma arising from a PTC was confirmed through excisional biopsy, and wide excision was performed. One month postoperatively, a cystic mass was observed and was suspected to have local recurrence; however, bursitis was confirmed after excisional biopsy. After 1 year of follow-up, the patient maintained an improvement without recurrence or any other surgical complications.In addition to being a very rare disease, MTPC occurred in the elbow of a man who does not fit the general etiology; therefore, it is considered an interesting case, and we report this case for academic contribution. MPTC is rare, accounting for <0.1% of all skin cancers, but it is a potentially aggressive form of skin cancer that arises from PTC. MPTC typically presents as a rapidly growing ulcerating mass with a firm and irregular border. It has the potential to invade the surrounding tissues and metastasize to other parts of the body.When it becomes cancerous, it is called a malignant transformation of PTC (MPTC). It is worth noting that PTCs occurring in non-scalp locations are generally rare and may present unusual symptoms, making them more challenging to diagnose.Generally, TC, PTC, and MPTC are more common in elderly women and tend to occur in areas of the skin with a high density of hair follicles, such as the scalp. However, they have also been reported in other locations, including the neck, face, back, chest, and extremities.Here, we report a rare case of MPTC that occurred on the elbow joint with olecranon bursa invasion, which is not a common area, and was treated with wide excision.This study was conducted in conformity with the World Medical Association Declaration of Helsinki, and the protocol was approved by the Institutional Review Board of Dongguk University Medical Center . As per the CARE guidelines, written informed consent was obtained from the patient legal guardian for inclusion of clinical and imaging details for the purpose of publication. A 77-year-old man presented at our hospital with a solitary pinkish mass on his left elbow that had persisted for several years Fig. A. The leAn excisional biopsy was performed for the diagnosis. Histologically, an atypical cystic lesion with no granular layer and abrupt necrotic keratinization was observed Fig. A. AdditiAfter confirmation of MPTC, a wide excision with a 1-cm safety margin including the bursa was additionally performed. However, a frozen biopsy revealed deep tumor invasion at the base; therefore, additional resection of the deep fascia was performed to secure a sufficient base safety margin. Because anconeus muscle herniation was observed, fascia reconstruction was performed with a Prolene mesh designed to match the fascial defect to prevent further herniation.One month after surgery, the patient complained of a 1.5 × 1.5 cm sized cystic formation at the surgical site. An excisional biopsy was performed again under the suspicion of local recurrence. However, the final diagnosis was bursitis, not recurrence. After 1 year of follow-up, the patient maintained an improvement without recurrence or any other surgical complications Fig. .,2 It mainly appears in sun-exposed and high hair follicle density areas, and more than 90% of patients have lesions on the scalp. It usually occurs in women in their 60s, with a 4-fold higher occurrence rate than in men. Clinically, it is benign, but can be confused with squamous cell carcinoma because it appears as a red, slightly raised lump that may be accompanied by crusts or ulcers. PTC is a transitional form between TC and a true malignant pilar tumor or MPTC.–3PTC is a rare tumor that originates from the outer root sheath of hair follicles. This term was first proposed by Jones in 1966 and is also known as Wilson Jones scalp tumor. As of 2018, only 187 cases had been reported. However, the actual pathogenesis of PTC in MPTC has not been identified. Several studies have suggested that p53 mutation is a key point, as in non-melanoma skin cancer. Takata et al performed DNA analysis of trichilemmal carcinoma arising from the PTC wall and reported that the loss of chromosome arm 17p containing the p53 gene resulted in mutation. Approximately 30 cases of MTPC have been reported until 2004.–8 To our knowledge, there have been no case reports of elbow MTPC.MPTC was first proposed by Saida et al in 1983, and it is known that TC can develop into PTC due to repetitive trauma or inflammation and rarely progresses to MPTC.,6 This keratinization is found primarily in the outer root sheath. Varying levels of inflammation can be present, as indicated by lymphocyte, histiocyte, plasma cell, and occasionally neutrophil and eosinophil levels. In PTC, mitosis is low and mitoses are observed as 0 to 4 per 10 high-power fields; however, if strong mitotic activity or numerous cytonuclear atypia or aneuploidy are observed and irregular infiltrate patterns in the cystic wall are observed, MTPC should be suspected. As keratin pearls may be observed, care must be taken to differentiate them from squamous cell carcinomas. Additional immunohistochemistry, such as CK 16, CD 34, or ki-67, can also confirm the diagnosis.–10MPTC is clinically difficult to differentiate from PTC and can be confirmed through pathological findings. PTC has characteristic histological features of trichilemmal keratinization, which is an abrupt transition of nucleated epithelial cells to keratinized cells without the formation of a granular layer.–14 Recently, Moh micrographic surgery achieved good results. However, because the probability of local recurrence between 6 months and 10 years is 3.7%, continuous monitoring is required. Additional postoperative radiotherapy or chemotherapy may be needed if lymph node or distant metastases are present. Several studies have reported improved clinical regression in patients who received postoperative radiotherapy.,12 Therefore, patients with high-risk features for local recurrence or metastases may need multidisciplinary treatment plans.A clear guideline for treatment has not yet been presented, but a wide excision with a safety margin of 1 cm arriving at the periosteum is required in MPTC.Here, we report a case in which MPTC, a very rare skin cancer, which occurred in the elbow of a man with uncommon etiology. This is a successful case that has maintained improvement without local recurrence through wide excision and bursectomy. To our knowledge, this is the first case of MPTC that occurred in the elbow. Therefore, we report this article for future academic contributions.Conceptualization: Dong Yun Lee, Jung Soo Yoon.Data curation: Kang Min Han.Formal analysis: Kang Min Han.Investigation: Jung Soo Yoon.Resources: Jung Soo Yoon.Supervision: Jung Soo Yoon.Writing – original draft: Dong Yun Lee.Writing – review & editing: Kang Min Han, Jung Soo Yoon.


Carcinoid syndrome (CS) is a unique constellation of symptoms caused by release of vasoactive substances from neuroendocrine tumors . Neuroendocrine tumors are rare with an annual incidence of 2 in 100,000 people . Up to 50% of patients with these tumors will develop carcinoid syndrome, which is characterized by symptoms caused by elevated levels of serotonin and most commonly include fatigue, flushing, wheezing, and non-specific gastrointestinal symptoms such as diarrhea and malabsorption  . Over time, patients with carcinoid syndrome can develop carcinoid heart disease (CHD). CHD refers to the cardiac complications that occur when the vasoactive substances, such as serotonin, tachykinins, and prostaglandins, secreted from the carcinoid tumors. These complications most commonly include valvular abnormalities, but can also present as coronary artery damage, arrhythmias or direct myocardial injury . While CHD is not typically an initial feature of carcinoid syndrome, it does eventually occur in up to 70% of patients with carcinoid tumors   . CHD is associated with significant morbidity and mortality due to the risk of progressive heart failure . In this case, we describe a 35-year-old Hispanic woman in South Texas with undiagnosed carcinoid syndrome for over 10 years that eventually progressed to severe CHD. In this patient’s case, we emphasize how lack of access to healthcare resulted in delay of diagnosis, appropriate treatment, and worsened prognosis in this young patient.The online version contains supplementary material available at 10.1186/s40959-023-00176-z. Carcinoid syndrome (CS) is a unique constellation of symptoms caused by release of vasoactive substances from neuroendocrine tumors . NeuroenA 35-year-old female with no pertinent past medical history presents to the cardio-oncology clinic for evaluation after a recent diagnosis of Stage IV neuroendocrine carcinoid tumor. The patient admits to having gastrointestinal and cardiac related symptoms for many years. Due to her lack of insurance, she had previously been obtaining care in Mexico. Her symptoms began 12 years ago with abdominal pain, for which she was treated with cholecystectomy in 2010. Despite this intervention, her symptoms persisted and progressed to include nausea and diarrhea. Over time they worsened, and this time were attributed to infectious colitis and treated with antibiotics and ranitidine, again, without resolution of her symptoms. In 2015, she developed cardiac symptoms with fatigue and exercise intolerance. Over the years, she began experiencing more symptoms including headaches, shortness of breath (SOB), intermittent leg swelling, abdominal fullness, and abdominal pain.Finally, in September 2021, her abdominal pain became severe enough that she sought care at a local hospital in South Texas. CT abdominal imaging during the visit revealed a mesenteric mass and multiple lesions in her abdomen and liver. MRI was recommended to better characterize the lesions. Unfortunately, due to her uninsured status, the MRI was delayed by another 3 months. In December 2021, she obtained coverage and was able to complete the MRI. Her MRI showed an enhancing lobulated mesenteric mass measuring 2.4 × 2.7 cm and innumerable T2 hyperintense liver lesions which were concerning for liver metastasis  after a new murmur was noted on the patient’s physical exam. The TTE revealed CHD with evidence of right heart failure (enlarged right ventricle and right atria), severe tricuspid valve regurgitation, possible pulmonary valve stenosis, and pulmonary hypertension.She was referred to a cardio-oncology clinic in August 2022. On initial evaluation, her physical exam was notable for JVP at 12 cm H2O, giant V waves, 1 + bilateral lower extremity edema, and auscultation of a murmur at the 4th sternal border. A follow up transesophageal echocardiogram (TEE) confirmed the diagnosis with visualization of a thickened tricuspid valve with limited motion and torrential tricuspid regurgitation  is a major cause of morbidity and mortality in patients with carcinoid syndrome (CS) . As illuMost cases of CS are difficult to diagnose because of the rarity of the condition and the non-specific symptoms it presents with. One study showed that diagnosis of CS can be delayed by up to 7 years . UnfortuOnce the diagnosis of CS is made, prompt treatment with somatostatin analogues, most commonly octreotide, should be initiated. Delayed diagnosis of CS is thought to increase chances of developing CHD because it results in prolonged myocardial exposure to vasoactive substances, specifically serotonin, that induce cardiac valvular fibrosis . While swithout cardiac involvement and semiannually for those with cardiac involvement [Regular screening for CHD should also be performed in all patients with CS. Guidelines recommend screening with TTE annually for patients olvement . TTE is olvement . Once CHolvement , 11.As illustrated in our patient’s cause, timely diagnosis and treatment of CS are imperative for prevention of CHD. Once CS is identified, prompt treatment with a somatostatin analogue and regular screening for CHD with TTE should occur. Unfortunately, this patient already had advanced CHD that required tricuspid valve replacement near the time of her initial CS diagnosis. Poor access to the US healthcare system leads to a delayed diagnosis, which resulted in significant morbidity and poor prognosis for this young, 35-year old patient. This case highlights the importance of adequate access to healthcare for timely diagnosis and treatment of CS, appropriate screening for CHD once CS is diagnosed, and appropriate monitoring and therapy when CHD develops.Additional file 1: Video 1. Transesophageal echocardiography demonstrating a torrential tricuspid regurgitation with enlargement of the right atrium.


A 54-year-old female presented to the otolaryngology (ENT) outpatient department with an eight-month history of unilateral nasal obstruction and headache. There was no change in the sense of smell, rhinorrhoea, facial pain, or associated epistaxis. On examination, there was a large, erythematous mass in the superior aspect of the right nasal cavity, filling the space between the nasal septum, middle, and superior meatus. The rest of the ENT examination was normal. Vital signs were all within the normal range. There was no significant past medical history, and she had tried steroid nasal spray without any benefit. She had a complete resolution of symptoms from surgical intervention, and the mass was confirmed to be an angiofibroma through histopathology. This case report discusses the importance of considering nasopharyngeal angiofibroma as a differential diagnosis for patients presenting with unilateral nasal masses, including female patients, regardless of age. Juvenile nasopharyngeal angiofibroma (JNA) is a rare, benign vascular tumor that usually occurs in adolescent males, often demonstrating aggressive features with local invasion ,2. ThereA 54-year-old female presented to the ear, nose, and throat (ENT) outpatient department with unilateral nasal obstruction and headaches for the past eight months. She denied problems with her sense of smell, nasal discharge, facial pain, or epistaxis. Initially, she was managed in the primary care setting with steroid nasal spray. However, as she did not show any improvement, she was referred to ENT. She has no significant past medical history. On examination with rigid nasal endoscopy, a substantial erythematous mass was identified within the superior aspect of the right nasal cavity. It occupied the space between the middle and superior meatus and extended towards the nasal septum.A computed tomography (CT) scan revealed a well-defined, homogeneous, enhancing mass that filled the right nasal cavity Figure . The masThe procedure was successful using an endoscopic approach, although there was some intraoperative bleeding Figures , 4B. To The patient had follow-up appointments two weeks and four weeks after the operation, where the nasal fossa was examined with a rigid nasal endoscopy in the outpatient department. There were no remnants or recurrences of the mass found during the examination. The patient had another follow-up appointment scheduled four months later. During the appointment, the patient remained asymptomatic, and the examination was normal.The diagnosis of nasopharyngeal angiofibroma was later confirmed by histopathology examination, which revealed vascular space of various sizes, ranging from dilated branching vessels of various thicknesses to slit-like capillaries. These were separated by fibrocellular stroma with fibroblasts Figure .JNA is a rare benign tumor affecting predominantly adolescent males, with the average age of presentation being 14 to 25 years old ,7. DurinJNA classically presents as a painless, progressive unilateral nasal obstruction, occasionally accompanied by epistaxis resulting from its highly vascular nature. Given our patient’s history, gender, and age group, we considered several differential diagnoses, including malignancy, hemangiopericytoma, and inverted papilloma.Preoperative radiological imaging, such as CT, magnetic resonance imaging (MRI), and angiography, is valuable in assessing JNA . The comJNA is locally invasive and aggressive, likely attributed to its non-encapsulated and highly vascular nature. These factors contributed to a relatively high recurrence rate of 24.5% with an average follow-up period of 49 months, as reported in a recent meta-analysis by Reyes et al.  have shoTo date, there have been only a limited number of reported cases of JNA in females. Marcos et al. and Massimo et al. described two JNA cases in post-menopausal females  ,12. OverPost-menopause, the significant decline in estrogen production leads to a relative increase in the androgen-to-estrogen ratio. Linking to the occurrence of postmenopausal JNA-as observed in our case study and supported by existing reports ,12-we suGiven its rare incidence and association with elevated androgen levels, we recommend screening for causes of hyperandrogenism in female patients, e.g., medications and rare renal and ovarian androgen-secreting tumors. Detailed history-taking could help identify chronic conditions like polycystic ovarian syndrome (PCOS) and non-classic congenital adrenal hyperplasia (NCCAH). Further research is required to elucidate the relationship between JNA and androgen levels in females, understand its pathogenesis, and set directions for potential non-invasive interventions.JNA lacks a definite pathogenesis; however, studies and case reports suggest its association with hyperandrogenism. The uncommon occurrence in females highlights the need to consider JNA as a differential diagnosis in nasopharyngeal mass cases. Further research is required to understand the link between JNA and androgens across different gender and age groups.


Painless obstructive jaundice is a well-recognized clinical sign of hepatocellular pathology or obstruction of the biliary system. Bile duct tumors are a known etiology of painless obstructive jaundice. Here, we present a case of obstructive jaundice, which was initially thought be caused by cholangiocarcinoma based on computerized tomography imaging and endoscopic retrograde cholangiopancreatography but was later found to be hilar metastasis from an undiscovered colon cancer. Bile duct tumors often arise de novo from the proliferation of epithelial cells within the common bile duct and may be further classified by their anatomical location or malignant potential -5. AlthoThis case report was previously presented as a meeting abstract at the American College of Gastroenterology Annual Scientific Meeting in October 2020.A 61-year-old man with no known medical history presented with nausea, vomiting, jaundice, and dark urine for two weeks. Review of systems was otherwise negative. He was a tobacco user and had four tattoos. He denied alcohol, intravenous, or other drug use. He had no recent use of acetaminophen or herbal medications. He had no recent travel, exposure to ill contacts, history of hepatitis, or risky sexual practices. He had no known personal history of inflammatory bowel disease or gastrointestinal malignancy.His vitals were within normal limits on presentation. On general examination, the patient was an elderly male with scleral icterus, but other systems, including the abdomen, were unremarkable. CT abdomen revealed a porta hepatis mass at the CBD, concerning for cholangiocarcinoma. There were also multiple focal areas of the liver, involving the right lobe extending into segment 4, worrisome for additional large areas of metastatic cholangiocarcinoma. He was admitted for further workup. Endoscopic ultrasound was performed and endoscopic retrograde cholangiopancreatography (ERCP) revealed a tumor extruding from the CBD Figure .The CBD mass and a hepatic mass were biopsied, and a stent was placed. Immunohistochemical staining of the biopsies were negative for CK7 but positive for CK20 and CDX2, in keeping with a colonic primary, but there was no clinical evidence of a primary CRC  panel positive Figures , 4.The patient was scheduled for oncology follow-up.Bile duct neoplasms may arise from the proliferation of cholangiocytes along the intrahepatic or extrahepatic portions of the bile duct -5. They There have been exceedingly rare cases of patients with a history of colon cancer developing metastasis to the common bile duct, including after the treatment of their primary malignancy -11. A reHistology is often key in determining whether a bile duct tumor is primary or secondary, as it may be difficult to differentiate based on clinical presentation or radiologically. On histology, primary cholangiocarcinomas are known to express CK7. Meanwhile, tumors with an anatomical origin in the colon will not express CK7 ,13,14. ICRC is the second leading cause of cancer-related deaths in the United States, and therefore this index case reveals a previously unreported manifestation of a clinically relevant disease. It is important to ensure age-appropriate screening, starting at age 45 years, in average-risk adults . The goaThe existing literature reports exceedingly uncommon cases of CBD tumors being diagnosed after CRC, but this is the first case to report CBD tumor leading to the diagnosis of CRC. In this index case, painless obstructive jaundice was a presenting manifestation, but this is not typically associated with CRC. This case shows that in the exceedingly rare cases in which CRC metastasizes to the common bile duct, painless obstructive jaundice may occur. Clinicians should be aware of this unique presentation so that similar cases are not missed and for future cases to be further characterized and studied.


Diagnosis of uterine smooth muscle tumors depends upon histologic characteristics as both benign and malignant share clinical features such as metastases. A benign metastasizing leiomyoma is a rare benign smooth muscle tumor that metastasizes to extrauterine sites with simultaneous uterine leiomyoma or previously biopsy-proven leiomyoma during myomectomy or hysterectomy. Benign metastasizing leiomyoma metastasizes outside the uterus, predominantly to the lungs and lymph nodes. However, the involvement of other organs, such as the heart, liver, spine, and soft tissue, is also reported. Here, we present a case of a 42-year-old woman with a history of uterine leiomyoma with prior myomectomy and hysterectomy, who presented with worsening back pain and lower extremity weakness and was found to have an acute cord compression, a serious complication caused by mass effect and a medical emergency that requires prompt attention to prevent permanent spinal cord damage. Sacral soft tissue biopsy and T11 spinal bone biopsy both demonstrated leiomyoma with immunostains positive for desmin, smooth muscle actin, and positive estrogen and progesterone receptors. No atypia, necrosis, and mitosis were identified. The patient had hepatic and pulmonary metastasis on imaging. The final diagnosis was benign metastasizing leiomyoma. There is no standard treatment for benign metastasizing leiomyoma. Both surgical and pharmacological approaches are employed. Although most cases are benign, there is a possibility for life-threatening complications. Benign metastasizing leiomyomas can be considered when multiple soft tissue tumors are found in premenopausal women with a history of uterine leiomyomas. Multidisciplinary discussion between oncologists, gynecologists, and relevant specialists is crucial in the optimal evaluation and treatment of benign metastasizing leiomyoma. Uterine leiomyomas are one of the most common benign uterine tumors in women of reproductive age in the United States, and their prevalence is as high as 80% in certain ethnicities. Benign metastasizing leiomyoma occurs in predominately premenopausal women . Only apHere, we present a rare case of a 42-year-old female with a history of uterine leiomyoma with prior myomectomy and hysterectomy, who presented with back pain and lower extremity weakness, was found to have an acute cord compression, and diagnosed with benign metastasizing leiomyoma.A 42-year-old female from Jamaica with a past medical history significant for uterine leiomyoma, asthma, anemia, class III severe obesity with body mass index (BMI) of 45, and chronic sciatica, presented to the emergency department with back pain and bilateral lower extremity weakness. Past surgical history was notable for total abdominal myomectomy, hysterectomy, two cesarian sections, and partial gastrectomy. There was also a history of uterine and prostate cancer in the family. The patient reported ongoing back pain for the past year, the onset of which she attributes to lifting a heavy object. The patient recently noticed symptoms of sciatica. The patient was recently discharged from the hospital on methocarbamol (Robaxin) and a lidocaine patch for symptomatic treatment of her lower back pain but proceeded to experience difficulty walking with lower extremity numbness and tingling. There was also associated paresthesia in the perineal region, but the patient denied any urinary/bowel retention or incontinence.Vital signs and labs were unremarkable. Physical exam was notable for bilateral lower extremities weakness. Computed tomography (CT) abdomen/pelvis demonstrated a round soft tissue lesion measuring 2.6 x 2.4 x 2.8 cm adjacent to the inferior paraspinal muscles, T11 interosseous hemangioma involving the entire vertebral body. Magnetic resonance imaging (MRI) of the thoracic and lumbar spine confirmed abnormality of the T11 vertebral body with significant epidural extension into the spinal canal posterior to T11 and T12 vertebral bodies, with solid soft tissue nodule in subcutaneous fat of the lower back at S1 segment, superficial to the posterior lumbar fascia  agonist (leuprolide) was initiated to treat benign metastasizing leiomyoma. One and a half months later, the patient was hospitalized again after a fall with worsening back pain and paresthesia. The patient had another biopsy in T11 epidural bone to confirm the diagnosis of benign metastasizing leiomyoma.Pathology of T11 bone biopsy showed spindle cell neoplasm consistent with leiomyoma. No necrosis or cytologic atypia was identified. Estrogen receptor (ER) was positive, progesterone receptor (PR) was positive, Ki-67: 2-4%, and HMB45 was negative. The immunohistochemical profile was similar to the prior biopsy from the sacrum  and schwannoma (S100 positive). Other spindle cell neoplasms such as melanoma, nerve sheath tumors, and sarcoma were ruled out using HMB45, melan-A, SOX10, and S100. Smooth muscle tumors of uncertain malignant potential (STUMP) need to be considered for differential diagnosis. STUMP refers to smooth tumors that exhibit histological characteristics exceeding diagnostic criteria for leiomyoma but insufficient to be diagnosed as leiomyosarcoma.Pathogenesis of benign metastasizing leiomyomaThe exact pathogenesis of benign metastasizing leiomyoma is unknown. It is postulated that the cells of benign metastasizing leiomyoma originated from the uterus due to the strong relationship with uterine leiomyomas. Estrogens play a significant role in the origin of benign metastasizing leiomyoma as estrogen metabolites are promoting mutations. It has been hypothesized that benign metastasizing leiomyomas originated from a single site. A study by Patton et al. assessed clonality by analyzing the polymorphic CAG repeat sequence within the androgen receptors . Their sAlthough benign metastasizing leiomyoma has been primarily associated with leiomyomas, other types of smooth muscle tumors in the uterus, such as leiomyosarcomas, endometrial stromal tumors, and smooth muscle tumors of uncertain malignant potential, are hypothesized to be related to benign metastasizing leiomyoma .Treatment of benign metastasizing leiomyomaDue to the lack of randomized clinical trials, there is no standard treatment to guide the optimal treatment of benign metastasizing leiomyoma. Asymptomatic patients with stable clinical courses might not require prompt treatment . Both phPrognosis of benign metastasizing leiomyomaDue to its benign nature, the prognosis of benign metastasizing leiomyoma is usually favorable . HoweverBenign metastasizing leiomyoma is a rare, cytologically and histologically benign, smooth muscle tumor that metastasizes to extrauterine sites with simultaneous uterine leiomyoma or previously biopsy-proven leiomyoma during myomectomy or hysterectomy. In this case, biopsies of soft tissue sacral mass and T11 bone showed benign histology yet the tumors had metastasized. Due to their location, they were compromising the patient's neurological function. The liver and lung nodules were incidental and currently stable. Although most cases of benign metastasizing leiomyoma are benign, life-threatening disease complications may occur. Our case presented an acute cord compression, a medical emergency that requires prompt attention to prevent permanent spinal cord damage. There is no standard treatment for benign metastasizing leiomyoma, but GnRH agonists often successfully shrink the tumor. In a premenopausal patient, metastatic lesions may not be pathognomonic for malignancy. A thorough histologic evaluation is essential. A multidisciplinary approach between oncologists, gynecologists, and relevant specialists in each case of benign metastasizing leiomyoma is crucial for optimal evaluation and treatment.


Lymphangiectasia is the benign malformation of lymphatic channels associated with either focal or diffuse dilation of vessels and impaired lymph drainage. This malformation has the potential to create a cystic mass due to the accumulation of lymphatic fluid. While rare in adults, intussusception, the telescoping of the proximal bowel into the distal bowel, can be caused by a mass within the bowel. In this case, a near-obstructing cystic colon mass developed in a 74-year-old man; this was later found to be a large lymphangiectasia. In addition, this near-obstructing colonic lymphangiectasia served as the lead point in a colo-colonic intussusception. Due to this complication, the mass was immediately removed by a laparoscopic oncologic right-extended hemicolectomy which proved to be both diagnostic and therapeutic. Intussusception, the telescoping of the proximal bowel into the distal bowel, is oftentimes considered an urgent surgical issue that can lead to complications such as bowel obstruction and intestinal ischemia. While many cases of intussusception are idiopathic and found in children, masses can serve as lead points of telescoping bowel in adults. This condition in adults can be concerning for potentially malignant processes and must raise concern in clinicians. Of the cases of adult intussusception, 70-90% require definitive treatment, and surgery is most often the treatment of choice .Lymphangiectasia is a benign malformation of lymphatic channels associated with either focal or diffuse dilation of vessels and impaired lymph drainage. In the intestine, these vessels can be located within the mucosa, submucosa, or subserosa . Here, wA 74-year-old White male 10 days status post uncomplicated laparoscopic right inguinal hernia repair presented to the emergency department with bleeding from a wound site, right lower quadrant abdominal pain with distension, and testicular pain. He was concerned about surgical site bleeding and scrotal bruising after resuming his warfarin a few days prior. He was experiencing flatus and had a recent non-bloody bowel movement. The patient has a history of atrial fibrillation, sick sinus syndrome with a pacemaker, type 2 diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and laryngeal cancer treated by radiation (2.5 years prior). He has a history of chronic constipation secondary to opioid use for chronic pain. He reported that he had never had a colonoscopy. On physical exam, tenderness and ecchymosis of the right lower quadrant and right side of the scrotum were noted. The surgical incisions were clean, dry, and well-approximated. There was a nontender, nonpulsatile mass upon palpation of the right upper quadrant. All other systems are reviewed and found to be negative.An abdominal CT with and without contrast from the emergency department showed a colo-colonic intussusception in the hepatic flexure with an ovoid hypodense mass measuring 4.7 x 3.8 cm x 4.8 cm suspicious for being the lead point of the intussusception Figure . The CT A colonoscopy revealed sigmoid diverticulosis and a near-obstructive soft, smooth, polypoid cystic lesion with a broad base located near the hepatic flexure Figure . The lesWhile in the supine position, the patient was put under general anesthesia and intubated. The abdomen was insufflated in normal fashion and we appreciated a right colonic mass with nearby tattooing that did not appear to extend into the circumferential tissue Figure . A laparFinal surgical pathology results showed lymphangiectasia forming a thin-walled cystic structure (5.0 cm) with adjacent dilated smaller lymphatic vessels and stromal edema Figure . AdditioThe first case of lymphangiectasia was reported by Waldmann et al. in 1961 and since then it has been studied well . The accThe primary type of lymphangiectasia is the result of congenital lymphatic malformation leading to lymphangiomatosis, the presence of diffuse lymphangiectasia in an organ or across multiple organ systems. Patients with this disease have poor lymphatic movement throughout the body. This lymphatic malformation within the intestines is known as “Waldmann’s Disease,” which can cause diffuse small vesicular lymphatic collections on the gastrointestinal mucosa that leak lymphatic fluid into the gastrointestinal tract . This lySecondary lymphangiectasia can have a variety of causes; however, it is most often caused by the obstruction of lymphatics. This obstruction impedes the drainage of lymphatic fluid through the thoracic duct into the left subclavian vein. Lymphatic fluid builds up creating a cystic structure that has the potential to burst, creating a protein-losing enteropathy that causes similar complications to those seen in primary lymphangiectasia. Additionally, rupture of such structures has the potential to cause gastrointestinal bleeds . An incrThis case is an example of secondary lymphangiectasia. Due to the patient’s age and presentation of a solitary collection of lymphatic fluid, primary lymphangiectasia can be ruled out. While there are many potential causes of secondary lymphangiectasia, there is no clear identifiable source apparent in the case presented. Imaging modalities to identify lymphatic malformations have progressed significantly. Traditional CT imaging can show cystic structures but offers little more information regarding lymphatic anatomy due to the limitations of the study. Lymphoscintigraphy with Tc-99m-labeled dextran allows for the accurate tracking of lymphatic collections but fails to present a high-resolution image . Novel mThere is no true consensus on the management of lymphangiectasia. Treatments vary depending on patient presentation. In focal intestinal lymphangiectasia, surgery or embolization is considered curative. If a patient has diffuse or extensive intestinal lymphangiectasia, surgery is usually not indicated due to the need to resect multiple sections of the bowel . Our patLymphangiectasia, while rare, can present as a near-obstructing colonic mass that can cause other complications such as intussusception. Although not high on the list of differential diagnoses, lymphangiectasia should be suspected when a cystic mass in the abdomen is seen. We report a case of transient colo-colonic intussusception in a 74-year-old man caused by a singular large intestinal lymphangiectasia with a good outcome. Resection of this cystic structure proved both diagnostic and therapeutic, and the patient had no lasting problems.


We reported two patients, a 45‐year‐old lady and a 48‐year‐old man, known cases of untreated liver and lung hydatid cysts complicated with bronchobiliary fistulae. Surgery was performed, and bronchobiliary fistulae were diagnosed intraoperatively. Lobectomy was done on the lobe, which was chronically infected. Symptoms resolved after surgery in both cases. Green‐colored sputum in a patient with a history of echinococcosis should raise the physician's attention to the probability of a connection between the bronchial tree and the biliary tract. Surgery in advanced cases is a suitable therapeutic option. Intraoperative images showing the bronchobiliary fistula; Blue arrow indicator of middle lobe fistula; green arrow indicator of diaphragmatic hole. The patient was a known case of lung and liver hydatid cysts. She had a past medical history of pleural effusion due to a rupture of the hydatid cyst 2 years before admission. A preliminary diagnosis of pneumonia was assigned, and a chest tube was inserted due to consolidation and pleural effusion. Recurrence of hydatid cyst was also suspected, and surgery was advised, but the patient did not consent and was discharged after consolidation in her chest was relieved. She received antibiotic therapy for her pneumonia and albendazole to treat the hydatid cyst. Two years later, due to recurrent pneumonia attacks and bilioptysis, she was admitted to our hospital for decortication of the lung hydatid cyst.We obtained abdominopelvic and chest ultrasonography. Liver containing hypoechoic structure, measuring about 50 × 30 mm in the right lobe of the liver with peripheral calcifications, suggestive of hydatid cyst was reported. Also, chest ultrasonography showed no pleural effusion on the left side and minimal to mild peripheral effusion on the right side. A preoperative chest computed tomography (CT) scan was also provided Figure .The patient was scheduled for the operation. The operation was performed under general anesthesia in the lateral decubitus position. Due to severe adhesion of the lung, at first, pneumolysis was performed. During pneumolysis of the lower lobe, adhesion to the diaphragm was detected. After meticulous dissection of the lower lobe from the diaphragm, we detected a fistula between the liver and lower lobe of the lung, presumably assumed to be the cause of bilioptysis. Then, via the fistula tract, the hydatid cyst of the liver was removed. Complete irrigation with copious normal saline was done. Also, right lower lobectomy was performed. The diaphragm was rechecked for any fistula or bile leak, in which the fluid was clear without any sign of bile leakage. The diaphragm was subsequently repaired, and two chest tubes were inserted.Obtained tissue samples were sent for histopathological evaluation, in which macroscopic examination showed the lower lobe of the lung with a size of 16 × 14 × 7 cm. The pleural surface was rough and brown in color. A creamy bulging area with a size of 3.5 × 2 × 1 cm was present on the surface. Serial cut sections showed a cystic space with the greatest diameter of 2.5 cm near the base of the lung. Cut sections of the bulging area showed cystic space filled with homogenous creamy material. In other parts of the parenchyma, red color with patchy yellowish discoloration was seen. These findings were in favor of hydatid cyst  a year before admission due to a hydatid cyst of the liver. In physical examination, he had stable vital signs.Previous to his admission at our hospital, a spiral CT had been taken in another center, which showed a large hydatid cyst with exophytic growth arising from the utmost superior part of the right hepatic lobe and extending to the subdiaphragmatic location associated with suspected fistula tract into the thoracic cavity, which indicated a complicated hydatid cyst with hepatopulmonary fistula formation. The suspected fistula was measured at about 20 mm anterior–posterior, 13 mm in transverse, and 30 mm in craniocaudal extension.We took another CT scan for the patient Figure  and scheA chest X‐ray was taken postoperatively Figure , and the3BBF is an extremely rare condition defined as the abnormal interconnection between the right bronchial tree and the biliary tract.Diagnosing BBF is challenging, and the only specific sign may be bilioptysis, which can be more or less abundant. The diagnosis should be based on clusters of clinical arguments, paraclinical evidence, and radiological evaluations.Roy J Mukkada and colleagues used endoscopy combined with cyanoacrylate glue and microcoils to treat a stent‐induced BBF.Tatjana N Adzić‐Vukičević et al. applied percutaneous drainage and antibiotic therapy for echinococcosis induced BBF.Surgical and non‐surgical interventions are valid measures to treat patients with BBF diagnosis. It is worth mentioning that noninvasive approaches like ERCP, MRCP, and percutaneous transhepatic cholangiography (PTCD) are preferred over traditional surgical approaches in non‐complicated patients with less severe fistulas.In our case, BBF was not suspected before the operation and was detected during thoracotomy. Also, since the patient had repeated pneumonia, fever, and cough, thoracotomy was chosen for the patient. Surgical intervention was the first choice for our patients. It provided us with great access to relieve several pleural and diaphragmatic adhesions, complete hepatic cyst removal, fistula excision, diaphragmatic closure, and lobectomy. This procedure has been used several times in patients with BBF and the management of hydatid cystsOur center is based among the locations considered endemic for cystic echinococcosis. The disease should be adequately managed before presenting any further complications, such as superinfections or, in our case, fistula.4In summary, green‐colored sputum in a patient with a history of echinococcosis should raise the physician's attention to the probability of a connection between the bronchial tree and the biliary tract. Surgery in advanced cases, like our patients, is a suitable therapeutic option with a satisfactory prognosis.Parviz Mardani: Conceptualization; investigation; supervision. Hooman Kamran: Data curation; resources; writing – original draft. Fateme Khosravi: Writing – original draft. Reza Shahriarirad: Data curation; investigation; project administration; supervision; writing – original draft; writing – review and editing. Pardis Shahabinejad: Writing – original draft. Bita Geramizadeh: Data curation; investigation; supervision; validation. Neda Soleimani: Data curation; investigation; validation. Armin Amirian: Investigation; supervision.No financial support was received for this case report.The authors declare that they have no competing interests.The present study was approved by the Medical Ethics Committee of Shiraz University of Medical Sciences. The purpose of this study was completely explained to the patients and was assured that their information would be kept confidential by the researchers.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Fibrosarcoma is a rare, highly malignant tumor that develops from uncontrolled overgrowth of fibroblastic cells. It may start as a painless lump or swelling under the skin. But as it grows, it can push surrounding structures - organs, muscles, nerves, or blood vessels - and lead to pain and tenderness. The treatment of fibrosarcoma depends on several factors such as size, grade, location of primary tumor, extent of spread, age, and general health condition of the patient. The main treatment is surgical removal of the primary tumor with wide-margin excision and amputation if localized in the limb. Prior to surgical intervention, radiotherapy can be applied to reduce the tumor size or following surgery to lower the risk of recurrence. Chemotherapy is indicated in cases of metastasis. Unfortunately, the prognosis of fibrosarcoma is not favorable. For high-grade fibrosarcoma, the five-year survival rate is around 30% and for low-grade fibrosarcoma, it is 50-80%, with recurrence in the first two to five years post-surgery. We encountered a case of high-grade fibrosarcoma with aggressive growth in a 36-year-old male, requiring above-knee amputation. Fibrosarcoma is a fibroblastic neoplasm originating from mesenchymal cells, also known as soft-tissue sarcoma that is part of a broad heterogeneous group of tumors that comprise more than 175 molecular subtypes  and freqBenign and malignant neoplasms mimic fibrosarcoma. Low-grade fibromyxoid sarcoma, malignant fibrous histiocytoma, sclerosing epithelioid fibrosarcoma, dermatofibrosarcoma protuberans, extra-abdominal desmoid fibromatosis, leiomyosarcoma, liposarcoma, and synovial sarcomas are some of the differentials of true adult fibrosarcoma. Cytogenetic analysis can be used to detect and characterize chromosomal abnormalities that help in diagnosis ,4. The mImaging tests can be done to identify the detailed picture of the tumor and confirmation with biopsy and staining to distinguish between fibrosarcoma and other spindle-cell neoplasms with the use of immunochemistry is considered though it is not sufficient. New markers, such as miRNA expression profiles, may represent an additional supportive diagnostic step . If the We report a case of high-grade fibrosarcoma (30 cm in size) in a 36-year-old man, originating in the thigh and requiring surgical above-knee amputation.A 36-year-old black male presented with the chief complaint of draining blood and pus from a mass in the right thigh that, as per the patient, had been present for approximately seven years and had been enlarging steadily over time and recently started draining. He hadn’t reached out for any medical assistance before this. The patient had difficulty bending the right knee and mentioned the occasional loss of strength in the affected extremity and falling down. On examination, the mass was 30 cm by 25 cm and was firmly fixed in the anterior thigh, and abutting the underlying musculature. Areas of denudation, ulceration, and exophytic areas with punctate bleeding and serous discharge were noted Figure . AdditioAt presentation, CT angiography of the right lower extremity was done, which showed a 22 cm necrotic mass in the anterior compartment of the right leg at the level of the distal femur, which had replaced nearly all of the anterior thigh musculature with no erosion of the adjacent femoral diaphysis  was recommended, followed by radiation. The orthopedic prosthetic specialists were consulted regarding femur preservation and guidance to the above knee amputation was recommended with guidance to permit prosthetic assignment. Regarding a transfemoral amputation, 50% of the femoral bone needs to be preserved with myodesis. In our case, the complete length of the hamstring would be excised, depending on clear margins. The quadriceps wound is preserved and brought forward. The stump would be fashioned for future prostheses. Debulking of the quadriceps was an alternative, leaving the patient with a nonfunctional limb and an increased risk of positive margins.The patient returned to the emergency department four days post-biopsy. On examination, seropurulent discharge was present with an associated leukocytosis of 17.79/uL, and sepsis was suspected the patient was started on empiric antibiotics and admitted to the ICU. An amputation was agreed upon as the definitive procedure. A week later, a high amputation was performed with the anterior incision approximately 4 cm above the gross tumor and closure with a posterior flap. The hospital course was complicated by anemia for which a blood transfusion was given. There was gradual resolution of the leukocytosis postoperatively with stabilization of his hemoglobin level prior to discharge. One week after surgery, the patient was admitted to acute inpatient rehabilitation, received physical and occupational therapy services, and made steady progress in performing Activities of Daily Living (ADL) and functional mobility. The patient was provided with a wheelchair and skilled training to improve safety during functional transfers and ADLs. The patient was transferred to a skilled nursing facility for wound management and physical therapy, with an eventual recommendation for shaping the residual limb and prosthesis fitting.Our case presentation highlights a young man diagnosed with an aggressively growing fibrosarcoma in his right anterior thigh involving the entirety of the quadriceps muscle. This patient represents a population in the South Bronx, a region that is a low-socioeconomic sector of New York City. Access to care is affected by many factors, as in our patient's case, where he did not seek early medical attention due to lack of insurance. Possible un-education limited this patient's suspicion to a much more malign pathology. Cancer health disparities have grown as per the National Cancer Institute , and effThe morbidity of this young patient brings to light a possible surveillance mechanism for patients and primary care physicians when they encounter a mass. Urgent referral to a surgeon and an oncologist should be the priority. Fibrosarcoma mainly arises in areas of collagen-rich connective tissue, most commonly around the thighs, knees, arms, and trunk. Fibrosarcomas are usually spherical masses of firm consistency with sharp demarcation from surrounding tissue and on average 3-8 cm in size . Due to In a clinical setting, there are more than 50 different histological types of soft tissue sarcomas, each with unique clinical manifestations and prognoses. Sarcomas are also different in terms of metastasis. Some sarcoma types tend to metastasize to regional lymph nodes such as epithelioid sarcoma -3. SarcoFirst, radiological imaging, such as MRI, is recommended, as it adequately demonstrates soft tissue structures. Histological characteristics typically exhibit monomorphic spindle-shaped fibroblasts arranged parallel to each other. Depending on the tumor size, lymph node involvement, and metastasis, fibrosarcoma is divided into the following stages - IA ; IB , IIA ; IIB (mid-grade/high-grade are larger than 5 cm); III ; and IV  . Due to Chemotherapy, such as doxorubicin, is recommended to reduce recurrence. Some other agents, such as actinomycin D and ifosfamide, are also effective, with a response rate of above 15%. Neoadjuvant treatment with the MAID  regimen has proven beneficial . A theorData from the National Cancer Institute's Cancer Surveillance, Epidemiology, and End-Result (SEER) program showed that blacks were more predisposed to the development of sarcomas . The genCytogenetically, congenital infantile fibrosarcoma is characterized by the majority of cases having a translocation between chromosomes 12 and 15  that results in the formation of the fusion gene, ETV6-NTRK3, plus individual cases exhibiting trisomy for chromosomes 8, 11, 17, or 20. However, studies have indicated that genetic alterations and few familial outpouchings are reported for the development of soft tissue sarcomas. Genetic studies have found a chromosomal rearrangement in some fibrosarcoma [A decision as to whether a major amputation is appropriate should be made in a multidisciplinary meeting and in conjunction with the patient. Forequarter and hindquarter amputations have been reported, indicated after disease recurrence has occurred following a previous amputation . Limb-spFibrosarcomas or fibrosarcomata are rare and debilitating tumors, especially when the extremities are involved, with the possibility of amputation or limb salvage surgery with chemoradiation. Recurrence is high with soft tissue tumors, which also leads to revision of surgery. Striking a balance in achieving appropriate tumor resection whilst preserving limb function remains the central challenge in the management of the extremity. Early implementation of surveillance by the primary care provider could aid in the appropriate evaluation of the mass with surgical oncology and oncological services, especially in underserved areas.


Macrodystrophia lipomatosa (MDL) is a rare congenital variant of focused gigantism that is non-hereditary. Typically, MDL presents with localized gigantism in either the hand or foot. In this case report, we present the unique instance of a 12-year-old girl who has experienced enlargement of the first and second toes on her right foot since birth. Plain radiographs and MRI findings revealed the accumulation of fatty tissue around the first and second toes, medial and lateral aspects of the first metatarsal, extending up to the medial plantar arch of the foot. To enhance foot functionality and alleviate any issues with wearing footwear, a successful reconstruction surgical intervention was performed. As a result, the patient can now wear shoes without any difficulties. MDL is a very uncommon kind of congenital localised gigantism, and surgical consultation is frequently performed for cosmetic reasons. A rare congenital, non-hereditary variant of focused gigantism is known as macrodystrophia lipomatosa (MDL) . GeneralA 12-year-old female child was referred from a secondary centre with a history of enlargement of the first and second toes of the right foot since birth. The child was diagnosed at birth but has not been on follow-up since then. The child was brought by parents as the deformity was progressively increasing in size over the years causing difficulty in attaining proper footwear, leading to troubled ambulation. However, the child did not complain of any pain during ambulation even for long distances or climbing up and down the stairs.This child is the third child of four siblings in a non-consanguineous marriage. She was born via spontaneous vaginal delivery, and there is no significant prenatal or perinatal history. No family history of similar presentation or any other similar manifestation or congenital anomalies in other siblings.On examination, the right foot's first and second toes are evidently enlarged, with the first toe appearing to be bigger than the second toe. The rest of the other toes appear as normal-sized as the left foot. Both the toes grew in a divergent fashion with massive soft tissue overgrowth over the plantar aspect Figure . NeurovaRadiographical imaging showed large first and second metatarsals, along with large all phalanges of the first and second toes. There was a marked increase in the soft tissue surrounding both toes, with a lateral view of the imaging showing gross soft tissue overgrowth over the plantar aspect Figure .The MRI of the right foot showed bone and soft tissue enlargement of the first and second toes. There is an accumulation of fat tissue with no discernible capsule around the first and second toes, medial and lateral aspects of the first metatarsal with extension up to the medial plantar arch of the foot. A soft tissue lesion was noted deep to the flexor hallucis longus, involving the lateral digital nerve of the first toe. There was no evidence of infiltration to adjacent bone and joint seen, and no features of vascular malformation were seen. The flexor and extensor tendons of the foot appear intact. The MRI findings are reported as macrodactyly lipomatosa Figures -4.A preoperative incisional biopsy was not done for this patient, as no evidence of malignancy was seen. Right first toe and second toe disarticulation and reconstruction were done through fish mouth incisions made along the first and second toe proximal interphalangeal joint (PIPJ), extended into the first webspace. The proximal phalanx of both the first and second toes refashioned with flexor and extensor tendons is anchored to the proximal phalanx. Excessive fat tissue over the plantar aspect was excised, and satisfactory wound closure was achieved Figure .Histopathological examination showed lobular proliferation of mature adipocytes separated by thick fibrous septae. No lipoblast, stromal atypia, or other types of evidence of malignancy was seen. A benign proliferation of fibrofatty tissue was consistent with macrodactyly. Upon further follow-up at the clinic, the wound healed well over the right foot's first and second toes. There is no numbness or discolouration over the toes or foot, indicating a good neurovascular status Figure . The chiIn 1925, Feriz introduced the term macrodystrophia lipomatosa (MDL), a rare congenital, non-hereditary variant of focused gigantism in the foot or hand. Feriz explained the term as an overgrowth of the unilateral lower limb . Fatty oAlthough MDL's etiopathogenesis is not fully understood, there are a number of theories that attempt to explain it . AccordiTo the best of our knowledge, no published article has reported an exact incidence due to the disorder's rarity and various terms used to describe the disorder. In the distribution of MDL, men outnumber women by a large margin. Accordingly, Wu et al.  reportedGenerally, MDL patients usually seek medical attention later in life and more commonly for cosmetic than for mechanical problems. Surgery continues to be a major component of the treatment for macrodactyly . TherefoIn conclusion, MDL is a rare type of congenital localised gigantism, and surgical consultation is frequently requested for aesthetic reasons. Histopathology and imaging work together to confirm the diagnosis. Surgical treatment should be well-planned with the aid of imaging and tailored accordingly to each case for the best outcome in both cosmetic and functional requirements. A multidisciplinary approach and additional systematic research with more patients are needed to investigate the relationship between mutations and clinical phenotype and prognosis of the MDL disorder.


Two patients with papillary thyroid carcinoma and an elevated thyroglobulin had false-positive imaging studies from intraosseous hemangiomas (IH). A 62-year-old man presented with a palpable lytic skull mass suspicious for a bone metastasis after computed tomography (CT) and magnetic resonance imaging (MRI) scans. Surgical excision confirmed an IH. The second patient is a 64-year-old woman whose I-123 whole-body scan with single photon emission computed tomography/CT demonstrated radioiodine uptake in the right frontal bone. Her MRI and CT scans were also consistent with an IH. These cases reveal the limitations of nuclear imaging and of CT and MRI scans in distinguishing metastatic differentiated thyroid cancer from IH in patients with lytic bone lesions. Because no imaging studies are definitive for an IH, bone cranial lesions may warrant resection to establish a diagnosis and avoid potential brain invasion by a malignancy or unnecessary radioiodine treatment. Thyroid cancer is the most common endocrine carcinoma . The evaA 62-year-old man had a thyroidectomy and node dissection for a 5-cm columnar cell variant of papillary thyroid cancer (PTC) with minimal extrathyroidal extension, extensive vascular invasion, and lymphatic invasion. Nine of 35 nodes (<1 cm) contained metastatic PTC with extranodal extension. He was treated with 150.8 mCi of radioactive iodine (131-I). The posttherapy SPECT/CT scans revealed only residual thyroid tissue, with no suspicious lung nodules. His posttreatment thyroglobulin (Tg) level was 0.34 ng/mL (0.34 µg/L) with a negative Tg antibody < 0.4 U/mL (<0.4 kIU/L), and a neck ultrasound was unremarkable. The original tumor staging was American Joint Committee on Cancer 8th edition stage II and the American Thyroid Association risk stratification was intermediate with an indeterminate response to therapy. One year later, a recombinant human TSH-stimulated I-123 WBS demonstrated no radioiodine uptake, but the stimulated Tg rose to 2.2 ng/mL (2.2 µg/L). The patient was not reevaluated until 3 years after diagnosis, when the TSH-suppressed Tg level rose to 34.1 ng/mL (34.1 µg/L) , and ultA 64-year-old woman underwent a thyroidectomy for a large nodular goiter that contained a 2.1-cm encapsulated follicular variant of PTC with focal capsular invasion without lymphovascular invasion or extrathyroidal extension. This tumor was regarded as American Joint Committee on Cancer stage I and American Thyroid Association low risk for recurrence, but the unstimulated Tg rose from 2.7 to 4.1 ng/mL (2.7 to 4.1 μg/L) with a Tg antibody <0.4 U/mL(<0.4 kIU/L) over time . One yeaA head CT scan showed a lytic lesion  and B wiThis finding was stable on comparison to a CT scan performed 5 years earlier and a brain MRI scan performed 3 years earlier for headaches, when the lytic lesion had been regarded as characteristic of an IH. Review of the MRI scan shows the lesion was 1.0 × 0.5 cm and hypointense on T1-weighted images  that enhThe TSH-suppressed Tg continued to rise without change in the small lung nodules on CT scan, consistent with tumor progression likely in additional nonvisualized micrometastases in the lung.No intervention was performed. A repet brain MRI 1 year later showed to change in the lytic lesion and her thyroglobulin level has remained low and stable.Benign and malignant disease may develop in the cranium. Malignant lesions may be osteolytic, sclerotic, or mixed. Single osteolytic tumors are particularly worrisome for metastases from thyroid cancer. However, in this report, a single osteolytic lesion in the frontal bone of 2 patients with thyroid cancer was IH. IH are rare and account for fewer than 1% of all bone neoplasms . When thIn case 1, additional MRI sequences were ordered to improve characterization of a skull lesion including FFE, FLAIR, and fat-suppressed images . NuclearThis case report highlights a benign bone pathology, IH, that can be mistaken for metastatic thyroid cancer when it presents as a lytic lesion on CT scan, radioiodine-persistent lesion on radioiodine WBS, enhancing destructive lesion with extracranial extension on MRI, and/or a hypermetabolic lesion on F18-FDG-PET scans. CT and MRI scans have complementary roles in helping determine the nature of cranial lesions. When a skull lesion is suspected, MRI sequences  may improve visualization by suppression of the signals from cerebrospinal fluid and lesional/cranial fat. Because no imaging studies are definitive for an IH, clinical decision-making needs to include consideration of the current risk of that patient for metastatic disease and surgical excision for pathological diagnosis to avoid unnecessary treatment of metastatic disease. Biopsy is not recommended because of the risk of bleeding and infection of the vascular tumor.Intraosseous hemangiomas (IHs) are rare benign vascular tumors of the bone and, when occurring in the cranium, most often located in the frontal bone.Computed tomography and magnetic resonance imaging scans are complementary in the diagnosis of IH, but many of their characteristics are typical of metastatic tumors.Additional magnetic resonance imaging sequences will improve lesional detection by suppressing signal from cerebral spinal fluid (T2-weighted fluid-attenuated inversion recovery) and lesional/cranial fat (T1-weighted fast field echo and T2-weighted fat suppression).False-positive radioactive iodine whole body scans and F18-FDG positron emission tomography scans may occur because trapping of isotope in IH with slow blood clearance.Because no imaging studies are definitive for an IH, bone cranial lesions may warrant resection to establish a diagnosis, avoid potential brain invasion by a malignancy, or unnecessary radioiodine treatment if iodine avid.All authors made contributions to authorship. H.K. was involved in the preparation of the manuscript. S.L.L., F.T.D., and D.M. were involved in the management of these patients and manuscript preparation. All authors approved the final draft.


Spigelian hernia, also known as lateral ventral hernia, is a type of hernia arising through the Spigelian aponeurosis. Unlike many other ventral hernias that occur beneath the layer of fat and abdominal skin, Spigelian hernia is situated within the abdominal wall muscles. Spigelian hernia often presents with few symptoms and may exist for a long time without being diagnosed or detected. We report a case of Spigelian hernia causing an intestinal obstruction treated with surgical emergency abdominal wall reconstruction using the sublay technique. Identification and evaluation of cases with the potential for hernia occurrence are crucial for the safety of patients undergoing surgery. Spigelian hernia accounts for 1%-2% of all ventral hernia cases. Currently, there are no reports on Spigelian hernia in Vietnam. However, a few reports on surgical management of Spigelian hernia have been published worldwide, with approaches including laparoscopic and open surgery, and these reports have indicated that abdominal wall reconstruction using the sublay technique is feasible as it is associated with fewer postoperative complications and shorter hospital stays. Here, we describe the case of an 87-year-old woman presenting with swelling and pain in the lower left quadrant of the abdomen. A preoperative diagnosis of Spigelian hernia causing intestinal obstruction was established, and we proceeded with abdominal wall reconstruction using the sublay technique. The patient was discharged three days after surgery without any postoperative complications. Spigelian hernia was first described by Belgian anatomist Adriaan van den Spiegel in 1645, and, later, Klinkosch reported the first case of Spigelian hernia in 1764 , and theAn 87-year-old woman presented with abdominal pain and a protrusion in the lower left quarter of her abdomen. The protrusion appeared about a year ago, but it had been gradually increasing in size Figure . The pat2. On physical examination, there was a tender protrusion measuring 3 × 4 cm in the lower left quarter of the abdomen. An abdominal CT scan revealed that the small bowel is located anteriorly to the left abdominal wall and extends to the hernia orifice (Figure The patient had no history of abdominal surgery or abdominal trauma. She was slightly overweight with a BMI of 26.5 kg/mThe CT scan confirmed the presence of a Spigelian hernia in the lower left quadrant, with the hernia orifice formed through the Spigelian fascia. Prior to surgery, we were able to definitively diagnose a Spigelian hernia causing acute intestinal obstruction. Emergency surgery was performed with the consent of the patient and her family. We used the sublay technique for abdominal wall reconstruction with the placement of a polypropylene mesh. The patient was given general anesthesia, and a 5-cm incision at the hernia site was made.After dissecting through the subcutaneous layer of the abdomen, we found that the small intestine had herniated through the hernia orifice. We enlarged the hernia orifice and released the small intestine from the hernia. We repositioned the hernia orifice and accurately diagnosed it as an incarcerated Spigelian hernia. We then examined the small intestine and found it to be healthy, with no signs of bowel necrosis. After returning the small intestine to the abdominal cavity, we measured the hernia hole and selected a suitable mesh. The hernia hole was an oval shape, measuring 30 × 40 mm, located on the outer edge of the left rectus muscle. We dissected the posterior sheath of the left rectus muscle and the transversus abdominis muscle on the right side of the hernia hole to create a space. We then sutured the posterior rectus fascia layer and the transversus abdominis muscle with 2.0 absorbable sutures. We used a 6 × 11 cm polypropylene mesh and placed it in the space behind the rectus muscle and the transversus abdominis muscle. We then closed the remaining layers of the abdominal wall with interrupted sutures using 1-0 non-absorbable sutures. The operation time was 100 minutes, with no intraoperative complications. The patient was discharged home three days after surgery, with no postoperative complications.Spigelian hernia occurs through the Spigelian aponeurosis, which is the aponeurosis of the transversus abdominis muscle bounded laterally by the semilunar line and medially by the lateral border of rectus abdominis Figure .This type of hernia usually occurs in people aged 50-60 years, is more common in women than in men, and occurs more frequently on the left side than on the right. Spigelian hernia can occur anywhere along the semilunar line, but most commonly it occurs in the Spigelian hernia belt, a 6-cm wide horizontal area above the interspinous plane, which is the plane joining the anterior superior iliac spines . The exaIn summary, Spigelian hernia is a rare condition with a mass and pain in the lower abdominal wall. Diagnosis and treatment are difficult with beginner surgeons. We have successfully reported the treatment of Spigelian hernia using the sublay mesh and assessed the feasibility of this approach for Spigelian hernia.


This condition is basically a self-limiting disease; however, laparoscopic appendage excision may be required for recurrent cases (1). Epiploic appendagitis is a rare condition but should be considered in patients with acute abdominal pain.A previously healthy 48-year-old man presented with sudden-onset lower left abdominal pain, which persisted for 3 days. On physical examination, he had left lower quadrant tenderness. Laboratory results showed an increased white blood cell count (9.8 × 1000/μl) and increased C-reactive protein (1.8 mg/dL). Abdominal computed tomography (CT) revealed a fat-density ovoid structure with a high-density rim adjacent to the sigmoid colon and surrounding inflammatory fat, which was consistent with epiploic appendagitis . The patNoneMI wrote the first draft and managed the submission processes. All authors (1) made substantial contributions to the study concept and data analysis/interpretation; (2) drafted the manuscript and revised it critically for important intellectual content; (3) approved the final version of the manuscript to be published; and (4) agreed to be accountable for all aspects of the work.We have obtained informed consent for the publication of this case report.


Foreign body (FB) ingestion is a common event in children. The management of the ingested FB depends on the location, type, number, size of the FBs, patient age, and symptoms. Although most FBs pass spontaneously through the gastrointestinal tract without causing serious injuries, the ingestion of multiple high-powered magnetic pieces, especially neodymium magnets (NMs) increases the risks of morbidity and mortality. Supravesical hernia (SH) is rarely occurs in children, and few studies have reported SH in pediatric patients. We report an extremely rare case of ingested NMs that migrated into an internal SH in a pediatric patient.A 3-year-old boy who had accidentally swallowed two NMs 3 days ago presented with vomiting and lower abdominal pain. X-ray imaging and computed tomography (CT) suspected the presence of a 1.0-cm radiopaque FB located in the terminal ileum dorsal side of the bladder. Although his abdominal pain was gradually getting better after oral feeding, repeat abdominal X-ray imaging showed that the FB was in a stagnant in position. Therefore, surgical intervention was planned to remove the FB 1 week after his admission. Under general anesthesia, laparoscopic and fluoroscopic examinations were performed and the cecum was found adhered to the retroperitoneum between the right medial umbilical fold and the right wall of the urinary bladder. The FB was presumed to be located at the tip of the incarcerated cecum in the retroperitoneal space. Peritoneum incision was started near the medial inguinal fossa, and the Retzius space was opened in a manner similar to the transabdominal pre-peritoneal approach for inguinal hernia repair. Consequently, the patient was diagnosed with internal SH with FB migration. The incarcerated cecum was pulled out, which revealed intestinal wall perforation. The FB remained in the retroperitoneal space in the pelvic cavity. The FB was easily removed using intestinal forceps and identified as combined two NMs. The postoperative course was good, and the patient was discharged on postoperative day 5.We experienced an extremely rare case of a pediatric patient who swallowed multiple NMs that migrated into an internal SH, and the laparoscopic minimally invasive removal was successful. Foreign body (FB) ingestion is a common event in children . The manSupravesical hernia (SH) is one of the rare internal hernias that are sometimes found in men after the age of 50 years . The intSome studies have reported FB cases with intestinal hernia –8. TheseIn this report, we describe a rare case of ingested NMs that migrated into an internal SH in pediatric patient. The precise location of the NMs was identified with multiple examination modalities, and they were successfully removed by laparoscopic approach.A 3-year-old boy presented with vomiting and lower abdominal pain with a 3-day history of symptoms. He had no significant medical, surgical, or family history. On physical examination, he was afebrile with normal vital signs. Although he had tenderness localized to the right lower abdomen, his abdomen was soft without a rebound. Laboratory tests revealed high levels of inflammatory markers , with a normal lactate level. An X-ray imaging revealed the presence of a 1.0-cm radiopaque FB located in the right lower abdomen area Fig. . When heTherefore, surgical intervention was planned to remove the FB 1 week after his admission. Under general anesthesia, endoscopic examination for the total colon and terminal ileum region was initially performed under fluoroscopic guidance; however, we could not find the FB in his intestinal tract, so laparoscopic observation was then performed. After pneumoperitoneum induction, three trocars with a 5-mm diameter were placed into the single-incision laparoscopic surgical port at the umbilicus and a trocar into the right abdominal quadrant. Upon inspection, the cecum was found adhered to the retroperitoneum between the right medial umbilical fold and the right wall of the urinary bladder Fig. A. The ceThe incarcerated cecum was very carefully pulled out from the retroperitoneum between the right medial umbilical fold and the right wall of the urinary bladder, which revealed the perforated intestinal wall. The FB remained in the retroperitoneal space in the pelvic cavity Fig. B. The FBRare earth metals, such as neodymium, are used in highly powered magnets that are commonly used in toys, kitchen utensils, desk items, and many household products mainly because of their impressive strength-to-size ratio . Its bouInternal SH was first reported by Ring in 1814, and it is an extremely rare condition, particularly in children. SH occurs in the triangular space surrounded laterally by the medial umbilical ligament, medially by the median umbilical ligament (urachus), and inferiorly by the transverse vesical fold, and it is classified as external or internal depending on the direction of sac extension , 12–14. In this report, a 3-year-old boy accidentally swallowed two NMs 3 days ago and was admitted with vomiting and lower abdominal pain. CT showed that the FB was suspectedly located in the terminal ileum dorsal side of the bladder. However, by laparoscopic observation, the FB was found in the tip of the incarcerated cecum in the retroperitoneal space. Subsequently, the Retzius space was opened in a manner similar to the TAPP approach for inguinal hernia repair, which revealed the precise anatomical location of the FB in the incarcerated cecum; as a result, the diagnosis of SH with FB migration was made.Lee et al. demonstrated his management strategy for FB ingestion in 2018. If multiple magnets or a single magnet with a metallic FB is located in sites beyond the stomach, symptomatic children must consult a pediatric surgeon to plan for surgery; however asymptomatic children may be closely followed using serial X-ray imaging to monitor the progression of the FBs . In this. To our knowledge, this is the first case in which an ingested NMs were removed from an internal SH. Further preparation and dissemination of knowledge to get parents’ attention to NM ingestion are required.Although the precise mechanism of how this extremely rare internal SH with NM ingestion occured, speculatively, the NMs in his cecum was strongly drawn to attracted some metal on the child’s body such as the buckle of the car seatbelt, and the cecum with the NMs was incarcerated into the supravesical fossa, which led to the development of an internal SH Fig. . To our We experienced an extremely rare case of a pediatric patient who swallowed multiple NMs that migrated into an internal SH. Although the minimally invasive removal with a laparoscopic technique was successful after careful observation, early surgical intervention might be desirable.


A 71-year-old woman with a lesion extending around the entire luminal circumference along a 10-cm length of the distal duodenum was referred to us at Karolinska University Hospital. Esophagogastroduodenoscopy (EGD) revealed an irregular, heterogeneous, flat lesion . The suA colonoscope  was used with an ST Hood . Mucosal incision was performed, starting distally and progressing to the proximal side. The tunnel technique was used, and three tunnels were created. Complete ESD was performed and the lesion was resected en bloc . The ciVideo 1 Endoscopic submucosal dissection of a large circumferential adenoma in the descending duodenum.The patient started fluid intake on Day 1 and was discharged on Day 3. Oral prednisolone was started on Day 1, for a total of 6 weeks, to prevent stricture formation. The pathological analysis of the resected specimen showed an adenoma with LGD and negative horizontal and vertical margins . EGD 4 Duodenal lesions involving the entire luminal circumference are rare. To our best knowledge, there are only two reports describing piecemeal endoscopic mucosal resection and laparoscopic and endoscopic cooperative surgery for circumferential superficial nonampullary duodenal epithelial tumors (SNADET)Endoscopy_UCTN_Code_TTT_1AO_2AG


The first clinical presentation of a hernia developing along the Spigelian line had been reported by Klinkosch. The Belgian anatomist Adriaan van der Spieghel (Adrianus Spigelius) was the first to describe the semilunar line now known as the linea Spigeli in 1645. Spigelian hernias are rare and account for 1 % to 2 % of all abdominal wall hernias. Most of these hernia occurs in the lower abdomen where posterior sheath is deficient. The hernia ring is well defined defect in the transverse aponeurosis.A 60 year old female, presented with a palpable lump at the right lower quadrant of the abdomen since 7 month before her presentation.For the first time the swelling is small and painless then gradually increase in size and associated with dull aching pain. The swelling was reducible with a defect of size 4 × 4 cm palpable in right iliac fossa. There was a positive cough impulse. The swelling was non tender. Other hernial orifices were normal. No inguinal lymphadenopathy noted. Abdominal ultrasonography done revealed a defect in abdominal wall in right iliac fossa with reducible bowel content. Depending on basis of clinical and investigations, a diagnosis of Spigelian hernia was made. After preparation for surgery, exploration done. The defect measuring 4 cm in length was identified and anatomical repair was done with nylon- 0, by suturing medial border of internal oblique and transverse abdominus muscle to the lateral border of rectum abdominal wall followed by hernioplasty by mesh.Spigelian hernias are rare multifactorial disorder leading to defect in the transversus abdominis muscle in anterior abdominal wall. Spigelian hernias carry a significant risk of incarceration and strangulation of sac content. The management of spigelian hernias is almost always surgical which can be done in a traditional open fashion or laparoscopically. •The first clinical presentation of a hernia developing along the Spigelian line had been reported by Klinkosch.•Spigelian hernias are rare and account for 1 % to 2 % of all abdominal wall hernias.•Most of these hernias occur in the lower abdomen where posterior sheath is deficient.•Spigelian hernias carry a significant risk of incarceration and strangulation of sac content.•The management of spigelian hernias is almost always surgical which can be done in a traditional open fashion or laparoscopically. The BelThe portion of the transversus abdominis aponeurosis between the lateral semilunar line and the lateral border of the medial rectus muscle is called the spigelian aponeurosis. Spigelian hernias are found between the layers of abdominal muscles along the semilunar line and are known as lateral ventral, interparietal, intermuscular, or intramural hernias. They retain a specific position along the semilunar line (spieghel), but are called “interstitial hernias” and should be distinguished from interstitial hernias .Most of these hernias occur in the lower abdomen where posterior sheath is deficient. The hernia ring is well defined defect in the transverse aponeurosis .Factors leading to increase tension on the abdominal wall aponeurosis or increase intra-abdominal pressure, such as straining due to many causes like bladder outlet obstruction, chronic cough, obesity or multiple pregnancies are also believed to be risk factors for development of Spigelian hernia .Because of masking the Spigelian hernia by abdominal fat and the aponeurosis of the external oblique this make the diagnosis difficult . The fasThis work has been reported in line with the SCARE criteria .2A 60 year old female, presented with a palpable lump at the right lower quadrant of the abdomen since 7 month before her presentation.3For the first time the swelling is small and painless then gradually increase in size and associated with dull aching pain. She denies any history of bowel or bladder alteration. No associated history of fever, nausea, vomiting, change in bowel habit or abdominal distension. The swelling appeared on walking, straining and subsides on lying down for first time but later on it was not but still reducible. Regarding other review of systems no significant symptoms. She was not smoker and not alcoholic. She had negative drug, medical and surgical history, also she had no psychological problem.On clinical examination, vital parameters were within normal limits. On local examination, fullness was noted in right lower abdomen without signs of inflammation. On palpation she had a 6 cm × 6 cm well demarcated swelling in right iliac fossa lateral to rectus margin. It had a smooth surface and skin over the swelling had no scars sinuses or dilated veins. The swelling was reducible with a defect of size 4 × 4 cm palpable in right iliac fossa. There was a positive cough impulse. The swelling was non tender. Other hernial orifices were normal. No inguinal lymphadenopathy noted. Abdominal ultrasonography done revealed a defect in abdominal wall in right iliac fossa with reducible bowel content. Depending on basis of clinical and investigations, a diagnosis of Spigelian hernia was made. Her routine investigations were normal and her abdominal X-ray showed no signs of bowel obstruction.After preparation for surgery, exploration done under general anesthesia by an oblique incision over the swelling and was found to have herniation through a defect along the lateral border of rectus sheath .Fig. 1HeThe defect measuring 4 cm in length was identified and anatomical repair was done with nylon- 0, by suturing medial border of internal oblique and transverse abdominus muscle to the lateral border of rectum abdominal wall  followedPost operatively, patient had an uneventful recovery. She followed up for 9 months after surgery where the patient was asymptomatic and clinical examination was unremarkable.4Spigelian hernias are rare inter-parietal hernia which is also called “spontaneous lateral ventral hernia” or “hernia of semilunar line”. Sometimes it is called intraparietal, interstitial, intramuscular or intra mural hernia because it is locked between the different muscle layers of the abdominal wall . The “SpThe hernia sac surrounded by extra peritoneal fatty tissue is often intra-parietal passing through transverse and internal oblique aponeurosis and spreading out behind the intact aponeurosis of external oblique . The herThe preoperative diagnosis is often difficult because the clinical symptoms of Spigelian hernia are not characteristic due to the rarity of Spigelian defects and lack of personal clinical experience . The diaAlways surgical intervention is the management of Spigelian hernias which is done either by open technique or laparoscopically, with a low recurrence rate after surgical repair, a lower morbidity and shorter hospital stay associated with laparoscopic technique . In our 5Spigelian hernias are rare multifactorial disorder leading to defect in the transversus abdominis muscle in anterior abdominal wall and subsequent protrusion of visceral content through the hernia defect. Spigelian hernias carry a significant risk of incarceration and strangulation of its content. Clinical presentation is often vague, leading to delayed diagnosis. Physical examination along with CT scan is the most definitive radiologic test in establishing a diagnosis of a Spigelian hernia. Surgical intervention is the always the management of Spigelian hernias, which can be done in a traditional open fashion or laparoscopically and has a low recurrence rate after surgical repair.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval for this study  was provided by the Ethical Committee of Al-Kindy Teaching Hospital, Baghdad, Iraq on May 2022.Protocol number: N/A.N/A.Dr. Safaa Hadi Abdulsattar AlshihmaniM.B.Ch.B - F.I.B.M.SAl-kindy Teaching Hospital, Baghdad/IraqSafaa Hadi Abdulsattar Alshihmani.N/A.N/A.


Gangrenous cholecystitis (GC) is a severe form of acute cholecystitis (AC) with ischemia and necrosis of the gallbladder (GB) wall. Patients with GC are sicker than the usual AC patients, and their surgical treatment is more complex and linked with a higher risk of morbidity and mortality. Typically, the first imaging modality used to assess patients with clinically suspected AC is ultrasound. However, if the ultrasound results were inconclusive, a CT scan might help evaluate these individuals. Our study presents a 62-year-old male who presented with mild right upper quadrant discomfort. However, an abdominal computed tomography CT scan showed a pericholecystic fluid collection with a sign of GB perforation that was managed with subtotal cholecystectomy. Five days after the operation, the patient was discharged to home in excellent condition. Acute cholecystitis (AC) is the most frequent complication of cholelithiasis and is a serious and life-threatening condition . The preA 62-year-old male patient with a history of hypertension and diabetes mellitus type 2 presented to our department with RUQ abdominal discomfort for three days, associated with nausea, with no history of vomiting, loss of appetite, abdominal distention, or change in bowel habits. On admission, the patient had stable vital signs and was afebrile. Physical examination revealed mild RUQ tenderness. However, Murphy’s sign was negative. The abdomen was soft and lax. No scars, hernias, or masses were found. Laboratory workup showed a high white blood cell count 15 cells/l) and C-C-reactive protein (CRP) (230 g/dl). The liver function test was normal. A chest X-ray was normal, with no subdiaphragmatic air. An abdomen ultrasound (U/S) revealed a pericholecystic fluid, nondistended thick gallbladder (GB) , and stones impacted in the GB neck with subhepatic fluid collection, suggesting the diagnosis of AC with micro perforation. Additionally, a CT scan of the abdomen with contrast was performed , so the decision was to proceed with subtotal cholecystectomy. Two surgical drains were inserted, one in the pelvis and the other in the subhepatic space; both were removed on day 4 after the surgery. CT control on day 3 after the surgery showed no leakage or fluid collections (Figure The postoperative course was uneventful; the patient was started on a soft diet on day 2 and discharged on day 6 after the operation. Histopathologic examination confirmed the diagnosis of acute on top of chronic cholecystitis with necrotic tissue. AC in patients might develop into GC in around 2-29.6% of cases . It resuGB perforation is a life-threatening condition that can be masked in a patient with diabetic neuropathy, so in these patients, the surgeon should lower the threshold for CT imaging and raise the suspicion of severe intra-abdominal disease even in the setting of mild abdominal pain, as in our case. Early diagnosis and management are essential in cases of perforated GB to decrease morbidity and mortality. Subtotal cholecystectomy could be a surgical option in cases where it is challenging to identify Calot's triangle and the presence of severe abdominal adhesion.