Mesenteric leiomyosarcoma (LMS) is a rare gastrointestinal mesenchymal tumor. It was often misdiagnosed as a gastrointestinal stromal tumor (GIST) until the introduction of immunohistochemistry staining (IHC) in 1998. Currently, a positive IHC staining for smooth muscle markers represents the main diagnostic modality. Herein, we present a case of Mesenteric LMS in a 68-year-old woman, who presented with nausea, vomiting, and abdominal pain and was found to have a right-sided mesenteric tumor encasing the right ureter, with right hydroureteronephrosis. The patient underwent surgical removal of the tumor and IHC stains were compatible with LMS. She achieved remission until she developed recurrence 12 months after initial diagnosis and subsequently expired due to postoperative complications when re-resection was attempted. Typically, mesenteric LMS carries a poor prognosis with a propensity for hematogenous metastasis. In the absence of a standardized protocol for therapy, early surgical resection is the only known curative modality but with a high risk of recurrence. Leiomyosarcoma (LMS) is a rare malignant soft tissue tumor that originates from smooth muscle cells, with an incidence rate of 1 per 350,000 cases . AlthougCase reportA 68-year-old woman with a history of type 2 diabetes mellitus, essential hypertension, and latent tuberculosis presented to the hospital with generalized fatigue, weakness, and unintentional 10-pound weight loss over two months. She also reported abdominal pain, nausea, vomiting, and diarrhea for two days but denied fever, chills, and night sweats. At presentation, vital signs were normal. Her examination showed a soft, nondistended abdomen with mild right upper quadrant tenderness on palpation, but without hepatosplenomegaly, and with a negative Murphy’s sign.Laboratory studies showed a hemoglobin of 9.9 gm/dl, and a white blood cell of 9.7 Thou/cu mm. Blood smear showed normochromic normocytic anemia with mild anisocytosis. The iron panel was normal apart from mildly elevated serum ferritin with a normal vitamin B12 and RBC folate level. The patient had a colonoscopy done one month before her presentation in another facility which was reportedly negative.3 right-sided mesenteric mass causing extrinsic compression of the right mid-ureter with prominent right-sided hydroureteronephrosis  of the chest, abdomen, and pelvis revealed a 5.7 x 4.2 x 5.7 cms Figure . No pulmA CT-guided biopsy of the mass was performed and was suspicious for smooth muscle neoplasm. After insertion of a right-sided ureteral stent and improvement of the patient's symptoms, she underwent an exploratory laparotomy, which revealed a mass encasing the right mid-ureter, which was resected and underwent subsequent ureteroureterostomy. A complete surgical excision was performed as per operative report; however, tumor cells were present at the inked resection margin, hence, it was classified as an intralesional excision. Pathologic examination also demonstrated neoplastic cells with atypical elongated nuclei with abundant pleomorphism, heterogeneous chromatin, and atypical mitoses. The tumor was graded according to the French Federation of Cancer Centers Sarcoma Group (FNCLCC) on the basis of tumor differentiation (score 1) . FurtherIHC staining of the tumor cells was strongly positive for actin, smooth muscle actin (SMA), and vimentin and focally positive for desmin and caldesmon Figure ; however3 enhancing mass compressing the right ureter and causing hydronephrosis. Exploratory laparotomy was performed, and a 3 cm retroperitoneal right lower quadrant mass was found and appeared to be arising from the ascending mesocolon with right ureter obstruction. She underwent right hemicolectomy and right nephrectomy and pathology confirmed recurrence. Unfortunately, the patient developed postoperative complications resulting in her death six days postoperatively.The patient remained disease-free for one year, until she presented with recurrent nausea, vomiting, diarrhea, and diffuse abdominal pain. A repeat CT scan of the abdomen and pelvis was worrisome for tumor recurrence, as it revealed a 2.0 x 1.8 x 2.7 cmMesenteric LMS was first described in 1963 by Kato et al. and is derived from the smooth muscle of mesenteric blood vessels , which mThe prognosis of LMS is quite poor as the overall five-year survival rate is at 20% to 30%, which is thought to be due to the large available space in the abdominal cavity, rendering the tumor undetectable until late in the disease course ,9.In our current literature review, we performed a PubMed database search using the keyword “mesenteric leiomyosarcoma” and since IHC was introduced in 1998 as an essential element to differentiate between GIST and LMS ,12-15, aLiterature review resultsData were analyzed after all 19 eligible cases were compiled. The median age of presentation for patients with mesenteric LMS was 55 years range: 13-86), and 68% (n = 13) were females. When mentioned, patients most commonly reported abdominal pain or palpable abdominal mass. Interestingly, one rare case presented with posterior reversible encephalopathy syndrome (PRES) [-86, and Although the size of the tumor was not always reported, the largest reported tumor was 230 mm , with a Given that LMSs originate from smooth muscle cells, confirming the diagnosis with IHC is necessary for accurate diagnosis . SMA n . All patients were managed with surgical resection, apart from two cases where modality of treatment was not reported. The extent of resection was dependent on whether there is an invasion of adjacent structures. Only 37% (7 cases) underwent chemotherapy and of those, six cases underwent palliative/salvage chemotherapy ,9,10,13,Postoperative serial imaging such as a CT chest, abdomen, and pelvis is recommended in LMS. As noticeable in our review, 63% n = 12) of patients had positive metastasis in a median of 13-months and 21% (n = 4) showed recurrence of primary tumor within a median of 6.5 months (Table 2 of patiThe median follow-up time for the cases presented n = 17) was 22.6 months range: 3-59), and consistent with the findings of Kato et al. [9, and co7 was 22.Mesenteric LMS are rare tumors, with aggressive behavior as manifested by their high metastatic rate. The clinical course appears to be variable based on location and histologic characteristics. Differentiating LMS from GISTs histologically can be challenging, given the diversity in morphology. Perhaps, the best way of separating the two entities is by IHC. As LMS are derived from smooth muscle cells, they stain positively for smooth muscle markers and negatively for intestinal markers. Conversely, GISTs arise from the interstitial cells of Cajal and stain positively with C-kit, DOG1, and CD34.In this report, we review the common clinical and diagnostic characteristics of mesenteric LMS and highlight the limitation of our knowledge in this rare entity. Therefore, further research is needed to optimize management and improve the prognosis of LMS.


Obturator hernia is a rare condition, characterized by the herniation of an intestinal segment between the obturator and the pectineus muscles through the obturator foramen. Obturator hernias usually occur in the elderly and are less common in males than in females, with a male-to-female ratio of about 1/14. In recent years, the use of diagnostic imaging, especially CT, to determine the causes of intestinal obstruction has been improved to allow for an early and accurate diagnosis, even of obturator hernias, which are extremely rare in male patients. We report a thin elderly man, without a history of surgery and with chronic constipation and an unremarkable Howship-Romberg sign, which was correctly diagnosed before surgery as an obturator hernia using CT. Obturator hernia is a rare condition that accounts for approximately 1%-3.9% of all abdominal hernias and 0.4%-1.6% of all cases of mechanical intestinal obstruction . In addiIn the literature, obturator hernia is most often reported in men. Clinical diagnosis is usually based on patients with predisposing factors, but in men presenting an obturator, the hernia is rarely posed, which may lead to delays in diagnosis, possibly causing fatal complications in patients. Herein, we report an unusual case of an elderly man with a small body, chronic constipation, and unremarkable clinical symptoms of an obturator hernia, according to preoperative diagnosis using CT.2), who visited the emergency department with complaints of an acute onset of right-side groin pain, followed by diffuse abdominal distension with pain, lasting for one week. He also complains of nausea, mild vomiting, and constipation for the past several days. No other significant medical history was reported. On examination, his abdomen distended with tenderness on palpation of the right lower abdomen, with no peritoneal signs. The digital rectal examination showed a normal stool. A local examination was not noted as an inguinal hernia or fullness in the right groin region and a Howship-Romberg sign. The laboratory findings were unremarkable, with mild leukocytosis (11 G/L).A 76-year-old thin and frail man (BMI = 18.1 kg/mInitial abdominal radiographs showed evidence of dilated small bowel loops with multiple air-fluid levels, consistent with an obstruction with no pneumoperitoneum Figure . An ultrA diagnosis of the right-side obstructed obturator hernia was made. The patient was optimized and admitted to emergency laparoscopic surgery. Laparoscopy confirmed the left obstructed obturator hernia, and forceps could not be used to pull it into the abdominal cavity. Then, laparotomy via a midline incision was carried out, showing that the incarcerated intestinal hernia as a Richter-type hernia protruding through the right obturator canal was an ileal loop of 3-4 cm and located 60 cm from the ileocecal junction. There were pre-gangrenous changes, including necrosis of its mesentery and a constriction ring in that bowel segment, which was resected, followed by anastomosis (Figure In summarizing the articles that we considered in our literature review, we found that favorable factors predisposed patients to hernia formation, including a larger obturator foramen in the wider pelvis, a loss of the peritoneum fat stroma covering the obturator canal and a history of multiple births in an emaciated body, with concomitant medical illness and without previous abdominal surgery. Other factors associated with increased abdominal pressure include ascites, chronic constipation, and chronic obstructive pulmonary disease.Diagnosis of an obturator hernia before surgery is difficult due to its non-specific symptoms and because there is usually intestinal obstruction. Clinical diagnosis based on the Howship-Romberg sign presented pain spreading along the medial thigh to the knee because of a nervous blockage by the hernia mass and pain increasing when the leg was spread out and rotated outside in 13%-68% of cases ,8,9. ThiThe most prominent clinical condition of our patient was intestinal obstruction. While he had a thin body and frequent constipation and had not had previous abdominal surgery, we did not consider the possibility that it might be an obturator hernia at the hospital, because he was a man. Thus, the Howship-Romberg sign, as well as the Hannington-Kiff sign, were not recorded before the CT scan. These specific signs were also unclear at the clinical examination, after the established diagnosis of obturator hernia by CT scan . ThanapaAn abdominal X-ray and ultrasound only show the usual signs of bowel obstruction. An ultrasound can give more information if Valsalva's maneuver comparison is performed on the unaffected side of the subject, suspecting an abdominal wall hernia, but this seems to be only detected in cases of inguinal region hernias . CT imagAbdominal and pelvic CECT present dilated bowel loops and fluid-air levels with transition points in the obturator foramen. Confirmation of an obturator hernia, when the CT findings were showing bowel herniation through the obturator foramen and lying between the pectineus muscle anteriorly and external obturator muscle posteriorly, may present an air-fluid level. The venous phase of CECT also provided additional information on the thickening and reduced enhancement of the intestinal wall, which could help to predict the gangrenous degree of the strangulated obturator hernia, as in our case.The use of abdominal and pelvic CT associated with ultrasonography may increase the preoperative diagnostic accuracy and be particularly important in those patients with a negative Howship-Romberg sign . The CT The incidence of multiple hernias is not rare, including indirect or indirect inguinal, femoral, and obturator hernias, accounting for 23% of cases . TherefoObturator hernia is an uncommon condition, which is especially rare in men, and this fact may delay preoperative diagnosis, causing a high risk of late bowel complications. Therefore, in the case of a thin older male patient, without a history of surgery and with favorable factors, such as chronic constipation, it is necessary to think about finding specific signs, such as the Howship-Romberg sign, and to perform early abdomen and pelvic CECT scans that cover the upper thigh area, which would allow for an exact diagnosis and prediction of necrosis of the intestinal segment in strangulated obturator hernias.


During pregnancy, decidual tissue can occur beyond the endometrium, predominantly on the surface of the uterus, fallopian tubes, and ovaries. This condition, called ectopic deciduosis, generally is not accompanied by any symptoms and complications, does not require treatment, and resolves completely soon after labor. However, rarely it can present with acute abdomen syndrome or imitate peritoneal malignancy and, thus, cause diagnostic difficulties and unnecessary interventions. Here, we report a challenging case of a pregnant woman admitted with acute peritonitis caused by ectopic deciduosis that mimicked peritoneal carcinomatosis. This uncommon manifestation of deciduosis hindered correct diagnosis and led to excessive surgery. While the management of the patient presented is regrettable, the case highlights the natural history of deciduosis, and therefore, important lessons could be learned from it. Ectopic deciduosis refers to an abnormal occurrence of decidual tissue (decidua) outside the uterus , 2. WhilDeciduosis is a benign condition that typically does not cause any symptoms and resolves spontaneously 4-6 weeks after labor , 10. How3 with 80% neutrophils. The levels of C-reactive protein (CRP) and interleukin 6 (IL-6) were elevated to 47 mg/L and 113 pg/mL, respectively. The performed abdominal and pelvic ultrasound (US) did not reveal an enlarged appendix or adnexa but showed slightly dilated bowel loops and a moderate amount of fluid in the RLQ and rectouterine pouch. The fetal heart rate was 160 beats/min. Due to suspected acute appendicitis, the patient underwent surgery.A 36-year-old Caucasian woman  presented to the emergency room at 32-week gestation with acute lower abdominal pain, mild fever, and nausea. Before this admission, her pregnancy was uneventful and carefully screened. The patient had a history of myopia and laparoscopic removal of endometrioid ovarian cysts 3 years before. She never smoked and denied any cancer history. At presentation, she had a temperature of 37.8°C (100.1°F), her pulse rate was 105/min, and her blood pressure was 104/66 mmHg. Her respiratory rate was 21/min, and her oxygen saturation was 96% on room air. Physical examination revealed a 32-week gravid uterus and guarding with rebound tenderness in the right lower quadrant (RLQ) of the abdomen; bowel sounds were decreased. Laboratory tests showed a leukocyte count of 17,000/mmThe performed diagnostic laparoscopy revealed numerous 3-5 mm yellow peritoneal nodules on the small bowel and cecum serosa . SimilarThe postoperative evaluation of suppurative fluid did not show bacterial growth. The final pathology of sampled tissues did not reveal any signs of malignancy and reported submesothelial fields of spindle and oval cells, forming bundles and swirls suspicious of decidual transformation Figures . The immth postoperative day. After delivery, the 2100 g (4 lb 10 oz) male newborn was transferred to the neonatal intensive care unit and discharged one week after. The patient underwent a control diagnostic laparoscopy six weeks after surgery that showed the complete regression of peritoneal nodules (Figures The patient recovered uneventfully and was discharged on the 6 Figures . Given tThis case demonstrates management challenges that physicians may face due to an uncommon presentation of ectopic deciduosis. As a rule, this obstetric condition does not cause any symptoms or laboratory abnormalities and resolves spontaneously 4-6 weeks after delivery , 9, 14. Imaging can significantly contribute to the differential diagnosis of acute lower abdominal pain during pregnancy and identify its causes, more common than ectopic deciduosis. The abdominal and pelvic US should be an initial test since it is noninvasive, not associated with ionizing radiation exposure, and informative in acute appendicitis or gynecological emergencies , 23. MagThe macroscopic appearance of the ectopic decidua is insidious as it lacks specific features and can be easily mistaken for a tumor. In general, it presents as small yellow to tan elastic, sometimes focally hemorrhagic, nodules or plaques localized on the surface of the uterus, fallopian tubes, ovaries, and pelvic peritoneum without any exudate , 2, 4, 9Generally, ectopic deciduosis is a self-limited condition that resolves completely in the early postpartum period and on its own not requiring any treatment . HoweverA thorough pathological assessment of surgical specimens, which is the key in making a diagnosis of ectopic deciduosis, requires time and resources and cannot be performed intraoperatively with frozen sections. In general, microscopic evaluation of the decidua shows large cells with spindle, oval, or polygonal shape that form bundles or clusters in the submesothelial layer , 2, 10. The presented case demonstrates diagnostic challenges caused by an uncommon manifestation of ectopic deciduosis that led to excessive surgery. This benign obstetric condition should be always kept in mind for differential diagnosis when the peritoneal spread of tumor-like lesions is found during pregnancy and the early postpartum period, and sufficient but not excessive biopsy of suspicious nodules is required for an accurate diagnosis. We believe that our clinical experience and its analysis will aid physicians in the appropriate management and reduce the risk of undesirable outcomes.


Neuroendocrine tumors (NETs) are rare tumors that are often asymptomatic and were once considered benign. A specific subtype that we will dive into in this article is appendiceal neuroendocrine tumors (ANETS). ANETs are the most common tumors located within the appendix. Most often, they present as acute appendicitis and are found incidentally on pathology reports status post appendectomy. The objective of this article is to show that even though most of the ANETs are benign and fully treated via surgery, ANETs still have the potential to become malignant and metastasize. Our patient fits the common features seen in ANETS. She is a middle-aged woman with vague abdominal pain and no clear diagnosis on gastrointestinal (GI) workup. Computed tomography (CT) confirmed appendicitis, and pathology reports status post-surgery confirmed stage IV, pT4, Nx, M1 - poorly differentiated neuroendocrine carcinoma of the appendix with omental metastases. In 1907, Dr. Siegfried Oberndorfer was the first scientist to characterize the neuroendocrine tumor (NET), which he referred to as “benign carcinomas” and subsequently named them Kazinodes or “carcinoma -like” tumors -3. ANETsThis article was featured as a poster in the Society of Hospital Medicine - West Virginia Chapter.A 61-year-old obese female presented to the gastroenterology clinic for evaluation of nagging abdominal pain that had been present for eight months. She described the pain as sharp, localized to the periumbilical region/left upper quadrant, and lasting for a few minutes to a few hours at a time. The pain occasionally escalates to 10/10 in intensity. She currently has no associated symptoms and denied any aggravating or relieving factors. Past medical history reveals irritable bowel syndrome with alternating periods of diarrhea and constipation, bloating, nausea, well-controlled asthma, and gastroesophageal reflux disease (GERD). She described her diarrhea as watery, occurring three times a day and not present throughout the night. She had no history of fevers, odynophagia, dysphagia, frank hematemesis, hematochezia, or melena. She has an extensive past surgical history, including laparoscopic cholecystectomy, open abdominal hysterectomy with bilateral salpingo-oophorectomy, caesarian sections x 2, and tubal ligation. She was currently taking Prilosec and asthma medications. Family history was insignificant. She had never smoked and denied any frequent alcohol use or illicit drugs.On physical exam, she appeared chronically ill but in no acute distress. Her abdomen was obese, soft, and tender to deep palpation in the epigastric area. Fullness is noted in the right lateral aspect of the right upper quadrant. No rebound tenderness or guarding was noted. Positive bowel sounds were present in all four quadrants. Labs, including hepatic function, complete blood count (CBC) with differential, and basic metabolic panel (BMP) are all within normal limits Tables -3. She wApproximately three months later, she reported to the emergency department (ED) for abdominal pain, where a CT abdomen was performed and showed a dilated appendix with inflammatory stranding concerning for acute appendicitis as well as a supra-umbilical incisional hernia containing no loops of the bowel Figures -6. DurinShe was subsequently seen by an oncologist who performed a positron emission tomography-computed tomography (PET-CT) scan that showed no definite evidence for metastatic disease s/p appendectomy Figure . The patDuring a 16-year period, 7,970 appendectomies were performed in one hospital, and of those, 74 patients (0.9%) presented with appendiceal tumors . Primary malignant tumors of the appendix were found in 0.1% of all the appendectomies . ANETs aSurgery is largely curative, with most patients living a long and fruitful life afterward. Surgery guidelines are relatively straightforward, although the classification is a little more debated over. As a general rule, ANETs <1 cm hardly ever metastasize and are treated by appendectomy alone while ANETs >2 cm call for a right hemicolectomy due to the high risk of metastasis . Tumors Due to the misconceptions that NETs were once proposed to be nonmalignant, as Dr. Oberndorfer originally believed, there have been two new classification schemes, the first was presented by ENETS in 2006 and the other by the American Joint Committee on Cancer (AJCC), which appeared in AJCC 8th edition in 2010 -12. ThesOur patient lines up with the typical demographics and clinical presentation seen in ANETs. She is a 61-year-old female with vague abdominal pain who had a full GI and GU workup with no definitive diagnosis. She eventually obtained a CT abdomen, which came back as acute appendicitis. While in surgery for the laparoscopic cholecystectomy, it was very fortunate that the surgeon removed much of the abdominal fat in the hernia sac, which came back positive for poorly differentiated neuroendocrine carcinoma. The appendix was positive as well and had a final pathology report of stage IV: pT4, Nx, M1 poorly differentiated neuroendocrine carcinoma of the appendix with omental metastases. Due to the metastases, large tumor size, high mitotic rate, and Ki67%, surgery was not the treatment option but rather immunotherapy medications. Unfortunately, her disease continues to cause her significant pain even with the placement of a hydromorphone PCA pump. The patient is in good spirits and continues to be optimistic about treatments, although she understands the grave prognosis that she is faced with.Neuroendocrine tumors (NETs) were once believed to be non-malignant and of little clinical significance. Dr. Siegfried Oberndorfer’s research into carcinoid tumors sparked a new revolution for NETs. Appendiceal NETs (ANETS) happen to be the most common tumor found in the appendix overall. Over the years, the malignancy rate has been very low indeed, but as in our patient's case, statistical outliers do exist and need to be explored. The purpose of this case report is to show that ANETS can be a malignant tumor with the potential for metastases and should not be taken lightly. Whether ANETS are malignant or not, they usually tend to be asymptomatic. ANETS often present in middle-aged women and are most often found when a patient presents with symptoms congruent with acute appendicitis. CT or other imaging confirms the diagnosis of acute appendicitis and an appendectomy is earned. It is not until postoperative pathological reports come back positive for ANET that the neoplasm is finally known. Thanks to the WHO, ENETS, and AJCC, there are specified guidelines on how to classify each type of ANET and what the best treatment and follow-up is. Surgery is largely curative if the ANET is caught before it can grow too large or has the opportunity to metastasize. In the case of metastasis, as in our patient, immunotherapy can be initiated if the patient so wishes. Close follow-up should be applied for all types of ANETS.


A retro odontoid pseudo tumor is a mass lesion lying posterior to the odontoid process along the dura. It is a disease process seen in inflammatory and non-inflammatory conditions causing chronic atlanto-axial instability. This type of mass has the potential to enlarge causing cervicomedullary compression and symptoms of myelopathy. In the past, authors have relied on a more invasive, direct approach to decompress the mass including an anterior trans oral odontoidectomy and a posterior trans-dural resection. The objective of this case report is to describe the use of an indirect approach, cervical fusion with decompressive laminectomy, to successfully treat a retro odontoid pseudo tumor in a geriatric patient. A male patient in his late 90’s presented with inability to ambulate, global paresis, and long tract signs in the upper extremities. He was found to have a large odontoid mass with compression at the cranio-cervical junction. He underwent cervical fusion with instrumented fixation from C1-6 and decompressive laminectomy from C4-6. Over a follow-up period of two years, there was improvement in the patient’s motor weakness and ambulation. Radiographic evaluation at the two-year mark showed marked reduction in pannus size. Indirect approaches to decompression in patients with retro odontoid pseudo tumor using techniques such as cervical fusion may be a safe for effective treatment in patients of advanced age, with multiple co-morbidities, and inability to tolerate lengthy surgical procedures. This retro odontoid mass may also be referred to as an odontoid pannus or phantom tumor.Retro odontoid pseudo tumor is a disease entity characterized by a mass lesion lying posterior to the odontoid process . On MRI, this produced a T2 hyperintense signal at the medulla consistent with encephalomalacia, or medullary atrophy . The patient also had diffuse spondylosis, or degeneration, of the cervical spine along with central stenosis at the C4-5 and C5-6 level . Both an MRI of brain and CT angiogram were obtained and failed to reveal any other pathology. The posterior odontoid mass was found to be due to his rheumatoid arthritis.The authors had a long discussion with the patient and family in view of his advanced age and the risks of proceeding with surgery. Their primary surgical goal was to improve both his functional status and activities of daily living. Given his significant decline in functional status leaving him wheelchair-bound with high morbidity risks and poor quality of life, it was decided that the benefits of intervention outweighed the risks. The patient was medically optimized prior to surgery with full cardiac evaluation and clearance to decrease perioperative risk. His clinical presentation, physical exam findings, and pre-operative imaging were suggestive of compression of both the lower medulla and cervical spine and so we elected to complete a multi-level laminectomy. The patient would undergo posterior cervical arthrodesis, or fusion, with instrumented fixation from C1-6 with decompressive laminectomy  from C4-6 to treat associated stenosis, or narrowing of the spinal canal. Intraoperative neuromonitoring was utilized along with fluoroscopy for localization and lateral mass screw placement. The authors utilized an arterial line and a large bore 16-gauge intravenous catheter in the antecubital fossa to ensure adequate access for fluids and blood pressure monitoring. No signal changes were noted intraoperatively and patient was successfully extubated.A post-operative CT scan is provided . The patient was placed in the ICU for post-operative monitoring. He tolerated the procedure well and his hospital course was uncomplicated. He was discharged in stable condition for a short course of inpatient rehabilitation.The patient was followed up for two years. There was improvement in his motor weakness symptoms and he was eventually able to ambulate without an assisted device. Radiographic evaluation at the two-year follow-up mark showed marked reduction in the pannus and associated cyst with resolution of T2 hyperintense signal within the medulla . While there are reports in the surgical literature of smaller-sized pannus causing cervical spinal cord compression, we have been unable to identify any reports of such a large odontoid pannus with associated cyst and medullary compression.Retro odontoid pseudo tumor or odontoid pannus can be seen in inflammatory disease entities such as rheumatoid or psoriatic arthritis, and in the non-inflammatory settings .However, there are a few instances where no atlantoaxial instability is noted on imaging and yet there still may be development of this mass lesion. In the past, authors have recommended a direct form of decompression with removal of the odontoid pannus. Surgical treatments included anterior trans oral odontoidectomy and posterior transdural resection. However, these surgical approaches have been associated with higher infection rates, spinal cord injury and in some instances reoccurrence of the mass.Authors have reported good radiographic and clinical outcomes one case report with complete resolution or reduction in mass size over a 45-month period, obviating the need for a transoral anterior approach.We also elected this approach to reduce surgical risk and morbidity associated with surgery. The use of C1-2 fusion is a known safe treatment for atlanto-axial instability and has been extended as a treatment for painful arthritis.There is also literature supporting the use of C1 laminectomy for indirect decompression and reduction in pannus size. This strategy may be useful for patients unable to tolerate prolonged surgeries with significant blood loss and lengthy anesthesia exposure.Retro odontoid pseudo tumors or odontoid pannus is a disease process characterized by formation of a posterior mass with possible cystic formation, which may lead to marked compression on vital neuronal structures at the cervico-cranial junction. Certain risk factors have been associated with an odontoid pannus including rheumatoid arthritis, Os odontoideum, or malunion of odontoid fracture. The basis of this disease process is believed to be due to atlanto-axial instability.However, this may not be true for all cases, since it has been found that indirect techniques in the form of C1 laminectomy have helped reduce pannus size. In this patient’s case, we proposed cervical fusion and avoided a transoral approach due to his advanced age and inability to tolerate a more invasive procedure. After our two-year follow-up, the pannus and associated cyst had significant reduction with resolution of cord signal change within the medulla.We therefore support the use of posterior fixation for treatment of this disease process, particularly in older patients. Further investigations of the pathophysiology of this disease process are warranted to help create a more unified treatment approach. Whichever surgical intervention is decided, early recognition and treatment of spinal cord compression can help improve neurologic outcomes.The authors declare no conflict of interest.


Bowel obstruction is a rare but well reported complication of blunt abdominal trauma (BAT). Obstruction is most often seen acutely caused by bowel wall hematomas and chronically as a result of post-traumatic strictures. Here, we present a novel case of BAT causing a subacute obstructing bowel wall hematoma.A healthy, 32-year-old male presented to our emergency department with three days of nausea and vomiting. Chart review revealed he had been seen two weeks prior after a high-speed motor vehicle collision. During that initial visit, the patient had a benign abdominal exam and was discharged without imaging. On this return visit, the patient was found to have a large, obstructing colonic hematoma.Because emergency physicians care for patients in both the acute and subacute phases of trauma, clinicians should recognize the more subtle sequelae of BAT. Bowel obstruction is a common diagnosis made in the emergency department (ED). Classic causes include strictures, hernias, and malignancy. Rarely, clinicians may see a wide range of less common precipitants, from foreign objects to enteroliths.A 32-year-old male presented to the ED after experiencing three days of nausea and vomiting. Additionally, he reported anorexia with constipation for three days, and obstipation for one day. He had no relevant past medical history, was taking no medications, and had no allergies. Review of the electronic health record revealed the patient had been evaluated two weeks prior following a motor vehicle collision (MVC). He had been the restrained driver in a two-car collision with associated airbag deployment and heavy front-end damage. He was seen approximately 30 minutes after the MVC at a community hospital without a trauma center designation. At the time, he was hemodynamically stable and did not have any abdominal pain or bruising. He was evaluated by an attending physician and, after a primary and secondary trauma survey, was discharged without any indication for imaging or further evaluation.For the current ED visit, his presenting vital signs were as follows: temperature 97.8 degrees Fahrenheit; heart rate 89 beats per minute; blood pressure 126/73 millimeters of mercury (mm Hg); respiratory rate 20 breaths per minute; and oxygen saturation 98% on room air. Physical examination revealed a soft but diffusely tender abdomen with voluntary guarding in all quadrants. There was no rebound, rigidity, or palpable mass. Further, no external signs of trauma were appreciated. The remainder of his examination was unremarkable, including bowel sounds, which were present and normoactive. On history-taking he denied new trauma aside from the known MVC, and had been taking acetaminophen since the accident for pain control.Notable laboratory values were as follows: hemoglobin 13.2 grams (g) per deciliter (dL) (reference [ref] range: 13.5–16.5 g/dL), hematocrit 40.4 % (40.0–49.0% ref range), anion gap 9 milliequivalents (mEq) per liter (L) (ref range: 5–17 mEq/L), aspartate aminotransferase 21 international units (IU) per L (ref range: 8–40 IU/L), and alanine aminotransferase 14 IU/L (ref range: 15–45 IU/L). While awaiting computed tomography (CT), a point-of-care abdominal ultrasound examination was completed. There was no free fluid visualized in the hepatorenal, splenorenal, or pelvic windows. Further, there was no mass visualized within the abdominal cavity. Subsequently, a CT of the abdomen with intravenous (IV) contrast revealed a large intramural fluid collection occluding the lumen of the ascending colon, with resulting bowel obstruction. .We inserted a nasogastric tube – with return of non-bilious stomach contents – for gastric decompression and administered IV fluids. He was admitted to the surgical service for observation and was taken to the operating room two days later for bowel resection. He was discharged on postoperative day six. His course was complicated by a minor surgical site infection, which was managed with point-of-care drainage. No antibiotics were required. At his five-week follow-up appointment, he reported normal bowel movements and eating habits, and was cleared to resume full activity.Causes of post-traumatic bowel obstruction include hematoma formation, bowel wall edema, and late-presenting strictures.CPC-EM CapsuleWhat do we already know about this clinical entity?Post-traumatic bowel obstructions are known to occur within hours after trauma due to hematoma formation. Late-presenting obstructions are often due to strictures.What makes this presentation of disease reportable?A late-presenting, sub-acute bowel wall hematoma causing a post-traumatic obstruction has not been previously described in the literature.What is the major learning point?Intra-abdominal injury in the form of bowel obstruction from blunt abdominal trauma may only become apparent weeks after the incident.How might this improve emergency medicine practice?Patients presenting with abdominal complaints in the post-trauma setting should be evaluated for intra-abdominal pathology despite a previously negative exam.Cross-sectional imaging is crucial to the diagnosis and treatment of these injuries. The best imaging modality to diagnose bowel obstruction is CT with IV and oral contrast. Unfortunately, the patient in this case was unable to tolerate oral contrast due to unremitting nausea and vomiting. While the dual-contrast approach would have allowed us to better visualize smaller, more nuanced causes of bowel obstruction, we found an IV-contrast only approach was sufficient for this case.7Within this context, it is notable that CT with IV contrast is preferable to ultrasound (US). In this case, point-of-care US was attempted but was not diagnostic. Ultrasound has been described as an alternative imaging technique for diagnosing intestinal obstruction, appendicitis, and other bowel diseases.As the management of these conditions is nuanced and complex, it is imperative they are diagnosed in a timely manner. Yet subacute and rare presentations, like this one, risk going unnoticed. Based on our patient’s initial presentation to the ED, directly after his trauma, clinical guidelines did not point toward the need for additional workup.Initial management of patients with intraluminal hematoma includes bowel rest, insertion of a nasogastric tube for intestinal decompression, and observation. Definitive management is more intricate. Hematomas can be resorbed, some rapidly and spontaneously, but others have taken months.As this case demonstrates, emergency physicians should consider complications from recent trauma even in the absence of indications for imaging on initial presentation. A patient who presents with symptoms of bowel obstruction after sustaining remote blunt trauma should undergo a CT of the abdomen. As EDs often care for patients both in the immediate aftermath of traumatic injury and later in their lives, emergency physicians must recognize the more subtle, subacute effects of trauma, in this case, blunt abdominal trauma.


The occurrence of esophageal cancer after previous pneumonectomy for primary lung cancer is rare. This is the second case report of transhiatal esophagectomy after previous pneumonectomy due to lung cancer. In this case, selection of surgical approach for esophagectomy, was technically challenging and anatomic deformity in post pneumonectomy space had potential risk of physiologic disturbance, especially after thoracotomy option in solitary lung with limited capacity.We herein report a 58 year old man with history of left pneumonectomy and lymph node dissection due to mucoepidermoid carcinoma 19 years ago and recently admitted for esophageal carcinoma. He successfully was managed via transhiatal approach.Transhiatal esophagectomy in pneuminectomized patient is safe and recommended as first option. Esophagectomy in setting of prior pneumonectomy is a challenging issue, and there is little experience in this area with only a few cases reported to date –5. This A 58-year-old man referred to our teaching hospital with progressive dysphagia from 2 months ago. He could only take down soft drink. The patient had undergone left pneumonectomy and lymph node dissection for mucoepidermoid carcinoma (pT3N1M0) 19 years ago. He was worker with no history of smoking but recently became diabetic and was controlled with oral anti hyperglycemic drugs. He underwent barium swallow which showed irregular mass and deformity in lower third, then Esophagoscopy showed tumor in 32 cm from the incisors. Biopsies were taken and moderately differentiated squamous cell carcinoma was the confirmed diagnosis.Preoperative spiral chest and abdominal CT scan was done to evaluate the thoracic anatomy, lymphadenopathy and surgical plan and approaches. Whole body scan was done to assess the presence of any metastatic disease.CT of the chest demonstrated marked anatomic deviation, hyper expansion of the right lung, mediastinum shift to the left hemithorax, and reduced left intrathoracic space with heterogeneous opacification , 2. No mIn preoperative cardiovascular workup, ejection fraction was 60%, Pulmonary function test also showed a forced expiratory volume (FEV1) of 1.23 L (56% predicted), forced vital capacity (FVC) of 1.50 L (50% predicted). ABG in room atmosphere was normal and he could walk two floors up without dyspnea.Our assessment was based on the preoperative cardiovascular assessment, pulmonary function tests, data and imaging indicating the operability of tumor. The preferred method was an approach without thoracotomy due to limited lung capacity and possible physiologic disturbance. Thus, the initial operative plan was transhiatal approach. However, possible intra operative unpredictive findings may necessitate change the operative approach. Although transthoracic tree hole approach was an alternative favorite, operating in solitary lung and manipulation in this area may be hazardous. We had many difficulties in entering the left chest, due to extensive fibrotic scar tissue, obliteration of the post pneumonectomy space and significant anatomic distortion, so, the final decision was made to precede on Transhiatal esophageal resection without any neo adjuvant modality.A writhen informed consent was obtained from the patient and his relatives for possible major complications, high morbidity and mortality.Preparation of the colon was performed earlier. After careful preparation in well-equipped operating room, full monitoring and insertion of 2 intra venous line for immediate blood transfusion, the patient underwent laparotomy with upper midline incision. On abdominal exploration, no evidence of metastatic disease was seen. Esophageal hiatus mobilization and conduit preparation were performed in the standard fashion as: proximal duodenum and stomach with vascular pedicles were mobilized, gastric conduit for esophageal substitute on base of the right gastroepiploic and right gastric artery with cutting linear GI staple were prepared, and pyloromyotomy was performed.We encountered relative dense adhesions at the hiatus and distal of esophagus that extended into the left hemithorax. Esophageal hiatus was widened as much as possible to facilitate more access for paraesophageal tissue and more controlling of the vital structures.To facilitate adequate length for the cervical anastomosis, we performed a more extensive Kocher maneuver to allow greater conduit mobilization and avoiding possible colonic bypass.With careful dissection in posterior mediastinum and paraesophageal tissue, distal of tumor about 5 cm above gastro esophageal junction (GEJ) was palpable, and dissection continued into proximal tumor meticulously. It seemed dissection of paraesophageal tissue was feasible, not hazardous. Continuing dissection was promising and safe and confirmed our initial impression that blunt mobilization would be possible.Then left sided cervical incision from the sternal notch to the level of the cricoid cartilage medial to sternocleidomastoid was done, cervical esophagus was dissected from adjacent tissue carefully, dissection was continued in to upper thorax, the esophagus was mobilized from the trachea, great vessels and thick fibrous pleura and the mediastinal contents. Blunt dissection of esophagus from upper thorax and lower hiatus was performed simultaneously. Then the mobilized esophagus above sternal notch was cut, for removal of esophagus a Nelaton tube was inserted into the lumen and proximal portion of the tube circumferentially sutured to proximal edge of esophagus and extracted in to abdominal cavity.Because of dense adhesions we were hardly able to release the periesophageal tissue; however, our final specimen was stripped adventitial tissue.2 saturation was optimized and blood lost was near 500 cc.Then gastric conduit was brought up to the neck in a sterile manner and functional end-to-end anastomosis with separated absorbable monofilament suture was performed. A nasal gastric tube was inserted into the gastric conduit and pushed several centimeter after pyloromyotomy site as feeding tube. During operation, no adverse event and hemorrhage hemodynamic instability happened; OThe patient’s postoperative course in ICU was well managed. The next day he was extubated without any respiratory distress and complication. On the 3rd day after operation, warm tea, and then soft diet via NG tube was started, on 5th day patient was transferred to ward and on 9th day thin barium esophagogram showed good position of the new esophageal conduit, no evidence of a leak and normal emptying of the conduit . He toleThere is dilemma regarding the approaching side, as pneumonectomy has left substantial deformity in the ipsilateral thoracic space, whereas operating on the healthy side puts the lung at risk of respiratory difficulty . FollowiEsophagectomy through the right thoracotomy in patient that had undergone left pneumonectomy, would carry more complication, such as the potential pleural space contamination.Transhiatal esophagectomy is theoretically appealing in avoiding the thoracotomy but technically may not be feasible due to post pneumonectomy changes, and previous mediastinal lymph node dissection . HoweverThe principles of transhiatal esophagectomy in post pneumonectomy patients are the same as conventional, however it requires preparation of the colon as alternative substitute, more caution in tissue dissection, well equipped operating room, full monitoring, and availability of immediate blood transfusion. Also hiatus must be widened as much as possible for better accessibility of vital paraesophageal structures, allowing simultaneous use of laparoscope for adequate exposure and lysis of adhesions .In this patient neoadjuvant radiation therapy is not recommended because of concern of worsening of extensive fibrosis that is already present from previous pneumonectomy, although data this area is not adequate. One the most important reasons of selecting transhiatal approach was our greater experience in transhiatal esophagectomy than any others option and many of surgeons may be unfamiliar with post pneumonectomy area with many pitfalls. Moreover, transhiatal esophagectomy may protect the residual pulmonary reserve, managing the potential anastomotic leak better.Although our experience in this case revealed transhiatal esophagectomy in pneuminectomized patient is safe, and may be recommended as first option, but this surgical approach should be optimized on individual basis. The procedure presented here is applicable for tumors of the lower third, while tumors located in the upper and middle third may be impossible for resection with this approach; however, extracorporeal membrane oxygenation (ECMO) has been introduced to enable surgery in these patients .In pneumonectomized patient, transhiatal approach for resection of lower third esophagus cancer is safe and may recommended as first option; however, other safe options individually must to be considered.


Extrauterine adenomyoma is a rare type of benign tumor, characterized by nodular aggregate of smooth muscle, endometrial glands and endometrial stroma, arising outside the uterus. In this study we describe a case of primary ovarian adenomyoma associated with endometriotic cysts with contralateral serous borderline tumor in a 40-year-old woman and we highlight how preoperative exams could lead to the suspicious of invasive cancer. We provide a review of the literature, analyzing all cases of extrauterine adenomyoma published so far, classifying them on the basis of pathogenetic theories proposed, localization of the lesion, imaging modalities and treatment adopted. Abdominal surgery; Cancer surgery; Gynecology; Medical imaging; Radiology; Extrauterine adenomyoma; Ovarian adenomyoma; Uterus-like mass; Borderline ovarian tumor; Ovarian cancer. This rare type of benign tumor has been described in pararectal spaces, ovaries, broad ligament, peritoneum, cornus medullaris, bowel and liver , 2. The 2A 40-year-old woman para 0000 was referred to our Institution for a pelvic pain irradiated to the left flank. Her medical history was unremarkable and she did not assume regular medications. She did not report any general surgical procedure except for a cesarean section in 2015 for breech presentation. Her family history for gynecological malignancies was negative. At admission, she denied dyspepsia, bowel or urinary habits changes and she had regular menses. The pelvic pain onset was intermittent and persistent over the previous three weeks.Vital parameters were regular and the patient was apyretic. Clinical examination revealed a left iliac firm and painful mass with tenderness exacerbated by bimanual mobilization. On palpation the uterus and right adnexa appeared physiological and no blood nor atypical vaginal discharge was recorded. Blood tests were all in normal ranges. Alpha-fetoprotein, carcinoembryonic antigen, CA-19.9, CA-15.3, were all negative. Serum cancer antigen-125 was elevated, reaching 680.8 UI/ml.Transvaginal scan was performed by using a 5–7 MHz transvaginal transducers (Affiniti 70 - Philips). IOTA  terms and definitions were adopted to describe the ovarian lesion. The ultrasound (US) examination confirmed the presence of an irregular dishomogeneous solid mass of 63 × 62 × 60 mm, arising from the left ovary, with two hypoechoic cysts and regular margins .Figure 1The operator attributed a color score of 4 (highly vascularized) due to the presence of a single dominant vessel crossing the central part of the mass with multiple branches distributing to the periphery and surrounding the cystic areas , video 1https://doi.org/10.1016/j.heliyon.2020.e04406Supplementary data related to this article can be found online at Left ovary lesion, suspected for invasive epithelial ovarian cancer.Video 1Right ovarian lesion suspected for borderline ovarian tumor.Video 2The following are the Supplementary data related to this article:A positive sliding sign was present between the uterus and the pelvic sidewall. Furthermore, the right adnexa appeared to have an increased volume 55 × 31 mm) with an inner hemorrhagic area and an adjacent unilocular cystic lesion with irregular borders, multiple papillary structures and color score 3 , which confirmed the finding of an inhomogeneous adnexal solid-cystic left mass with an irregular contour, high contrast enhancement and a smaller contralateral solid-cystic lesion. No additional lesions were reported in the remaining abdomen nor in the thorax.An alleged diagnosis was malignant ovarian tumor, a comprehensive surgical staging was scheduled. Despite full information about her clinical condition, the patient refused concomitant hysterectomy, except in case of histological confirmation of an invasive tumor; she gave valid consent to bilateral adnexectomy and surgical abdominal staging. An endometrial biopsy was pre-operatively performed to exclude a coexisting uterine malignancy. At laparotomy, a left pelvic adnexal mass measuring 8 cm in greatest dimension was found. Furthermore, a right pelvic adnexal mass, measuring 5 cm in greatest dimension. This was adherent to sigma and uterine posterior wall; at the frozen intraoperative analysis two other oval nodes were found near the ovarian lesion .No additional lesions were found on exploration of pelvis and abdomen. The left adnexectomy was performed without complications and sent for frozen intraoperative analysis retrieving endometriotic cyst with hemorrhagic areas. Right adnexectomy was performed and the frozen section preliminary confirmed a tumor with borderline characteristics. Residual surgical staging, including peritoneal washing, multiple peritoneal biopsies and omentectomy, was performed. No suspicious lesions were found, lymphadenectomy was not performed because metastasis to the lymph nodes is not known to affect survival or recurrence .. [Upon gross examination, the left ovary lesion was greyish, lobulated, with a smooth surface, an irregular shape and had solid-elastic consistency. On the cut section, the mass showed a prevalent solid component with gray cystic areas filled with brown-chocolate fluid. Microscopy revealed the presence of two endometriotic cysts surrounded by a variable thickness of smooth muscle layers lined with endometrial glands and stroma without nuclear atypia resembling normal uterine myometrium and endometrium. These findings were consistent with uterus-like extrauterine adenomyoma associated with ovarian endometriomas Figures , 8 and 9.  All othe3.An extrauterine adenomyoma is a rare type of benign tumor, mainly located in ovaries. Since it was first described by Cozzutto et al. in 1981  subsequeCozzutto in his paper, proposed the theory in which adenomyomas could originate after a process of metaplastic transformation of endometriotic cells into smooth muscle, but this theory could not explain whole cases published later. Four other theories, from Rosai, Redman, Batt and Belmarez, have been proposed for explaining the pathophysiology of extrauterine adenomyomas and are described below.Rosai  suggesteSince some extrauterine adenomyomas responded to hormonal treatment, in 2005 Redman et al. , 32, 33 Batt et al. , 9 propoMost patients with ovarian adenomyoma had a presumptive ultrasound diagnosis of ovarian endometrioma. Moreover, most ovarian adenomyomas arise in the left ovary according to our case report. Several Authors , 11, 12 Notwithstanding the patient complained of pelvic pain which is a symptom often associated with endometriosis and a parameter introduced in LR1 (Logistic Regression) model of IOTA group to identify benign ovarian masses , 19. TheIn 2018, a review of literature of extrauterine adenomyoma was published by Paul [Analyzing the past medical history reported, we could classify each case report basing on pathogenesis: Mullerianosis' theory was respected in 52% of cases (22/42), Belmarez's theory  in 33% of cases (14/42), Cozzutto's theory (coexistence of endometriosis) in 19% of cases (8/42), subcoelomic mesenchymal metaplasia's theory  in 9,5% of cases (4/42) and Rosai's theory  in 2,4 % of cases (1/42).In nearly one-fifth of cases (8/42), no theory fits with the past medical history and the clinical presentation of each case reported. Due to the lack of data on this rare pathology, no theory is able to globally explain the pathogenesis of extra-uterine adenomyoma so far and more cases collection is needed.Analyzing the characteristic of extrauterine adenomyoma, abdominopelvic pain is the most common clinical sign at presentation. Endometriosis was reported in the medical history of eleven out of forty-two patients (26%), substantially according to the previous literature review  in whichSurgical management was the treatment approach in all cases of extra-uterine adenomyomas but only in 2 cases out of 42 a diagnosis of extra-uterine adenomyoma was correctly suspected in the preoperative phase by imaging. Ultrasonography was the most common imaging modality adopted as single diagnostic procedure ; more than one radiological staging technique  was used in 50% of the cases (21/42).In sixteen cases out of 42 a preoperative diagnosis was postulated, according to radiological findings or preoperative biopsies: malignancies in 7/16, ovarian thecoma/fibroma in 1/16, ovarian mass torsion in 1/16, myoma in 2/16, endometrioma in 2/16, serous cystadenoma in 1/16, leiomyomatosis peritonei/carcinomatosis in 1/16, and inguinal adenopathy in 1/16. Preoperative biopsies were performed in two cases, reporting extrauterine adenomyoma in one case and a suspect of adenomyosis versus endometriosis in the other one.Including our presented case, 4 cases  were associated with malignancy. Torres et al.  reported4Extrauterine adenomyoma is still a major challenge. The data available so far bring out the difficulties to correctly diagnose this rare entity preoperatively, due to the lack of a typical ultrasonographic pattern of presentation. This type of ovarian lesion may appear in middle aged women with no previous history of pelvic pain suggestive for endometriosis. The case herein presented shed light on the possibility that ovarian adenomyoma associated with endometriotic cysts may resemble the ultrasound features of ovarian malignancy according to validated IOTA models. The lack of knowledge of this rare entity may eventually lead to unnecessary diagnostic procedures and improper surgical approach.All authors listed have significantly contributed to the investigation, development and writing of this article.This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.The authors declare no conflict of interest.No additional information is available for this paper.


Based on histopathology and immunohistochemistry, a diagnosis of the classical variant of angiomyolipoma of the left broad ligament was made. The post-operative period was uneventful with no recurrence after 6 months of follow-up.Angiomyolipoma is a benign mesenchymal neoplasm of the renal parenchyma, accounting for 1% of all renal parenchymal tumors. However, this entity may rarely occur in extrarenal sites. Extrarenal angiomyolipoma has been documented in various sites of the body, but angiomyolipoma of the broad ligament was reported in only two cases. We report the reputed third case of angiomyolipoma of the broad ligament in a 33-year-old female, who presented clinically with abdominal distension. With a working diagnosis of low-grade neoplasm, an  A 33-year-old female patient sought medical care complaining of abdominal distension accompanied by feet edema. She referred abdominal pain and decreased urine output over the last 4 months. She denied any other symptom when actively questioned. Her past medical history was unremarkable and also denied smoking or alcohol consumption. On physical examination, the abdomen was distended with mild tenderness along with a large mass palpable in the hypogastric region. The remaining physical examination was normal. The laboratory workup and chest X-ray were normal. However, the pelvic ultrasonography (USG) depicted a large heteroechoic lesion in the left broad ligament extending to the pouch of Douglas, measuring 12×13.2 cm with internal vascularity. There was no lymphadenopathy; however, minimal ascites was noted. On contrast-enhanced computed tomography (CECT), a well-defined abdominopelvic soft tissue density lesion centered in the left broad ligament, with subtle heterogeneous enhancement on the post-contrast study, measuring 21.2×20×10 cm displacing the bowel loops superiorly and laterally, was noted. On per speculum examinations, the cervix was pulled up, and the vagina was healthy. On per vaginal examination, the uterus was bulky, and the pouch of Douglas was full. Cytological examination of the ascitic fluid examination was negative for malignancy. The USG-guided fine needle aspiration cytology attempted from the mass showed occasional stromal fragments, proliferating vascular fragments, and inflammatory cells in a hemorrhagic background. The USG-guided Tru-cut biopsy from the mass showed scant tissue bits with spindle cells along with many proliferating vascular channels suggestive of low-grade spindle cell neoplasm .en-bloc excision of the left broad ligament mass was performed. Per-operatively the mass was in the left broad ligament extending to the pouch of Douglas. The mass did not involve the uterus, the bilateral ovaries, and fallopian tubes. Grossly the mass was lobulated, encapsulated, and measured 21×20×10 cm  is an uncommon benign mesenchymal neoplasm of unknown origin, comprising of mature adipose tissue, muscle fibers, and thickened-wall blood vessels.-The PEComa group of tumors includes mainly the AML, lymphangioma, pulmonary clear cell “sugar” tumor (CCST), lymphangioleiomyomatosis (LAM), and the clear cell myomelanocytic tumor of the falciform ligament/ligamentum teres of various anatomical sites.,,Few cases of AML involving the female genital tract have been reported, but AML of broad ligaments is very rare.,Chopra et al.Immunohistochemically the myoid component was positive for smooth muscle actin antibody and negative for HMB-45. The vascular component was positive for CD 34, and the adipose tissue component was positive for S-100. Shakuntala et al.The classical variant of AML is a benign lesion with locally aggressive behavior, recurrence potential; however, metastasis does not occur.AML arising from the broad ligament is very rare. As far as we could get, we only found two cases described in the English literature. Although rare, AML should be kept in the differential diagnoses of the broad ligament masses, including those of malignant behavior. Since AML have recurrence potential, they should also be differentiated from the benign differentials. The characteristic histopathology comprising of mature adipose tissue, muscle fibers, and thickened-wall blood vessels with a panel of immunohistochemical markers is required for their accurate diagnosis. Considering that the AML is a benign entity, but with recurrence potential, complete surgical excision is desirable.


Cushing’s syndrome (CS) is rare in childhood and adolescence. The most common paediatric cause of CS is exogenous administration of glucocorticoids; either topical, inhaled or oral corticosteroids. Endogenous causes can be classified into adrenocorticotropic hormone (ACTH) independent and ACTH dependent causes. Herein, we report our experience of managing a 12 year old girl who presented with features of CS and was found to have an ectopic, ACTH-secreting bronchial carcinoid tumour, which was resected surgically. Our patient was managed successfully by multidisciplinary approach and has recovered from hypertension and Cushing’s habitus. The English language literature was searched from 2019 back, using PubMed, Google and Google Scholar. Keywords used for the search were; “Ectopic ACTH syndrome (EAS) in children”, “bronchial carcinoid in children” and “Cushing’s Syndrome in children”. Children with bronchial carcinoid tumours causing EAS were identified. Case variables such as age, sex, type of carcinoid, investigations, surgery, recurrences and outcome were reviewed. Fourteen cases of paediatric bronchial carcinoid producing ACTH were found with a mean age of 15.8 years and female preponderance. Most of the patients had a right lung lesion and histological appearance was typical of carcinoid tumour. Bronchial carcinoid is extremely rare in children and only 4% are associated with CS. The postoperative treatment of CS is challenging with a high prevalence of hypertension, increased body mass index and visceral fat mass, impaired cognitive function and decreased quality of life. A careful follow up is indispensable for monitoring recurrence of carcinoid and complete remission of CS. Paediatric Cushing’s syndrome (CS), is a condition which occurs due to excessive amount of glucocorticoids in body, either produced endogenously or administered exogenously. The most common cause for the condition is iatrogenic, like in adults due to excessive administration of glucocorticoids. The endogenous paediatric CS is a rare condition, which is broadly classified into adrenocorticotropic hormone (ACTH) dependent and ACTH independent CS. When the excessive ACTH is secreted by pituitary adenoma, it is called as CS and if the source of ACTH production is outside pituitary, it is called as, Ectopic ACTH syndrome (EAS). Athough rare, the bronchial carcinoids are the most common causes for EAS in children. The overall incidence for bronchial carcinoids is 3-5 tumors per million people per year and 4% of pulmonary carcinoids are associated with CS. The median age of presentation is 9.5 years, with a female predominance. We describe a case of ectopic ACTH secreting bronchial carcinoid presented to us with symptoms and signs of CS and review the present literature for paediatric cases of EAS due to bronchial carcinoid.Literature review was performed from the year 2019 back to the oldest available report in English, to analyse all cases of bronchial carcinoid tumours causing EAS in children. The online databases searched were PubMed/MEDLINE, Google Scholar and Google using the following keywords: “EAS in children”; “Bronchial carcinoid in children”; and “Cushing’s Syndrome  in children”. All articles that described paediatric patients with bronchial carcinoid tumours causing EAS were identified. Case variables such as age, sex, type of carcinoid, diagnosis, surgery and recurrences were reviewed. We also describe a teenage girl with an ectopic ACTH-secreting bronchial carcinoid tumour who presented with symptoms and signs of CS.Fourteen paediatric and adolescent patients with bronchial carcinoid tumours causing EAS were identified from nine case series and reports ,6,7,8,9 In a major series of ninety patients with EAS reported by Ilias et al , 35 patiA 12-year old girl presented with complaints of excessive weight gain, dry skin and weakness of limbs. There was no history of steroid intake or previous illness. On examination, she showed typical Cushing’s habitus, including “moon face”, abdominal striae, growth retardation, muscle weakness, dry and thick skin and excessive hair growth all over her body .2 (height 134.5 cm and weight of 41 kg) with BMI standard deviation score (SDS) of 1.22. Her SDS for height for age and weight for age were -2.2, and -0.10 respectively. On evaluation, her midnight and evening serum cortisols concentrations were high (She was hypertensive (130/90 mmHg) with a body mass index (BMI) of 22.7 kg/cmere high . A low dere high . To idenere high . The abdAfter management of hypokalemia and hypertension, she underwent right upper lobectomy as the location of tumour did not allow segmentectomy . The hisThe patient had vomiting in the immediate postoperative period for which hydrocortisone was started and tapered over a period of one week. There was persistent hypertension postoperatively for which calcium channel blocker and beta-blocker was continued. The patient became eucortisolemic three days after surgery with a cortisol concentration of 7.68 µg/dL . Over siEndogenous CS is a rare disorder in children and adolescents due to increased glucocorticoids, which in early childhood is more common in males but with a female preponderance in older children ,12. The In ACTH-dependent causes of CS, when the ACTH is produced by a pituitary adenoma, it is known as Cushing’s disease (CD).  CDis the most common cause of CS in children older than six years of age and is responsible in 75-90% of paediatric CS ,14. AdreCS patients can present with various signs and symptoms which differ depending on patients age and causes of CS . Growth The differentiation between ACTH dependent and independent causes of CS is made by measuring 8 am plasma ACTH concentrations. A value of ACTH >29 pg/mL has a sensitivity of 70% to diagnose an ACTH-dependent cause of CS . To idenIf ACTH-independent CS is diagnosed, adrenal CT or magnetic resonance imaging (MRI) is required to differentiate between adrenocortical tumour and primary nodular hyperplasia. When an ectopic ACTH secreting lesion is suspected, CT of the neck, thorax, abdomen and pelvis should be performed to localise the lesion. Octreotide scan, positron emission tomography (PET), DOTATE scan  and octreotide PET scan can also help in identification of lesion ,18. In oEAS is very rare in children in comparison to adults and is more common in female children from 10 year of age ,13. The Although bronchial carcinoid tumours are the most common intrabronchial primary tumour in children ,26 only Contrast-enhanced CT of the chest, with 5 mm thick sections or MRI of neck, chest and abdomen is considered first line for diagnosing ectopic ACTH secreting lesions ,27,30. ITravis et al ,33 reporThe treatment of choice for a bronchial carcinoid tumour is complete surgical resection with removal of involved lymph nodes ,27. LympA typical carcinoid tumour has a good 5-year survival rate of 88-92% and that of atypical carcinoid ranges from 60-75% ,30,35. TAlthough the surgical removal of the source of the hypercortisolaemia is the treatment of choice, medical agents such as antihypertensives and inhibitors of steroidogenesis, such as metyrapone and ketoconazole, can be used in the preoperative period to reduce the surgical risk, or when surgery is contraindicated and in postoperative period when the patient is not cured by surgical resection . The resThere was requirement for postoperative hydrocortisone in our patient, as she developed postoperative vomiting, headache and weakness, which was tapered and discontinued over a period of one month. This is similar to other reports ,38 whereThe postoperative treatment of CS is challenging with a high prevalence of hypertension, increased BMI and visceral fat mass, impaired cognitive functions and decreased quality of life ,39,40,41The complete remission of CS is a rare phenomenon, which was achieved successfully in our patient by multidisciplinary approach and she has recovered completely from hypertension and Cushing’s habitus. The timely diagnosis of cause of hypercortisolism and its appropriate management is the cornerstone of successful management.Paediatric pulmonary carcinoid tumours causing EAS and leading to CS is a very rare entity and the algorithm of investigations should be followed to reach to diagnosis. BIPSS is the investigation of choice to differentiate EAS CS from CS. CT of neck and chest will help to locate the site of EAS tumours. The treatment of choice is surgical resection of tumor and involved lymph nodes with the intention of achieving negative margins and to preserve as much lung parenchyma as possible The complete remission is possible in children with EAS but bronchial carcinoid tumours causing EAS  are aggressive in nature making good follow up mandatory in these cases to monitor for recurrence.


In this report, we publish virtual radiation-induced liver damage images obtained during surgery, along with the coherent pathology, in order to confirm the false-positive result through an optimally decisive radiological examination.Neoadjuvant chemoradiotherapy is currently the gold standard treatment for esophageal cancer prior to surgery. This radiation therapy will sometimes lead to liver damage parallel to esophageal lesions, which mimics liver metastasis visualized by We report a case of a Asian male patient with distal esophageal cancer who had undergone neoadjuvant chemoradiotherapy (5000 cGy). Subsequently, a new lesion was discovered during a positron emission tomography with computed tomography scan 6 weeks later, near the left caudate lobe of the liver during tumor restaging. To exclude the possibility of liver metastasis, serial imaging was conducted, which included liver sonography, computed tomography, and magnetic resonance imaging for a more intimate probe. The patient’s condition was verified as being liver inflammation change, as seen by the liver magnetic resonance imaging presentation. Thoracoscopic esophagectomy was performed with cervical esophagogastrostomy via the retrosternal route, along with a feeding jejunostomy. The procedure was performed smoothly, with an intraoperative liver biopsy also being conducted 2 weeks later, after positron emission tomography with computed tomography restaging. The pathology report revealed esophageal cancer in the form of poorly differentiated squamous cell carcinoma, pT3N1M0. The liver biopsy revealed obvious inflammation change after radiation therapy, which elucidated sinusoidal congestion with the attenuated hepatic cords and filled with erythrocytes. There was no evidence of liver metastasis. The patient recovered uneventfully and was discharged with his oral intake performing smoothly, and a stable condition was observed during 12 months of outpatient department follow-up.18F-fluorodeoxyglucose avidity are commonly seen in the caudate and left hepatic lobes of the liver during neoadjuvant chemoradiation for distal esophageal cancer, and these findings generally reflect radiation-induced liver disease rather than metastatic disease. Awareness of the pitfalls of a high 18F-fluorodeoxyglucose uptake in radiation-induced liver injury is crucial in order to avoid misinterpretation and overstaging. Except for the location of 18F-fluorodeoxyglucose uptake, the shape of the lesion, and an maximum standardized uptake value (> 10/h), a convincing liver magnetic resonance imaging scan or even a liver biopsy can provide accurate information for distinguishing radiotherapy-induced liver injury from liver metastasis.New foci of increased  It is most prevalent in countries in eastern and southern Africa and eastern Asia. Three-fourths of affected patients are male. Patients diagnosed with esophageal cancer have a very poor survival rate . There i disease . Approxi disease , 6.Use of PET-CT for restaging may encounter a dilemma in distinguishing radiation-induced hepatitis from the tumor with liver metastasis, which in turn may accentuate the false-positive rate of PET-CT with overstaging , 8. Acco18F-FDG revealed a distinct FDG uptake in the lower esophagus , carcinoembryonic antigen (3.27 ng/ml), and squamous cell carcinoma–related antigen (0.3 ng/ml), disclosed nothing remarkable. A further imaging survey was performed to clarify the new lesion. Liver sonography (Fig.  ng/ml, cThe hepatic parenchyma is radiosensitive and has traditionally limited the use of RT in treating liver tumors or other perihepatic tumors located in the upper abdomen . PreoperWhen a patient displays FDG activity in the left or caudate liver lobes after CRT, a more detailed investigation should be performed in order to confirm or exclude distant metastases . Our patReed and Cox were the first to describe the pathophysiology of RILD and suggested that retrograde congestion was the main culprit . AlthougThere are two types of RILD: classic RILD and nonclassic RILD . Patientet al. described a 61-year-old man with esophageal cancer who experienced a new increase in FDG uptake over the left lobe of the liver after undergoing 50.4-Gy RT, with the patient’s CT-guided liver biopsy revealing no liver metastasis [et al. involving 205 patients who were undergoing neoadjuvant chemoradiation therapy, 6 of the patients showed an increased FDG uptake in the caudate or left liver lobe as seen on a PET-CT scan. None of the patients had any detected liver metastasis, as proved by biopsy, additional images, or continuous follow-up [A similar report by DeLappe tastasis . In Oregtastasis . Additioollow-up .Characterizing RILD through noninvasive imaging has been challenging, and the techniques are still evolving . CT findNew foci from increased FDG avidity are commonly seen in the caudate and left hepatic lobes of the liver during neoadjuvant chemoradiation of distal esophageal cancer, and these findings can be RILD rather than metastatic disease . Awarene


Plantar fibromas are benign masses of fibrous tissue that develop in the arch of the foot arising from the plantar fascia. Symptomatology varies and is often related to weight bearing anatomic correlations or impingement of neurological or musculoskeletal structures. Several treatment options are available and include palliative measures, non-operative interventions and surgery, all with varying degrees of success and complication risk. The aim of this case study series was to assess surgical wound healing retrospectively in three patients who underwent wide en bloc plantar fibroma excision surgery for symptomatic lesions. Their incision was managed with a disposable closed-incision negative pressure therapy device  in lieu of surgical drains. All three patients demonstrated favorable outcomes without complications. Epidemiology and pathophysiologyPlantar fibromatosis (PF) is a rare disease characterized by nodules in the plantar fascia caused by disordered hyperproliferation of the fibrous tissue. It was first recorded by George Ledderhose in 1897 and is also referred to as Ledderhose disease [The National Institutes of Health classify PF as a “rare disease that affects fewer than 200,000 individuals in the United States” . PF is aPF is most often benign, but may cause pain and difficulty with ambulation and weight bearing as well as pain due to impingement of neurological or musculoskeletal structures as a result of the growing nodules . The nodTreatment optionsSymptom management is often the treatment of choice for plantar fibromas due to the characteristically benign nature. Some of these treatments include custom or over-the-counter orthotics to help with weight bearing, steroid injections, verapamil, radiation, extracorporeal shock wave therapy, tamoxifen hormonal therapy, and collagenase, all with varying degrees of success and scientific data to back up the effectiveness ,7.If symptom management does not alleviate the pain, or if the nodules continue to grow in size, surgical excision is the next option. There is a high rate of re-occurrence when only removing the fibroma itself, and for this reason excision of the entire plantar fascia is usually preferred ,8. SurgiAs with any surgical treatment, careful post-operative incision management is critical in preventing said complications at the incision site. There has been much research into the most beneficial post-operative wound management, particularly the most effective way to remove fluids such as blood and lymph from the area and keep the incision site clean. When fluids accumulate in the wound area, it can put pressure on the surrounding organs, nerves and vasculature, thus leading to pain and potential impairment of wound healing .Surgical drains are used in many post-operative patients to remove excess fluids from wound sites through the process of the active suction of a drain placed during the procedure . AnotherOne area of particular interest is that of a closed-incision negative pressure therapy (ciNPT) device such as Prevena™ by 3M + KCI . This device acts on the same principles as NPWT, but rather on a closed incision with a constant -125 mm Hg pressure applied over the site continuously . This isThere is a vast array of available information on this therapy for surgeries performed throughout the body. However, the foot is one that is lacking representation in the literature, particularly the plantar surface, which poses unique surgical healing challenges. There are currently no universal treatment guidelines for the use of ciNPT devices such as Prevena™ in plantar fibroma excision surgery. The aim of this retrospective case series was to demonstrate and further define healing outcomes utilizing this specific ciNPWT device for this unique surgical problem.Case 1A 56-year-old female presented for the evaluation of gradual onset bilateral soft tissue masses involving the plantar surface of both feet, with the left foot being significantly more symptomatic. Her past medical history included hypertension and high cholesterol. Social history included gainful employment in a moderately labor-intensive type job and several-year history of smoking. Her physical exam was essentially normal with the exception of somewhat firm, slightly mobile nodular masses involving both plantar foot surfaces in the region of the plantar medical arch Figure . Tendern Case 2Nearly a decade ago, a 58-year-old male presented for the evaluation of a painful soft tissue mass involving the left plantar foot. After conservative means were exhausted, he opted for surgery and elected to have a wide en bloc excisional removal of the mass. Pathology was consistent with PF. His post-operative period was uneventful and he remained asymptomatic for several years until November 2019. He presented again at this time for the evaluation of a gradually enlarging, symptomatic soft tissue mass in the same area as the original mass Figure . Upon ex Case 3A 62-year-old female presented for the evaluation of a symptomatic soft tissue mass involving the right plantar medial arch. Her symptomatology was relatively insidious by history and what prompted her visit was gradual intolerance of a certain shoe gear. She reported the mass was present for over a year but symptomology escalated about four months prior to initial evaluation. Her past medical history included hypertension, thyroid disease, Factor V Leiden pathology with a history of deep vein thrombosis, degenerative joint disease, and morbid obesity. Social history was unremarkable. Her physical exam was largely unremarkable except for significant pes planovalgus changes in both feet and a painful mass involving the right foot. Specific examination of the soft tissue mass revealed a mildly firm, slightly mobile, tender soft tissue mass in the medial plantar arch. Plain films demonstrated no acute process. Both non-operative and operative treatment options were offered and the patient chose the latter, electing for wide en bloc excision instead of complete fasciectomy. Prior to surgery, an MRI was ordered that demonstrated changes consistent with a solitary plantar fibroma lesion Figures , 11. Her Although the National Institutes of Health classify PF as a “rare” condition, this condition is certainly encountered in private practice . DevelopSeveral treatment options are available for PF. These include palliative measures, non-operative interventions, and surgery, all with varying degrees of success and complication risk. We presented three cases of surgical wide en bloc resection of PF lesions in which a battery-powered ciNPT device (Prevena™) was used successfully in lieu of surgical drains. All three patients demonstrated favorable outcomes without significant complications. While additional studies are necessary, we believe this plantar fibroma surgical case series demonstrated that the use of a battery-powered ciNPT device (Prevena™) was beneficial in reducing wound-healing complications such as swelling, fluid collections beneath the surgical site, and surgical site infection.


A thyroglossal duct cyst is a lesion that occurs as a result from failure of the thyroglossal duct to obliterate during fetal development. Malignant progression is a rare event that might occur in less than 1% of all cases. Because of its rarity, there are conflicting opinions regarding the management of the case. In the present study, a 46-year-old male presented with a painless neck mass that had increased in size over the last 6 months. There was no difficulty in swallowing and breathing, change in voice, significant weight loss, or any signs of hyperthyroidism. Laboratory workup showed that results were within normal limits. Thyroid gland ultrasonography and cervical contrast CT scan revealed a complex cystic mass that pointed towards a thyroglossal duct cyst. We performed Sistrunk procedure. Postoperative pathology examination revealed microscopic appearance of the thyroglossal duct cyst with a classic follicular variant of papillary thyroid carcinoma. Our latest follow-up showed no signs of tumor recurrence or any complications following surgery on locoregional status. As a fine needle aspiration biopsy cannot ensure a precise result in all of cases, it is essential to perform a solid physical examination and thorough supporting examination in deciding the precise management for the patient. A thyroglossal duct cyst (TGDC) is the most common form of congenital anomaly in thyroid development . ApproxiSistrunk procedure is a common option chosen for the surgery of a thyroglossal duct cyst, especially for those who are categorized into low risk patients, which consists of excision of the thyroglossal duct cyst, the middle part of hyoid bone, and the surrounding tissue around the thyroglossal tract . HoweverIn this report, we present a rare case of papillary carcinoma arising in the thyroglossal duct cyst along with a review of the literature focusing on the management of malignancy in the thyroglossal duct cyst.A 46-year-old male came to our surgical oncology clinic presenting with a chief complaint of a lump in the anterior compartment of the neck, located in the front and slightly to the right, which the patient had noticed since a year ago and has been increasing in size in the last 6 months. The patient denied any complaints of difficulty in swallowing, difficulty in breathing, change in voice, significant weight loss, or any signs of hyperthyroidism. The patient reported to have a history of dyslipidemia, and during inpatient care, we discovered that the patient had hypertension. The patient also reported to have undergone sinus surgery twice in the last 20 years. There was no significant family history.struma nodosa nontoxic).Physical examination on the patient showed a neck mass in the front area, in the midline slightly located to the right, mobile, with soft surface, painless, solid, with a well-defined border, and sized approximately 5 × 5 × 4 cm. During palpation, no lymph node enlargement was noted. Based on the findings above, the patient was given a working diagnosis of suspected benign right nontoxic goiter , followed by mixed papillary-follicular type (7%), squamous cell type (5%), and follicular type (1.7%), and also Hurthle cell and anaplastic type (0.9%) which has a worse prognosis , 22. In Management for malignancy of the thyroglossal duct cyst is still widely debated, mainly when the thyroid gland remains in normal condition. Some authors support the theory that thyroglossal duct cyst malignancy originated from the ectopic thyroid tissue that is located inside the cyst, while some others think that the malignancy occurs from metastasis of the thyroid gland . The samDue to rarity of malignancy in the thyroglossal duct cyst, currently, there is no single universal guideline for the management of the case. Patients are classified into low risk and high risk according to the revised 2009 American Thyroid Association (ATA) guideline regarding differentiated thyroid cancer and National Comprehensive Cancer Network risk stratification system with proposed modifications adjusted to fit for malignancy in the thyroglossal duct cyst. Patients who are grouped into the low risk category are (1) patients aged between 15 and 45 years old, without prior radiation history; (2) tumor size less than 4 cm; and (3) no distant metastases or lymph node involvement. The majority of the patients fall into this category, and for those who present with no involvement of the thyroid gland or suspicious findings, Sistrunk procedure is considered adequate –13, 23. There are four approaches regarding surgical management for thyroglossal duct cyst malignancy, which are (1) Sistrunk procedure alone , (2) SisMalignancy in a thyroglossal duct cyst is a rare event. Physical and supporting examinations are both crucial in deciding how the surgical procedure must be carried out. In our case, we would continue to observe the locoregional status by both physical and supporting examinations.


Tumor- or treatment- induced thrombocytopenia in solid cancer patients is common. In the postoperative setting, diagnosis of thrombocytopenia become more complex as infection, sepsis, drugs and transfusion come also into the equation.Herein, the case an otherwise-healthy 71-year-old male patient with a sizable recurrent malignant retroperitoneal tumor under pazopanib admitted with colon perforation and submitted to emergency left colectomy with end transverse colostomy is presented. Immediate postoperative period characterized by massive primary tumor growth and isolated acute severe thrombocytopenia. The patient treated with combined prednisone, IVIg and platelets transfusion along with medication discontinuation with no response.Sepsis-, drug- and heparin-induced thrombocytopenia, disseminated intravascular coagulopathy and secondary  immune thrombocytopenia (ITP) were included in the differential diagnosis. Based on exclusion, secondary drug- or tumor-induced ITP was the most prominent diagnosis. Concomitant presentation of thrombocytopenia along with massive primary tumor growth made Kasabach-Merritt syndrome also a probable diagnosis. However, neither secondary ITP nor Kasabach-Merritt syndrome has previously been associated with a retroperitoneal tumor in the literature.Although management of thrombocytopenia depends on etiology, in our patient’s case the diagnosis of secondary ITP and directed management did not result in a successful outcome. Tumor-iHerein, the case an otherwise-healthy 71-year-old male patient with a sizable recurrent malignant retroperitoneal tumor under antiangiogenic treatment admitted with colon perforation and submitted to emergency surgery is presented. The patient developed isolated acute severe thrombocytopenia in the immediate postoperative period; the most prominent diagnoses were: (a) sepsis- or drug- induced thrombocytopenia causing decreased bone marrow platelet production; and (b) secondary immune thrombocytopenia (ITP) , heparin-induced thrombocytopenia (HIT) and disseminated intravascular coagulopathy (DIC) causing increased platelet destruction . The pre2An otherwise-healthy 71-year-old male patient with a known sizable recurrent (the patient submitted elsewhere to a R2 resection to months prior) left retroperitoneal malignant fibrous histiocytoma under pazopanib (PO 800 mg daily) with infiltration of the left ureter under double J stent placed 3 months prior and the descending colon causing incomplete large bowel obstruction, admitted to the emergency department with symptoms and signs of peritonitis. Abdominal CT revealed the presence of: (a) a solid left retroperitoneal mass (approximate size16*10*12 cm) ; (b) infiltration of the left ureter with the presence of a double J stent; and (c) infiltration and perforation of the descending colon along with a large quantity of free intraperitoneal air and paracolic fluid . Emergen9/L) accompanied with hematuria occured. WBC count was normal, Hb count was 10.1 g/dL and regarding coagulation tests PT, aPTT, INR were normal, fibrinogen and D-dimmer was 198 mg/dL and 4.25 μg/mL respectively. Peripheral blood smear showed no red blood cells and leukocytes morphological abnormalities. The patient was afebrile; blood and urine cultures were negative. Chest and abdominal CT revealed  mil3The present report describes a patient with a sizable recurrent malignant retroperitoneal tumor under antiangiogenic treatment admitted with colon perforation and submitted to emergency left colectomy with end transverse colostomy. In the immediate postoperative period, massive primary tumor growth and isolated acute severe thrombocytopenia observed. In this complex case, there were certain questions that needed to be clarified in the decision making process.3.1Spontaneous bowel perforation is a potential complication in patients receiving antiangiogenic treatment. Qi WX et al. in a meta-analysis of 20 clinical trials including 5352 solid tumors patients receiving VEGFR inhibitors showed that the incidence of GI perforation was 1.3 % with a mortality of 28.6 %. Among cancer types, the highest incidence of bowel perforation was found in colorectal and ovarian cancer . [Our patient had a known recurrent left retroperitoneal malignant fibrous histiocytoma firstly operated in 2017. Two months prior presentation, the patient submitted elsewhere to a second exploratory laparotomy. At that time preoperative CT and colonoscopy staging revealed the presence of descending colon infiltration with associated incomplete obstruction. The tumor considered unresectable; however no palliative loop transverse colostomy performed. Although the patient had risk factors for perforation such as intact primary tumor, bowel infiltration and obstruction, postoperative palliative targeted therapy with pazopanib initiated due to the limited therapeutic options. Conclusively, no adding a colostomy during the second operation, colon infiltration and obstruction in combination with VEGFR inhibitor treatment all contributed to colon perforation.3.2Even a minor surgical trauma can influence pathophysiological processes that might promote postoperative metastatic spread and tumor recurrence. These pathophysiological processes encompass: (a) local effects including tumor seeding and wound healing response that can promote tumor cell migration, proliferation, differentiation, extracellular matrix remodeling, angiogenesis and extravasation; (b) local and systemic immunosuppression which impairs antitumor immunity and contributes to tumor cell survival; (c) cancer cell release into circulation and tumor cell dissemination by surgical manipulation of the tumor .The effects of antiangiogenic treatment on tumor growth are well documented. However less is known about the effects of antiangiogenic treatment discontinuation on tumor re-growth. Iacovelli et al. in their retrospective study of 63 metastatic renal cell carcinoma who discontinued antiangiogenic treatment showed that tumor re-growth was related to the reason of discontinuation; re-growth was higher in patients who discontinued treatment because of disease progression or toxicity and lower in patients who discontinued treatment because of a sustained response; interestingly this study showed that the higher the growth rate, the shorter the survival . In our 3.3In our patient’s case, the most prominent diagnoses of thrombocytopenia were sepsis- and drug-induced thrombocytopenia, HIT, DIC and secondary  ITP. Drug- and sepsis-induced thrombocytopenia was excluded as: (a) no sepsis criteria were present; (b) blood and urine cultures were negative; (c) chest and abdominal CT showed no imaging signs of pulmonary infection, superficial and deep surgical site infection; and (d) bone marrow biopsy revealed increased number and size of megakaryocytes . HIT wasIn our patient’s case, the massive primary tumor growth, as a result of major surgical trauma and antiangiogenic treatment discontinuation, and the development of thrombocytopenia can be associated with Kasabach-Merritt syndrome. The diagnosis of Kasabach-Merritt syndrome can be supported by the presence of: (a) the aggressive, rapidly enlarging and probably highly vascularized retroperitoneal tumor; and (b) thrombocytopenia and mild coagulopathy including mild decrease in fibrinogen and increase in D-dimmer . We beli4Thrombocytopenia in cancer patients is correlated with poor prognosis. In our patient’s case, secondary drug- or tumor-induced ITP was the most probable diagnosis. The concomitant presentation of thrombocytopenia along with massive primary tumor growth made Kasabach-Merritt syndrome also a probable diagnosis. However, neither secondary ITP nor Kasabach-Merritt syndrome has previously been associated with a retroperitoneal tumor. Although management of thrombocytopenia depends on etiology, in our patient’s case the diagnosis of secondary ITP and directed management did not result in a successful outcome.None.Ethical approval has been exempted by our institution.“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”.Boulas K was responsible for the study concept and design. Boulas K, Paraskeva A and Triantafyllidis A equally contributed in writing the paper. Hatzigeorgiadis A had the final approval of the paper.No unique identifying number requested for this case report.Hatzigeorgiadis A.Not commissioned, externally peer-reviewedNone.