We should keep in mind slowly growing malignancies when the lesion is located close to the synovial regions of the extremities. The diagnosis of certainty of myxofibrosarcoma is histological and is based on the demonstration of the myxoid matrix, fibroblastic cells with a curvilinear arrangement of the vessels. We should keep in mind slowly growing malignancies when the lesion is located close to the synovial regions of the extremities. The diagnosis of certainty of myxofibrosarcoma is histological and is based on the demonstration of the myxoid matrix, fibroblastic cells with a curvilinear arrangement of the vessels. The diagnosis of certainty is histological. We report the case of myxofibrosarcoma of the leg occurring in a 68‐year‐old patient.Sarcomas represent 0.5%‐1% of malignant tumors in adults.We report the case of myxofibrosarcoma of the leg occurring in a 68‐year‐old patient.2A 68‐year‐old male, without any particular history, consulted for a swelling of the right leg. There was no history of trauma. He did not present a fever nor a deterioration of the general state. Physical examination revealed a an erythemato‐papular infiltrated lesion on the anterior side of the lower leg and a second hyperpigmented lesion on the anterior‐inner side of the leg Figures  and 2. TThe biological examinations  were normal.The X‐ray of the leg showed an osteolytic image by near to the skin lesion with respect to the cortical. MRI showed a fibrous cutaneous lesion of the anterior surface of the limb lower right leg with trans‐aponeurotic expansion and contiguity corticoperiosteal extension to anterolateral tibia. A second lesion was noted in its intramuscular extension of the fibulars coming into contact over about 180 degrees of the medial circumference of the tibial artery Figure .Biopsies of the lesion with surgical removal of the tumor were performed. Histological examination of the piece confirmed the diagnosis of a myxofibrosarcoma whose high grade was justified by hypercellularity, high mitotic activity, pleomorphism, and intralesional necrosis Figures  and 5. TImmunohistochemical study was negative. The patient underwent resection of the tumor. After follow‐up of 6 months, he died probably of pulmonary embolism.3Myxofibrosarcoma is one of the most common sarcomas in adults. The term myxofibrosarcoma is currently preferred to the former name of malignant myxoid fibrous histiocytoma. The mean age of onset is 65 years (40‐80 years),The diagnosis of this condition is based on the characteristics of the myxoid zones. The proportion of myxoid areas required to diagnose myxofibrosarcoma remains controversial.Some authors require that 50% of tumor volume is myxoid area. For other authors, 10% of myxoid areas are sufficient for diagnosis.The differential diagnosis for this lesion is broad. It includes most of the benign and malignant myxoid lesions and can range from an infectious inflammatory process to malignant myxofibrosarcoma.Fibromyxosarcoma, whose name has evolved over time, is also called “myxoid variant of malignant fibrous histiocytoma.” These nominations constitute a histological description or terminology. This thus makes it possible to underline the differential diagnoses, which are the other sarcomas of the soft tissues. With the introduction of more stringent morphologic and immunohistochemical criteria in 2002 and reaffirmed in 2013, the World Health Organization renamed the myxoid variant of malignant fibrous histiocytoma with a predominant myxoid component (>50%) myxofibrosarcoma.Roland et al reported in a study of 3574 patients the distribution of the different histotypes of soft tissue sarcoma. These different histotypes are the differential diagnoses of fibromyxosarcoma .MRI may be contributory to the diagnosis by showing a tumor with T1‐weighted intermediate signal, heterogeneously enhanced and signal heterogeneity in T2.High‐grade myxoid lesions may appear cystic, with one component nodular non‐cystic revealed after injection of gadolinium.On x‐ray calcification and osteolysis are visualized in 5%‐20% of case. Local recurrence is observed in 60% of cases, when metastases are observed in 20% in cases in pleomorphic tumors.The treatment is often radical and relies on radical surgical excision, and a complement of neo‐adjuvant chemo‐radiotherapy can be proposed in case of high‐grade tumor.4High‐grade myxofibrosarcomas are poor prognosis. Imaging has a crucial role in diagnosis. Diagnostic confirmation by prior biopsy allows to program a tumor resection in en‐bloc. Management should be multidisciplinary, and sometimes, neo‐adjuvant chemotherapy and radiation therapy are required for locally advanced tumors.None declared.IR and FD: wrote the manuscript with support of IA. MS, HZ, ZA, BBD, and FB: approved the final version of the manuscript. FK and ACD: analyzed pathology images.Not applicable.


Rhabdomyosarcoma (RMS) is one of the most common soft tissue sarcomas of adolescents and young adults. Histologically, rhabdomyosarcoma is classified into embryonal, alveolar, pleomorphic, and spindle cell/sclerosing rhabdomyosarcomas with further subcategorization. More than 50% of embryonal rhabdomyosarcoma occur within head and neck. The retroperitoneum and pelvis are less common sites of involvement. Embryonal rhabdomyosarcomas affect mainly, but not exclusively, children between birth and 15 years of age. Alveolar rhabdomyosarcoma tends to affect older patients. The usual metastatic sites include lung, lymph nodes, and bone marrow. We are presenting a case of a 25-year-old male patient with symptoms of breathlessness, easy fatigability, and weight loss. On chest imaging, there were multiple lung nodules. A primary diagnosis of undifferentiated malignant neoplasm was made on lung biopsy. On immunohistochemistry, the malignant cells were positive for myogenin, myoblast determination protein 1 (MyoD1), and desmin. They were negative for neuroendocrine, germ cell, epithelial, melanocytic, and lymphoid markers. Further workup showed an abdominopelvic retroperitoneal mass on abdominal computed tomography (CT) scan. The biopsy on the retroperitoneal mass showed similar morphology and immunohistochemical profile. Unfortunately, the patient's condition deteriorated rapidly in the following weeks, and he passed away. Rhabdomyosarcoma (RMS) is one of the most common soft tissue sarcomas of adolescents and young adults. It accounts for an estimated 4.5% of all childhood cancers, with an incidence of six cases per one million annually . HistoloA 25-year-old male patient presented to the chest clinic with easy fatigability and breathlessness for more than a month. He had a history of weight loss. The chest x-ray revealed right-sided pleural effusion Figure . On chesA primary diagnosis of undifferentiated malignant neoplasm was made with a wide differential diagnosis. We considered neuroblastoma, lymphoma, and germ cell tumor. Immunohistochemistry with neuron-specific enolase, chromogranin, synaptophysin, Sal-like protein 4 (SALL4), and CD45 was done to rule out these diagnoses. Despite the unusual age bracket, the morphology was strongly suggestive of embryonal rhabdomyosarcoma, therefore myoregulatory proteins (myogenin and MyoD1) and desmin were added to the immunopanel. Cytokeratin and S100 were added to rule out the less likely differentials of carcinoma and malignant melanoma.On immunohistochemistry, the tumor was negative for neuroendocrine, germ cell, epithelial, melanocytic, and lymphoid markers Figure . Both myOn follow-up, the patient's condition deteriorated rapidly within weeks following the diagnosis, and he passed away.Rhabdomyosarcoma is a high-grade malignant neoplasm, with a morphologic appearance mimicking that of developing skeletal muscle. It accounts for 4.5% of all childhood cancers. The annual incidence is around six cases per one million per year ,2. HistoMore than 50% of embryonal rhabdomyosarcomas occur within head and neck region . RetropeMorphologically, embryonal rhabdomyosarcomas are composed of primitive mesenchymal cells that show variable degrees of skeletal muscle differentiation. They are moderately cellular, but in the typical pattern they often contain both hypo- and hypercellular areas with a loose, myxoid stroma sheets of small, stellate, spindled, or round cells with scant or deeply eosinophilic cytoplasm and eccentric, small oval nuclei with a light chromatin pattern and inconspicuous nucleoli. Feature of rhabdomyoblastic differentiation  can be seen . On hemaSince our case was a metastatic lesion in the lung, we would not rely solely on morphology as it can be deceptive in metastatic disease. In cases of less differentiated tumors, it has been seen that the best method to detect rhabdomyoblastic differentiation of the sarcoma is the demonstration of expression of MyoD1 protein and myogenin. Dias et al. demonstrated that positive nuclear staining in both markers is an important diagnostic criterion for rhabdomyosarcoma. It is considered the gold standard in differential diagnosis of this tumor from other neoplasms. Alveolar rhabdomyosarcomas shows three times more myogenin expression than embryonal rhabdomyosarcomas. According to their data, staining for myogenin is a simple, rapid, and accurate tool for differentiating between embryonal and alveolar rhabdomyosarcomas . SimilarThe patient was referred to the oncology department. An abdominal CT showed a retroperitoneal abdominopelvic mass. According to the literature, the most common retroperitoneal sarcoma is dedifferentiated liposarcoma followed by leiomyosarcoma . Rhabdomyosarcoma is far less common in retroperitoneum ,17. On HUnfortunately, the patient's condition deteriorated rapidly after the diagnosis, and he passed away two months after his presentation to the outpatient department.Embryonal rhabdomyosarcoma is considered to be more common in ages from birth to 15 years. The most common site for this malignancy is head and neck; retroperitoneum and abdomen are less common sites. Our case is an example of a retroperitoneal embryonal rhabdomysarcoma in a 25-year-old patient. The primary presentation in this case was with respiratory symptoms due to lung metastasis.


Angiosarcoma is a high-grade vascular tumor arising from endothelial cells of blood vessels. It represents less than 1% of the mesenchymal tumors. Uterine angiosarcoma is an extremely rare tumor with less than 25 cases reported in the literature. It usually presents in postmenopausal women as uterine mass and rarely can arise in a leiomyoma. It is included in the group of tumors of aggressive behavior and poor prognosis. Herein, we present a case of primary uterine angiosarcoma in a 56-year-old female patient with a history of fibroids presenting with pelvic pain and weight loss. Abdominal CT scan showed a large uterine mass and enlarged pelvic lymph nodes. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed, and on histopathologic examination, it was found to be primary epithelioid angiosarcoma of the uterus. Immunohistochemical stains for CD31, keratin MAK-6, and keratin AE1/AE3 confirmed the diagnosis. In conclusion, uterine angiosarcoma should be suspected in any rapidly growing hemorrhagic uterine mass, and appropriate sampling and immunohistochemical stains should be considered. Angiosarcoma is an aggressive vascular tumor that mainly arises from soft tissue but can affect any part of the body. It usually affects elderly males, and the head and neck are the most common sites of diagnosis . The incAs a term “primary” underlines, the tumor largely develops de novo with no history of radiation therapy and “epithelioid” as those tumors usually stain positive for the epithelial marker and negative for desmin and other mesenchymal markers.The patient was a 56-year-old white Caucasian female with a history of fibroids, atrial fibrillation on Coumadin, and diabetes mellitus. She presented to the hospital with two months of pelvic pain. The pain was constant and radiated into her bilateral lower back. She denied any vaginal bleeding or hematuria during this time. Menopause was at age 51. The patient was diagnosed with fibroids ten years ago and was told a year ago that the largest one was 12 cm and around the same size from her previous pelvic ultrasound, but she did not follow up regularly with the gynecologist. She also lost 42 pounds in the past year as well. No history of previous malignancy or radiotherapy was noted. On admission to the emergency department, her physical examination was unremarkable, other than abdominal tenderness. Her lab tests showed mild hypocalcemia and anemia. CT scan showed a uterine mass measuring approximately 12 × 10 × 10 cm and enlarged pelvic lymph nodes concerning for uterine cancer, and the patient was scheduled for a total abdominal hysterectomy with bilateral salpingo-oophorectomy. During the surgery, a left external pelvic lymph node was submitted for a frozen section and was reported as a malignant spindle cell tumor. The remnant of the frozen section and the tumor were all submitted for permanent sections.The specimen including the uterus, cervix, bilateral fallopian tubes, and ovaries weighed 1462 grams. The uterus measured 13.3 × 12.9 × 10.8 cm. Sectioning revealed a tan-red endometrium measuring 0.1 cm in thickness with two polyps measuring 1.1 and 0.9 cm in greatest dimension. The myometrium showed a protruded tan-brown mass, measuring 10.2 × 9.3 × 5.5 cm, with cystic spaces, extensive necrosis, and hemorrhage, and was seen invading deep into the myometrium. In the myometrium, there were two tan-white well-circumscribed nodules measuring 2.3 and 1.4 cm in greatest dimension. The separation between the mass and the nodules was very sharp, and there was no evidence to suggest that the mass could be arising from these nodules. Bilateral ovaries, fallopian tubes, and the cervix were unremarkable . MicroscAfter the diagnosis of uterine angiosarcoma, the patient received multiple courses of chemotherapy. Two months after the surgery, the patient presented with fatigue and weakness, and her CT scan showed worsening metastatic disease with new pulmonary nodules, enlarging retroperitoneal lymph nodes and fluid in the peritoneal cavity, and the patient died three months after the initial diagnosis.Primary epithelioid angiosarcoma of the uterus is an extremely rare tumor. Hara et al.  reviewedThe clinical presentation is usually uterine bleeding, anemia, and pelvic mass. Radiology is important to identify the uterine mass. However, the distinction between uterine angiosarcoma and other uterine tumor is almost impossible on imaging alone. One case report suggested that the presence of heterogeneity on T2-weighted MRI and areas of high signal intensity or what is called a cauliflower-like appearance may support the diagnosis of angiosarcoma of the uterus . The disThe characteristic histologic features of the tumor include a multilayer-infiltrating tumor with irregular anastomosing vascular channels and occasional tufting and papillary formation. The vascular channels are lined by large pleomorphic cells with abundant eosinophilic cytoplasm, open chromatin, prominent nuclei, and abundant mitoses along with foci of necrosis. Solid areas of pleomorphic epithelial cells or spindle cells can be identified as well . ImmunohThe pathogenesis of uterine angiosarcoma is not very clear. Although majority of the cases of primary uterine angiosarcoma arise de novo, seven cases were found to be arising from leiomyomata , 12. TheSome authors suggested that molecular analysis can be a useful diagnostic tool in challenging cases. Suzuki et al.  identifiThe management usually includes total abdominal hysterectomy with bilateral salpingo-oophorectomy followed by neoadjuvant therapy , 17. TheIn summary, we report a rare case of primary uterine angiosarcoma in a 56-year-old female. Although this tumor is very rare, it should always be considered in any patient with necrotic and hemorrhagic uterine tumor, and careful examination is necessary to identify any sarcomatoid component as these tumors usually have a very aggressive behavior and are associated with poor prognosis.


The sickle cell trait is considered a benign entity that generally does not show clinical manifestations. However, some complications have been described under certain conditions, such as a decrease in oxygen level, dehydration, and strenuous physical efforts. Among them, splenic infarct is a rare complication that presents as left upper abdominal pain in a situation of stress such as high altitude exposure. We present two cases of splenic infarcts in patients with undiagnosed sickle cell trait who showed to our institution with severe abdominal pain after coming from high altitude cities. The sickle cell trait (SCT) is found in individuals with an inherited hemoglobin S (HbS) gene and a normal one hemoglobin gene . The HbSBefore, it was considered as a benign condition with protection to malaria and no painful episodes. However, several complications have been described in the literature as case reports, including venous thromboembolism, renal involvement, and splenic infarcts . There aCase 19/L, and platelets of 453 x 109/L. Trying to find the cause, we ordered protein C, protein S, antithrombin III, factor V Leiden, and D-dimer tests, which came back negative. After that, we conducted hemoglobin electrophoresis, showing hemoglobin A (HbA) of 57.5%, HbS of 39%, hemoglobin A2 (HbA2) of 3.5%, and hemoglobin F (HbF) 1.9%. The patient was diagnosed with SCT, which was treated with hydration and pain management until symptoms resolved.A 25-year-old Hispanic male with no known past medical history presented to the hospital complaining of left upper abdominal quadrant pain. He stated that pain started after he returned from a trip to a location at 16,700 feet of altitude. In the hospital, his vital signs were within normal limits except for tachycardia. On the physical exam, there was splenomegaly with tenderness to palpation. The ultrasound showed heterogeneous images in the spleen compatible with ischemic lesions, which were confirmed later as splenic infarcts with computed tomography (CT) of the abdomen (Figure Case 29/L, and platelets of 157 x 109/L. His total bilirubin was 4.30 mg/dL, with indirect bilirubin of 3.49 mg/dL. Looking for a thrombogenic explanation, we studied protein C, protein S, antithrombin III, factor V Leiden, and D-dimer, but they were negative. Finally, the hemoglobin electrophoresis results showed HbA of 55%, HbS of 40%, HbA2 of 3.2%, and HbF of 1.8%, giving a diagnosis of SCT. During his admission, he was treated with conservative measures, such as symptom control and hydration, until he was discharged home.A 20-year-old Hispanic male with no known past medical history presented to our hospital complaining of left upper abdominal quadrant pain and jaundice. These manifestations presented after he went to a city located at an altitude of 10,341 feet. On the physical exam, the patient showed splenomegaly, which was tender to palpation. In the ultrasound, there were multiple heterogeneous images within the spleen. In the CT angiogram of the abdomen, there was notable splenomegaly and lack of enhancement of the spleen compatible with splenic infarct (Figure We presented two patients without known previous pathology who had sudden abdominal pain after traveling to high altitudes cities. One of the cases also had jaundice. Both of them were diagnosed with splenic infarcts, and further investigations revealed that they were SCT carriers.Splenic infarction is a rare and overlooked cause of abdominal pain . It can SCT is one of the described causes of splenic infarction. In the literature, from 1985 to 2013, only 34 cases of high altitude-related splenic infarcts in the SCT population were reported . These pPathophysiology consists of HbS polymerization secondary to hypoxia, causing red cells to sickle and occlude the tributary vessels of the splenic artery . The splSplenic infarction can lead to complications such as abscesses or pseudo-cyst formation, spleen rupture, and hemorrhage ,18,19. GAlthough splenic infarction associated with SCT is rare, this condition has to be kept in mind in patients who present with sudden abdominal pain after being exposed to high altitude. Once the splenic infarction is diagnosed, hemoglobin electrophoresis should be part of the workup to find the cause of the infarction. Finally, the management in the majority of cases consists of conservative therapy with symptomatic control and hydration.


Pulmonary metastasis of scalp angiosarcoma (SA) is a rare, but life-threatening disease, challenging to diagnose and manage. We report two cases of pneumothorax and hemothorax with pathologically proven metastasis of SA in the parietal pleura, which was not predictable from images and difficult to manage.A 73-year-old man with SA underwent chemoradiotherapy and surgical resection for primary skin lesion, was sent to our department to treat right empyema, which was developed during chest tube drainage for pneumothorax. Computed tomography (CT) showed multiple bullous lesions. We performed repetitive video-assisted thoracoscopic surgery (VATS) for the debridement and hemostasis; however, hemothorax was uncontrollable. The repeated cytology of pleural effusion showed no malignancy. We eventually performed fenestration and metastatic SA was pathologically diagnosed by the biopsy of parietal pleura. The patient developed respiratory failure and uncontrolled anemia, which were fatal.A 71-year-old man with SA previously treated with chemoradiotherapy was referred to our department for left pneumothorax. CT showed multiple bullous lesions at apex without any changes at parietal pleura. VATS was performed and the apex bullous lesion with air leakage was resected. The parietal pleura showed several dark-red spots and the biopsy was undertaken. The pathological diagnosis was a metastasis of SA along with visceral pleura and parietal pleura. The patient then developed right pneumothorax and left hemopneumothorax. Bilateral pleurodesis was ineffective and the patient died due to deteriorating general condition.In patients with a history of SA who develop pneumothorax and hemothorax, metastatic SA to visceral and parietal pleura should be always considered. Surgical biopsy, not cytology, is needed for pathological diagnosis. Lesions in the parietal pleura prior to hemothorax were thoracoscopically observed in one case. Surgeons must recognize that conventional surgical intervention or pleurodesis will have unsatisfactory results. Scalp angiosarcoma (SA) is a rare and aggressive malignancy of the skin, which sometimes metastasizes to the lung and causes pneumothorax. For thoracic surgeons, it is difficult to diagnose and manage this disease due to its scarcity and unusual presentation on imaging. In addition, hemothorax is another manifestation of metastatic SA; however, the intrathoracic appearance of pleural lesions causing hemothorax has not been reported.A 73-year-old man with SA underwent chemoradiotherapy  and surgical resection for primary skin lesion, was sent to our department to treat empyema 11 months after initial diagnosis. Computed tomography (CT) showed multiple bullous lesions , was referred to our department for pneumothorax 10 months after initial diagnosis. He developed left pneumothorax, and air leakage was not controlled despite chest tube drainage. CT before developing pneumothorax showed multiple bullous lesions in the bilateral apex area Fig. a. VATS wSA is a rare malignancy in skin and considered aggressive of all cutaneous angiosarcomas. Predilection for lung metastasis is a feature of this disease, and 90% of all patients were reported to die from pulmonary complications, such as pneumothorax and hemothorax –3. PulmoIn patient A, the development of empyema made it difficult to tell that the parietal pleura had metastatic SA. Apparently, cytology from pleural effusion was not enough for the diagnosis and histological examination of parietal pleura was necessary for diagnosis. Considering the possibility that metastasis in the parietal pleura had already existed in the first surgery, debridement might have caused uncontrolled hemothorax afterward in this patient. Consequently, the suspected uncontrolled infection made it impossible to give him chemotherapy.In patient B, we obtained the pathological diagnosis of metastatic SA from the resected lung and biopsy of the parietal pleura. We recognized an impressive intrathoracic finding of dark-red spots in the parietal pleura which can be the characteristic lesion of the parietal pleura metastasis of SA before developing hemothorax. To our knowledge, this thoracoscopic finding is reported for the first time in the literature. The patient had hemothorax in the left side after surgery, which was not controlled by repeated pleurodesis despite full expansion of the lung. Deterioration of the general condition was very rapid after the recurrence of pneumothorax and; therefore, we missed a chance to treat with chemotherapy.In general, pleurodesis using talc or OK-432 is considered effective in carcinomatous pleurisy when the lung is fully expanded by chest tube drainage ; howeverThis report firstly describes metastatic SA lesions in the parietal pleura before causing hemothorax. In patients with a history of SA who develop pneumothorax and hemothorax, surgical biopsy rather than cytology is essential for diagnosis. Surgeons must recognize that conventional surgical intervention or pleurodesis will have unsatisfactory results.


Solid pseudopapillary neoplasm of the pancreas is one of the rarest forms of pancreatic neoplasm. It was also known as Franz's tumor or Hamoudi tumor until the World Health Organization (WHO) labeled it as a solid pseudopapillary tumor in 1996. It typically affects young non-Caucasian females in their second or third decade of life. Treatment involves complete excision of the tumor which results in a complete cure in most of the cases. Three cases of solid pseudopapillary neoplasm (diagnosis confirmed by cytology) in young females, each presenting with different symptoms were studied. Each of the three cases was found to have the neoplasm at different sites of the pancreas and was subjected to different resection procedures. The cases were followed up for at least a year and evaluated for recurrences/metastases. Solid pseudopapillary neoplasm remains one of the most misdiagnosed tumors. The diagnosis depends on radiology and cytology. With a very high five-year survival rate, surgical resection remains the treatment of choice. The type of surgical procedure depends on the site, size and local invasion of the tumor. Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor accounting for approximately 0.2% to 2.7 % of primary non-endocrine tumors of the pancreas. These tumors have low malignant potential and a strong predilection for young women, with less than 10% of cases reported in men [SPN is an epithelial neoplasm consisting of discohesive polygonal cells that surround delicate blood vessels, which form a solid mass. It also consists of pseudopapillary structures formed by morphologically consistent cells. Areas of hemorrhage and cystic degeneration are also present in these neoplasms. These cystic parts result from the degeneration of pre-existing solid components . AlthougHere we present three cases, which occurred at three different sites of the pancreas and were resected using different surgical methods.Case 1A 20-year-old female presented to the gynecology outpatient clinic with an acute onset lower abdominal pain during her menses along with heavy vaginal bleed. At the time of presentation, she had mild pain which occasionally radiated to the umbilical region. On general examination, the patient had mild pallor. On deep palpation of the abdomen, she had mild tenderness in the hypogastrium.Ultrasonography (USG) of the abdomen and pelvis revealed no significant findings in the reproductive tract. A contrast-enhanced computed tomography (CECT) scan of the abdomen showed a 2 cm X 3 cm sized solid mass in the body and neck of the pancreas Figure . PreoperOn exploratory laparotomy, a 2 cm X 3 cm mass was seen in the body of the pancreas. The mass was seen compressing the splenic vein causing its complete obliteration. Multiple collateral vessels were seen around the tumor as sequelae of splenic vein thrombosis. The portal vein was free from the tumor. A central pancreatectomy  with splenectomy Figure  was perfCase 3A 22-year-old female presented with pain in the epigastric region for one and a half years. The pain was dull aching, and would wax and wane with time. It was unrelated to food intake, and water brash was absent. She also complained of nausea and anorexia over the past two months, and her bowel habit was normal. Swelling could be noted in the epigastrium, measuring 3 cm X 3 cm, smooth, firm in consistency, and tender on palpation.USG of the abdomen revealed an 8 cm X 7 cm hypoechoic mass arising from the pancreas. CECT scan of the abdomen and pelvis showed an 8 cm X 7 cm mass in the head of the pancreas Figure . All othIntraoperatively, an 8 cm X 8cm tumor was noted arising from the head of the pancreas. The mass could not be separated from the lateral wall of the portal vein. Hence, portal vein resection Figure  with endTable More than 90% of SPNs have been reported in women under the age of 35 years, with a female to male ratio of 20:1 and an average age of incidence of 28 years . The mosThere is no specific symptom complex that is related solely to these tumors of the pancreas, and due to their rarity, they often tend to be misdiagnosed . The mosRadiologic imaging and cytology form the basis of the diagnosis of these tumors. In CT scans, these tumors show no enhancement of the cystic portions and slight enhancement of the solid portions in the arterial phase and marked enhancement in the portal venous phase . USG-guiSurgical resection is the treatment of choice for these tumors. Resection is warranted with negative surgical margins. Depending on the location of the neoplasm, the type of pancreatectomy is decided. Pancreatoduodenectomy is performed for neoplasms in the pancreatic head, distal pancreatectomy for those in the pancreatic body/tail, and a central pancreatectomy is performed if the neoplasm is in the proximal body of the pancreas . InvolveThe five-year survival rate in patients undergoing surgical resection approaches 97% -4,11. ThThe SPN of the pancreas is a rare low-grade malignant neoplasm mostly affecting young women. The presenting symptom may be vague, or the patient may even be asymptomatic and thus is often misdiagnosed. Clinical findings along with radiological imaging and cytology form the basis of its diagnosis. Surgical resection of the tumor remains the mainstay of its treatment. Different surgical methods are used to resect these tumors depending on the part of the pancreas involved, the size of the tumor, and the extent of its local invasion.


Pharyngeal liposarcomas are very rare; still more rare are dedifferentiated liposarcomas in the pharynx. An 82-year-old man presented with dysphagia, voice changes, weight loss, nasal regurgitation of liquids, and coughing spells. A 3.5 cm mass was identified in the hypopharynx. The mass was biopsied and diagnosed as a benign fibroepithelial polyp. Continued symptoms and airway obstruction prompted a pharyngectomy, and the mass was then diagnosed as dedifferentiated liposarcoma. Due to infrequency and subtle histological findings, liposarcomas of the head and neck can be misdiagnosed and recur. Liposarcoma comprises only 1% of head and neck sarcomas . Thus, iAn 82-year-old man presented to the clinic for evaluation of a throat mass. He reported dysphagia that began 4 to 5 months previously with associated 17-pound weight loss. He denied throat pain but endorsed voice changes, frequent nasal regurgitation of liquids, food getting stuck, and frequent coughing spells. After a prolonged coughing episode, he went to urgent care and was given an analgesic with symptomatic improvement. However, his dysphagia progressed until he developed difficulty swallowing water. He had no family history of cancer. He went to his primary care physician for evaluation who referred him to gastroenterology for an upper endoscopy and a Modified Barium Swallow Study. The upper endoscopy revealed no concerns with his esophagus, but a referral to otolaryngology was recommended. In the office, a flexible laryngoscopy revealed a benign-appearing mass in his throat. A CT scan of the neck  showed aThe resected mass was four tan and soft, ovoid rubbery portions with focal overlying gray-pink glistening mucosa that measured 3.1-4.5 cm. Opposite the mucosal surfaces was an abundant cautery artefact. Cut sections showed pale tan to gray solid lobulated tissue; the largest with slightly edematous gray-white whorled cut surface that showed no degenerative changes.On microscopic examination, the neoplasm was predominantly composed of dedifferentiated areas with solid sheets of spindle cells in a fascicular and storiform pattern . There wTo further characterize the mass, immunohistochemical stains were ordered with results as follows: focally positive for BCL2, while negative for CD99, S100, CK OSCAR, SOX10, SMA, desmin, CD31, CD34, and ERG. Beta catenin was noncontributory. This profile helped to rule out other tumor types.MDM2 (12q15) by FISH, confirming the diagnosis of a liposarcoma.To support the diagnosis, fluorescence in situ hybridization (FISH) was performed. The posterior pharyngeal mass demonstrated amplification of At clinical follow-up, approximately one month after pharyngectomy, the patient reported improvement and was able to eat and drink without problems. He denied dysphagia, dyspnea, and odynophagia and began to gain weight. Laryngoscopy revealed the surgical site to be well healed and no obstruction of the pharyngeal airway was seen. A full-body PET CT scan was negative for avidity in the pharynx or elsewhere. A neck CT scan showed a 2.2 cm thickening of the posterior pharynx with fat attenuation, possibly representing residual liposarcoma, as the margins of the pharyngectomy specimen were thought to be microscopically involved by this tumor. At multidisciplinary tumor board, it was decided that a repeat CT scan will be obtained in three months to reevaluate the laryngeal thickening. Further treatment decisions may be made at that time.Liposarcoma is a malignant neoplasm of adipose tissue and may recur locally but usually does not metastasize unless dedifferentiated . DediffePharyngeal liposarcomas are very rare. Fewer than 100 have been reported in the literature. They predominantly (65%) occur in men . DediffeSymptoms vary by the site of involvement and tumor size. In the larynx, there is hoarseness, dysphonia, dysphagia, and airway obstruction. In the pharynx and larynx, there are signs of dysphagia and airway obstruction, respectively, accompanied by a slowly growing painless mass. The treatment of choice is wide local surgical excision that includes tumor-free margins . More agThe differential diagnosis of a pharyngeal mass includes benign and malignant entities such as fibrovascular polyp, lipoma, nodular fasciitis, carcinoma, sarcoma, lymphoma, and melanoma. Discriminating liposarcoma from lipoma by histology alone can be difficult, as the cytologic atypia of a well-differentiated liposarcoma can be subtle. Indeed, the majority of hypopharyngeal/esophageal WDLS in the past have been considered reactive polyps rather than malignant neoplasms . In addiMDM2 or CDK4 amplification by FISH is a sensitive and specific method for distinguishing liposarcoma from benign lipoma [MDM2 and CDK4 are located on chromosome 12q13-15, an area that is amplified in well-differentiated and dedifferentiated liposarcoma [Detecting n lipoma . MDM2 anosarcoma . ImmunohAlthough rare, liposarcoma of the head and neck is important to recognize. It can be misdiagnosed due to infrequency and subtle histological findings. The prognosis of liposarcoma in the hypopharynx is better than other sites, possibly due to earlier detection.


Gastric heterotopia rarely occurs in the small intestine beyond ligament of Treitz. Most cases of jejunal gastric heterotopia have been reported in children and young adults. Herein we report a case of jejunal gastric heterotopia presenting as a perforation peritonitis in a middle-aged adult.A 51-year-old male presented with abrupt onset abdominal pain of 1 day duration. Physical examination revealed abdominal tenderness and rebound tenderness as well as costovertebral angle tenderness. Abdominal computed tomography revealed pneumoperitoneum, suggestive of hollow viscus perforation. At emergency laparotomy, a perforation site was discovered in the jejunum 100 cm distal to the ligament of Treitz. On macroscopic examination, the mucosa contained a 3 × 4 cm ill-defined, shallow ulceration next to the perforation site. Microscopically, the mucosa surrounding the perforation site revealed gastric heterotopia which consisted of gastric foveolar epithelium along with abundant pyloric glands and a few fundic glands.To the best of our knowledge, this case is the presumed oldest jejunal gastric heterotopia patient presenting with perforation peritonitis ever reported.Jejunal gastric heterotopia should also be considered in the differential diagnosis of perforation peritonitis in adults. Most cases of jejunal gastric heterotopia tend to be congenital and have been reported in children and young adults . Jejunal2A 51-year-old male presented with abrupt onset abdominal pain of 1 day duration after eating a meal. At that time, the patient has been treated for pulmonary tuberculosis. He has had no drug history, allergies or specific family history. The patient felt some chills and did not have any fever. Physical examination was notable for abdominal tenderness and rebound tenderness as well as costovertebral angle tenderness. Abdominal computed tomography demonstrated pneumoperitoneum suggestive of hollow viscus perforation. Emergency laparotomy was performed by a fully qualified gastrointestinal surgeon in a university hospital. At laparotomy, a perforation site was discovered in the jejunum 100 cm distal to the ligament of Treitz. The size of perforation site measured less than 0.5 cm. Segmental resection of the jejunum with side-to-side anastomosis was performed. The resected jejunal segment measured 8 cm in length which secured appropriate margin of normal mucosa around the perforation site. Macroscopic examination revealed a 3 × 4 cm ill-defined shallow ulceration next to the perforation site . There w3Gastric heterotopia of the gastrointestinal tract occurs commonly in the esophagus and duodenum . GastricGastric heterotopia should be differentiated from gastric metaplasia which is an acquired lesion associated with chronic inflammation and only occupies part of mucosal thickness . MicroscUp to our knowledge, the oldest patient with jejunal gastric heterotopia reported in the English literatures was a 52-year-old woman  who pres4Although jejunal gastric heterotopia rarely occurs, it should also be considered in the differential diagnosis of perforation peritonitis in adults.The authors report no declarations of interest.None.No need for ethical approval.Written informed consent was obtained from the patient’s parents 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.Wonae Lee: Study concept or design, data collection, writing the paper.Ye Seob Jee: Primary operator, study concept or design.Not applicable.Wonae Lee.Not commissioned, externally peer-reviewed.


Lumbar hernias are rare lesions. They are exceptionally observed and reported. They are in most of the cases secondary to trauma or previous surgery but primary lumbar hernias are rare. Computed tomography (CT) is a very useful tool for the diagnosis of lumbar hernia. It can delineate the neck of the hernia and hernial contents. All lumbar hernias must be treated with surgery with two possible surgical approaches: the anterior approach and the laparoscopic approach. Many techniques have been described, including primary repair, local tissue flaps and conventional mesh repair. Bowel resection may be required in cases with strangulation. We report in this work an exceptional case of a 43 year old man with a past recent medical history of lumbar trauma who attended the emergency room for a lumbar mass. It was a soft, non-tender, reducible swelling, measuring from five centimeters in diameter, sitting in the right lumbar region. Computed tomography was performed. The hernia was located in the superior triangle of Grynfelt-Lesshaft and contained large intestine of the right bowel. That is called hernia of the Jean Louis Petit triangle. The patient had open surgery (by lumbar incision). We reintroduced the intestine back into the peritoneal cavity. We excised the sac, and repaired the defect by using synthetic mesh placed below the muscular layers, using a tension-free technique. He was discharged at the fifth day from our hospital. He has been followed up for four years with no recurrence or postsurgical sequelae.


We are presenting a case of pericardial tumor in an elderly female patient who presented with low-grade fever, purpuric rashes all over the body, grittiness in the eyes, and dry mouth with decreased oral intake, night sweats, weight loss, chest pain, and dyspnea. She was diagnosed with Sjögren’s syndrome secondary to systemic lupus erythematosus (SLE) with positive anti-nuclear antibody (ANA), anti-double-stranded DNA (anti-ds-DNA), and anti-Sjögren's-syndrome-related antigen A autoantibodies (SS-A/Ro) antibodies. Computerized tomography scan of the chest with contrast showed multiple calcified mediastinal lymph nodes and a well-defined solid cystic lesion adjacent to the left atrial appendage in favor of a pericardial tumor with minimal pericardial effusion. Biopsy could not be done due to the risk of cardiac tamponade and pneumothorax secondary sensitive location of the tumor. The patient was referred to the oncology and cardiothoracic surgery department for an opinion regarding resection of the tumor and further palliative management. This case is unique in a way that the current literature does not associate SLE with pericardial tumor, while our patient had no other primary malignancy or secondary metastasis ruled out on a positron emission tomography (PET) scan. Pericardial tumors rarely originate from the pericardium or metastasize from other sites. The primary benign tumors include pericardial cysts and lipomas. Malignant neoplasms include sarcomas, lymphomas, primitive neuroendocrine tumors, and mesotheliomas, being the most common malignant pericardial neoplasm. The first case of pericardial mesothelioma with autoimmune features dates back to 1984 . They usOur report highlights a case of Sjögren’s syndrome secondary to systemic lupus erythematosus (SLE) in a patient who had long-term symptoms of suggestive autoimmune disease, with no family history of SLE or Sjögren's. The patient was started on topical fluorides, tear and saliva substitutes along with prednisolone (1 mg/kg) and hydroxychloroquine . A computerized tomography scan of the chest with contrast showed an incidental finding of a pericardial tumor.A 70-year-old female of Asian ethnicity, known case of hypertension, presented to us with complaints of fever, itchy purple-colored rashes all over the body, grittiness in the eyes, and dry mouth with decreased oral intake, vomiting, night sweats, weight loss, dyspnea, and chest pain. The patient also had recurrent oral ulcers and alopecia but there was no joint pain, morning stiffness photosensitivity, or Raynaud’s phenomenon.On physical examination, thin build, pallor, poor skin turgor, koilonychia, angular cheilitis, oral ulcers, glossitis were the positive findings along with multiple palpable non-blanchable purpuric rashes on the limbs Figure  and abdoThe laboratory findings of the patient are presented in Table The rest of the autoimmune workup was negative. A primitive diagnosis of Sjögren’s syndrome secondary to systemic lupus erythematosus was made and further evaluation of the patient’s dyspnea was planned to rule out interstitial lung pathology. Chest X-ray showed cardiomegaly Figure , while tComputerized tomography scan of the chest with contrast was carried out, which showed an incidental finding of cardiomegaly with a well-defined solid cystic lesion of 5.06x2.82 cm adjacent to the left atrial appendage inseparable from the pericardium, in favor of a pericardial tumor along with some mediastinal lymph nodes Figure , 4. DiffThe term Sjögren’s syndrome was first described by Swedish ophthalmologist Henrik Sjögren who linked the triad of keratoconjunctivitis sicca, xerostomia, and polyarthritis. The first reported case of dry eyes and dry mouth was elucidated by Hadden and Hutchinson in 1871 . PrimaryThe common clinical features of Sjögren’s syndrome include keratoconjunctivitis sicca, xerostomia, salivary gland enlargement, rashes or skin irritation, vaginal dryness with dyspareunia, non-erosive arthralgias, generalized osteoarthritis, Raynaud’s phenomenon, and fatigue, while less common features include low-grade fever, interstitial lung disease, anemia, leucopenia, thrombocytopenia, vasculitis, cryoglobulinemia, lymphadenopathy, peripheral neuropathy, glomerulonephritis, interstitial nephritis, and renal tubular acidosis . KeratocSLE can increase the risk of many malignancies including non-Hodgkin’s lymphoma, Hodgkin’s lymphoma, leukemia, multiple myeloma, cervix, vagina/vulva, kidney, bladder, esophagus, gastric, hepatobiliary, lung, oropharynx, larynx, non-melanoma skin, and thyroid cancers, while it could reduce the risk of prostate cancer, breast cancer, and cutaneous melanoma . AdditioAs our case presented with fever, grittiness in the eyes, dry mouth, dyspnea, recurrent oral ulcers, alopecia, and non-blanchable purpuric rash, a workup suggestive of autoimmune pathology was carried out and returned positive diagnosing Sjögren’s syndrome secondary to systemic lupus erythematosus. Although it is interesting to see both of these together in the same patient as a new-onset at such an advanced age, it is also a well-known fact that one autoimmune disorder pre-disposes to the others. Our report highlights a rare association of a pericardial tumor with an autoimmune entity. SLE is associated with many cancers, while there are few cases in literature associating Sjögren’s syndrome with mesotheliomas which can include pericardial tumors also. This case is unique in a way that the current literature does not associate SLE with pericardial tumor, while our patient had been ruled out for any other primary malignancy or secondary metastasis.


Hip pain in a child can have infectious, inflammatory, traumatic, neoplastic, or developmental causes, which can make the diagnosis challenging. Meticulous history taking and a detailed clinical examination guide the radiological investigation. In this article, we address some of the main causes of hip pain in childhood and their findings on diagnostic imaging. Accurate diagnosis of pediatric hip disorders is essential for the characterization of early musculoskeletal changes. The diagnostic imaging methods employed in the evaluation of hip pain are characterized in A number of studies recently conducted in Brazil have underscored the important role that imaging methods play in the evaluation of the musculoskeletal system.The common causes of hip pain in childhood include congenital disorders and developmental dysplasia, as well as infectious, inflammatory, traumatic, rheumatologic, and neoplastic processes. Suspicion of the condition usually arises during the first 30 days of life. For infants ≤ 6 months of age, Graf’s method of ultrasound exam can be used for screening and confirmation, thus allowing early preventive treatment to be provided. Hip dysplasia is characterized as an abnormal ratio between the femoral head and the acetabulum. CT and MRI of the hip are useful in treatment planning, monitoring, and postoperative evaluation , positive culture, and, in the case of pyomyositis, increased creatine phosphokinase and myoglobinuria. Osteomyelitis and septic arthritis often occur in the metaphyseal region of the bone marrow. Osteomyelitis typically affects males between 2 and 12 years of age, whereas septic arthritis affects children of either gender between 4 and 16 years of age. Bone destruction, cortical erosion, and periosteal reaction are all better visualized on CT scans. In the absence of trauma, a fat-fluid level is suggestive of osteomyelitis. MRI is quite effective in the early diagnosis of osteomyelitis, as well as in assessing the extent of bone, soft tissue, and articular involvement. Osteomyelitic lesions show a hypointense signal on T1-weighted sequences and a hyperintense signal on fluid-sensitive sequences. In the post-contrast phase . Scintigraphy has high sensitivity but low specificity, being useful for verifying multifocality and for a diagnosis of exclusion when negativest phase , MRI det.Pyomyositis is a bacterial infection of the muscle. It typically affects children 5-9 years of age and is more common in males. CT is not sufficiently sensitive to evaluate soft tissues or to differentiate between abscesses and hematomas. MRI is the best examination for early diagnosis of soft-tissue disorders, as well as for concomitant arthritis or osteomyelitis, upon evaluation of contrast-enhanced fluid-sensitive sequences . . Ultrasound is useful for guiding aspiration biopsy and detecting joint effusion. Scintigraphy is useful for determining the location and distribution of infectious processes. As illustrated in .The X-ray findings in infectious arthritis include joint effusion, periarticular osteoporosis, reduction of the joint space, bone erosion, bone destruction, and, occasionally, ankylosis (late changes) and radiolucent foci, together with periosteal reactions or heterotopic bone formationsThe differential diagnosis of septic arthritis primarily includes transient synovitis of the hip and arthritis caused by rheumatoid or hematological diseases..Transient synovitis of the hip is a benign condition, of unknown origin, that is self-limited. It accounts for approximately 90% of cases of hip pain in children. The majority of cases are in individuals with a history of upper respiratory tract infection (approximately two to three weeks before the onset of symptoms) or mild trauma. The age at onset ranges from 18 months to 13 years, most cases occurring in individuals between 3 and 8 years of age. The MRI findings include unilateral or bilateral joint effusion, as well as mild synovial thickening and enhancement. As can be seen in .The diagnosis is made by exclusion. Ultrasound reveals anechoic joint effusion or with fine debris . An X-ra.Epiphysiolysis is best described as a fracture of the growth plate with a slipped capital femoral epiphysis . It is the most common abnormality of the hip in overweight male adolescentsOn MRI, epiphysiolysis presents as focal or diffuse physeal enlargement, best defined in coronal or axial T1-weighted sequences, together with irregularity and a hyperintense signal caused by bone marrow edema . . Late complications include pistol-grip deformity , degenerative osteoarthritis, and limb-length discrepancy resulting from physeal fusion  are sensitive to repetitive traction. The apophyses are subject to traction apophysitis or osteochondritis at the insertion site. In patients with apophysitis and no avulsion, X-rays appear normal. Although the MRI findings of apophysitis can be variable, the initial findings include low signal intensity on T1-weighted sequences with increased signal intensity in fluid-sequences, bone marrow edema, and mild enlargement of the physis (.In the acute phase of apophysitis, X-rays are useful for confirming the presence of incipient apophysitis, documenting the avulsion or fragmentation of a given apophysis, and ruling out other bone abnormalities such as epiphyseal fracturese physis . After hThe differential diagnoses of hip pain in the pediatric population are myriad. Therefore, timely, accurate diagnosis is essential to ensure early, effective treatment.In pediatric patients with hip pain, a measured approach to diagnostic imaging, contextualized by clinical and laboratory data, helps identify the correct diagnosis, avoid unnecessary interventions, properly manage cases, and prevent complications in adulthood.


The indication of surgical resection for liver metastasis from gastric cancer (GC) is still limited and controversial because of its more aggressive oncological characteristics than liver metastasis from colorectal cancer. Pyloric stenosis causes an inadequate oral intake and malnutrition in GC patients. We herein report a case of GC with these two factors that was successfully treated by the combination of gastro-jejunal bypass and chemotherapy, followed by curative R0 resection.A 60-year-old man was diagnosed with type 2 GC with liver metastasis and pyloric stenosis, which was confirmed as the HER2-positive type. He underwent gastrojejunostomy and received capecitabine and cisplatin (XP) + trastuzumab chemotherapy. After three courses of the XP + trastuzumab regimen, shrinkage of the primary lesion and liver metastasis was confirmed and his nutritional parameters markedly improved with a stable oral intake after bypass surgery. He underwent curative R0 resection by distal gastrectomy with D2 lymphadenectomy and partial hepatectomy. Histologically, viable tumor cells were observed in less than one-third of the primary lesion, and only scar tissue without viable cancer cells was noted in the resected liver specimen. His postoperative course was uneventful, and recurrence has not been detected in the 30 months after surgery without adjuvant chemotherapy.The present case report describes a successful strategy for advanced GC with pyloric stenosis and liver metastasis. Although chemotherapy is regarded as the standard treatment for recurrent and metastatic gastric cancer (GC) , hepatecPyloric stenosis is an obstructive condition of the gastric outlet induced by tumor growth in the pyloric area and causes nutritional disorders. Preoperative malnutrition is recognized as a negative indicator of short- and long-term outcomes after curative gastrectomy for GC , 9. FurtWe herein report a case of advanced GC with liver metastasis and pyloric stenosis that was successfully treated by the combination of gastro-jejunal bypass and chemotherapy, followed by curative R0 resection. This therapeutic strategy is a treatment option for advanced GC patients with these two factors.A 60-year-old man visited our hospital with bloody vomiting. Upper gastrointestinal endoscopy showed a circumferential ulcerative lesion measuring 40 mm at the pre-pyloric area, which caused tumor bleeding and pyloric stenosis Fig. a. BiopsyThe present case was diagnosed with advanced GC with potentially/technically resectable liver metastasis and a nutritional disorder due to pyloric stenosis. We considered two therapeutic options: (i) surgery (standard primary tumor resection with lymphadenectomy and liver metastasectomy) with/without adjuvant chemotherapy, and (ii) systemic chemotherapy (as a neo-adjuvant setting) followed by surgical resection. After sufficient discussions and the provision of informed consent from the patient and his family, we selected the latter therapeutic strategy. Before the introduction of systemic chemotherapy, we performed gastro-jejunal bypass (Roux-en-Y gastric bypass) with the laparoscopic approach to overcome the food obstruction issue. Since modified Devine exclusion was added to bypass surgery , 13, the2 capecitabine (Xeloda®) orally twice a day on days 1–14 and 80 mg/m2 cisplatin intravenously on day 1, which was repeated every 3 weeks. An intravenous injection of 8 mg/kg trastuzumab was administered on day 1 of the first cycle and then at 6 mg/kg on day 1 of subsequent cycles. Although grade 3 neutropenia according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) [As a systemic chemotherapy, capecitabine and cisplatin in combination with intravenous trastuzumab (the XP plus T-mab regimen) were selected. The postoperative course after gastro-jejunal bypass was uneventful, and the patient received initial administration on the 9th day after surgery. The XP regimen comprised 1000 mg/mLaboratory data after chemotherapy are summarized in Table We considered surgical curability and safety to be achievable at this point. The patient underwent macroscopic complete resection (R0 resection) by distal gastrectomy, D2 lymphadenectomy, and partial hepatectomy of S7. The previous transection line of modified Devine exclusion procedure was extended to the lesser curvature side in the second surgery Fig. .Fig. 4MaPathologically, the primary lesion was moderately differentiated adenocarcinoma (tub2) and invaded the subserosal layers (T3(SS)). Viable tumor cells were observed in less than one-third of the lesion and more than two-thirds were replaced with scar tissue Fig. a, indicaThe postoperative course was uneventful, and the patient was discharged from hospital on postoperative day 10. We proposed adjuvant chemotherapy; however, the patient and his family did not hope it. After enough consultation, we finally decided not to administer postoperative adjuvant chemotherapy. He was followed up every 3 months and has remained free from recurrence 30 months after surgical resection. The outline of the clinical course is summarized in Fig. The present case of GC had liver metastasis and pyloric stenosis. We preceded gastro-jejunal bypass and systemic chemotherapy for this case with obstruction of the food passage and clinically solitary liver metastasis. Chemotherapy was uneventfully administrated, and shrinkage of both the primary tumor and metastatic lesions was achieved. Furthermore, anemia, malnutrition, PNI score, and AFP level were all improved mainly by a stable oral intake after bypass surgery. We then safely performed curative R0 resection by distal gastrectomy, D2 lymphadenectomy, and partial hepatectomy.GC with distant metastasis (M1) is defined as Stage IV regardless of any T or N factor . DistantThe indication of surgery for stage IV GC with liver metastasis is still not defined. Previous studies demonstrated that the prognosis of patients may be improved by careful selection for surgical indication, such as non-serosal invasion of the primary tumor, one or a few liver metastases, and smaller size of metastatic lesions –4, 17–19The present case was Stage IV GC with one liver metastasis of 1 cm in size, and was considered to be technically resectable. Although there were two options, surgery first or chemotherapy first, we selected the latter after sufficient consideration and informed consent. This was a very difficult decision to reach and was ultimately based on the need to (i) monitor liver metastasis over time and confirm whether liver metastasis was truly solitary, and (ii) improve his general and nutritional conditions prior to radical surgery. Since the present case was technically resectable, this preoperative chemotherapy was considered as a neo-adjuvant setting.Recently, the long-term outcomes of the conversion therapy for GC have been reported by several institutes. Yamaguchi et al. treated 259 patients who had stage IV GC with chemotherapy and performed conversion surgery in 84 patients of them . The medThe nutritional status has been reported to have a number of clinical impacts on the management of GC patients, including surgical intervention and peri-operative chemotherapy , 24. RegThe ToGA trial confirmed the efficacy of trastuzumab for inoperable locally advanced, recurrent, or metastatic HER-2-positive adenocarcinoma of the stomach or gastro-esophageal junction cancer . Some caIn the present case, we successfully administered effective preoperative chemotherapy and performed R0 resection by distal gastrectomy and partial hepatectomy. However, this treatment strategy has several disadvantages. The patient might miss the opportunity for surgery due to disease progression during chemotherapy. Since a consensus for preoperative (neo-adjuvant) chemotherapy for such a case has not yet been established, further evidence is needed in the near future. Another disadvantage is that the patient underwent surgery twice in the current treatment strategy. Although physical stress generally needs to be minimized, the first surgery was considered to be necessary to secure an oral intake and increase the safety of consequent radical resection. Other disadvantages include the possibility of the adverse effects of chemotherapy for surgical intervention (increased postoperative complications), a longer treatment period, and higher treatment costs.The present case report demonstrates a successful strategy for advanced GC with pyloric stenosis and liver metastasis.


The benign glomus tumor is an uncommon cause of crippling pain most commonly associated with the fingers. This sheep in wolf’s clothing is identified by careful examination, confirmed by MRI, and often resolved with a simple procedure. Here we present a patient with chronic knee pain of 21 years duration. The glomus tumor arises from the glomus body which is broadly found in the dermis, and most densely in that of the digits. The glomus body participates in thermoregulation, acting as a blood flow shunt to alternatively reduce and promote convective heat loss. The glomus tumor is near universally benign though it’s hallmark is intense pain in the subungual location. We present the case of an extradigital glomus tumor causing chronic debilitating pinpoint pain in the anterior knee region which was fully alleviated with simple excision.A sixty-seven-year-old male diabetic with psoriatic arthritis presented to the plastic surgery clinic with an exquisitely painful ‘bump’ below the left knee first noticed several months earlier without clear etiology. Though the contour irregularity was new, his intense pain and hyperesthesia at this location seemed to develop shortly after repair of a ruptured quadriceps tendon 21 years previously. He had been plagued with pain in this region since then and learned to adjust most activities and avoid even the lightest touches, like a bedsheet. Multiple prior imaging studies including plain radiographs and MRIs over this lengthy period were unrevealing for the causative etiology. Despite the tenderness, he had no pain with ambulation, joint loading, or full knee motion. He denied overlying skin changes or concern for infection.Inspection of the left knee region revealed a mature vertical midline scar over the distal thigh and patella and a visible 1.5 cm mass approximately 5 cm distal to the inferior patellar margin without overlying skin changes. Attempts at examination were met with repeated quick jerking withdrawals. With time, he was found to have hyperesthetic skin over the entire patella and was exquisitely tender over the pretibial lesion. Pain was not reproduced with knee or distal extremity passive or resisted active motion. Gait was normal.Office-based ultrasound demonstrated a well-circumscribed homogenous echogenically gray nodule 10 × 15 × 5mm superficial to the patellar tendon. With Doppler imaging, it was extremely vascular with a strong pulsatile signal throughout the entire nodule. Subsequent MRI revealed an ovoid 4 × 13 × 8mm T2 hyperintense homogenously enchancing lesion with mild adjacent subcutaneous fat edema overlying the tibial tubercle.The patient underwent excisional biopsy of the mass under IV sedation. He was too anxious to attempt excision under local anesthesia and would almost involuntarily recoil with any attempt to approach the knee region. The surrounding tissues were infiltrated with epinephrine-containing local anesthetic and no tourniquet use was employed. Sharp dissection through the superficial soft tissue revealed a well-circumscribed deep purple mass overlying the patellar tendon. The mass was easily dissected free from the tendon and removed with 3.5x loupe magnification. Pathology confirmed the suspected glomus tumor and the diagnosis was supported by immunohistochemical studies that show positive staining for smooth muscle actin and negative staining for desmin, pancytokeratin, and S-100 (2). Furthermore, the lesion appeared well circumscribed and was without appreciable atypia or mitotic activity.At the patient’s first post-operative office visit, he was completely free of pain and tenderness in the entire knee region and easily tolerated direct pressure to the area. After nearly three years, he continues to be free from pain .The glomus body is a neuro-myo-arterial apparatus in the subcutis and reticular dermis which participates in thermoregulatory control. It is composed of an arteriole and venule with multiple shunts, perivascular contractile glomus cells, and non-myelinated nerve fibers which influence vessel diameter through sympathetic tone . In coldtumor is a benign lesion arising from the glomus body which usually presents in the distal upper or lower extremities of young adults. They have a predilection for the subungual region of fingers, corresponding to one of the densest collections of glomus bodies. Although the hand is commonly affected, cutaneous lesions can occur at other sites, and extracutaneous glomus tumors have been reported in the gastrointestinal tract, bone, mediastinum, trachea, mesentery, cervix, and vagina among other disparate anatomic sites [A glomus ic sites ,3. In thic sites . The tumic sites . In extric sites . Though ic sites .Patients with glomus tumors classically present with a triad of pinpoint tenderness, paroxysmal pain, and cold hypersensitivity. Localization of the lesion can be performed with Love’s test by applying pressure to the suspected area with the head of a pin or paperclip, eliciting intense pain. Love’s pin test has a sensitivity of 100% and accuracy of 78% . If a toMRI is the gold standard imaging technique for identifying and characterizing glomus tumors which have been described as appearing dark and well-defined on T1-weighted images and bright on T2-weighted images with diffuse enhancement after gadolinium administration ,8. This Doppler ultrasound can be used to help detect the high blood flow associated with these lesions with a sensitivity approaching 90% . RadiogrComplete excision is generally curative, with resolution of all symptoms. In the digit, a tourniquet is typically used to facilitate dissection.Glomus tumors are generally well-circumscribed sheets and clusters of uniform glomus cells around capillary-sized vessels. A pseudocapsule may be present. The glomus cells express vimentin and muscle actin isoforms. These tumors typically show no significant atypia but malignant degeneration has been described.Glomus tumors are benign lesions most commonly associated with crippling pain in the digits though they often occur in extradigital locations. In fact, over a 20 year period 61% of glomus tumors at one institution were extradigital .


Acinar cystic transformation (ACT), also known as “acinar cell cystadenoma,” is a rare and newly recognized benign pancreatic cystic neoplasm. However, its true malignant potential remains unknown. Here, we report a case of ACT with 15-year follow-up. A 10-year-old female initially presented with abdominal pain and was found to have a cystic lesion in the region of pancreatic head on computed tomography scan. She underwent an exploratory laparotomy, and the intraoperative biopsy of the cyst wall showed a true pancreatic cyst without malignancy. Her symptoms subsequently resolved, and she was placed under close ultrasound surveillance. For the next fifteen years, the patient was asymptomatic without any complications and had a successful pregnancy. Surveillance showed the tumor grew in size from 4.2 cm to 6.2 cm in diameter. In the latest five months, she noted occasional abdominal pain. A pylorus-preserving pancreaticoduodenectomy was performed. The resected cystic lesion was multilocular and lined by a single layer of bland epithelium ranging from nondescript flat/cuboidal epithelium to apparent acinar cells which were strongly positive for trypsin, so the final diagnosis was confirmed to be ACT. The prior biopsy was retrospectively reviewed to reveal similar epithelial lining. To the best of our knowledge, this is the longest period of follow-up for ACT to date. Our findings suggest that ACT is a slow-growing neoplasm without malignant transformation after fifteen years. Therefore, we recommend biopsy for histologic diagnosis followed by close ultrasound surveillance without surgical intervention in asymptomatic or young ACT patients. Acinar cystic transformation (ACT), also known as “acinar cell cystadenoma,” is an extremely rare benign pancreatic cystic neoplasm lined by cells with acinar differentiation without cytologic atypia . It was A previously healthy 10-year-old female presented to our hospital with a 2-month history of intermittent abdominal pain. An abdominal computed tomography (CT) scan done to rule out appendicitis revealed a 4 × 3 cm cystic lesion in the region of pancreatic head, and whether the lesion involved the pancreas at its head or not was unknown based on the images . The difFor the next fifteen years, the patient was asymptomatic without any complications and had a successful uncomplicated pregnancy. The abdominal ultrasound surveillance showed the tumor grew in size from 4.2 cm to 6.2 cm in diameter for 15 years. In the latest five months, the patient had noted occasional right mid abdominal pain and discomfort. A pylorus-preserving pancreaticoduodenectomy was then performed due to her recurrent pain and enlargement of the lesion.On gross examination, a multilocular cystic lesion was identified in the head of the pancreas with cysts ranging from 0.5 to 3 cm in size . The cysPancreatic cystic lesions are increasingly identified in recent years due to the significant improvement of medical imaging technologies. According to the histopathology, pancreatic cystic lesions can be categorized into three main groups: pseudocyst, cystic neoplasms with epithelial linings, and cystic degeneration of solid neoplasms such as solid pseudopapillary neoplasm, neuroendocrine tumors, and ductal adenocarcinoma. The cystic neoplasms with epithelial linings include serous cystadenoma, mucinous cystic neoplasm (MCN), intraductal papillary neoplasm (IPMN), and acinar cystic transformation (ACT). Distinguishing between the various types of cystic pancreatic lesions has important prognostic and therapeutic implications.Acinar cystic transformation (ACT) is an extremely rare benign pancreatic cystic neoplasm. Although it was firstly reported in 2002 as an incidental finding during autopsy . In the The preoperative diagnosis of ACT based on imaging is very difficult due to the lack of specific radiologic features of ACT. The cytology results of fine-needle aspirations are also usually inconclusive because of the limited cellularity . Due to KRAS, SMAD4, TP53, and beta-catenin in 4 ACT cases without mural nodules, supporting that ACT may be a nonneoplastic dilation of the acinar and ductal epithelium [To date, the pathogenesis of ACT still remains unclear. Khor et al. identified multiple chromosomal gains involving 1p, 3p, 5q, 6p, 7q, 8, 10q, 11, 14, 20, and X in one case of multilocular ACT with mural nodules by using array comparative genomic hybridization, suggesting ACT could be a neoplastic lesion . Howeverithelium , 25.Although ACT is no longer thought to represent the benign counterpart to acinar cell cystadenocarcinoma, the true malignant potential of ACT has not yet been determined due to the rarity of this entity and relatively short periods of follow-up in the reported cases. Up to now, there are no reports of malignant transformation or metastasis of ACT with up to 10-year follow-up, regardless of whether the ACT was completely resected or not .Here, we reported a case of ACT of the pancreas in a young female with 15-year follow-up. Our case report is unique in that it is the longest period of follow-up for ACT reported thus far in the literature. In our case, the patient had abdominal pain as first presentation and was found to have a cystic lesion in the region of pancreatic head on abdominal CT scan. During the exploratory laparotomy, the frozen section of an incisional biopsy was performed to confirm that the lesion was a true pancreatic cyst without malignancy. Due to the young age of the patient and lack of evidence of malignancy, the cystic lesion was treated with intraoperative drainage and unroofing. Then, our patient was placed under close ultrasound surveillance. For the next fifteen years, the patient did not experience any related symptoms or complications and the lesion grew from 4.2 cm to 6.2 cm in diameter (0.13 cm per year). In addition, the patient had a successful uncomplicated pregnancy during this period. Only in the latest 5 months, the patient started having occasional abdominal pain and discomfort. Then, a pylorus-preserving pancreaticoduodenectomy was performed due to her recurrent pain and enlargement of the lesion. The prior intraoperative biopsy slide was retrospectively reviewed and showed similar epithelial lining to that seen in the resection specimen, suggesting that ACT is a slow-growing neoplasm without malignant transformation after fifteen years.Currently, a surgical resection is recommended for both diagnosis and treatment of ACT. However, complete resections including distal pancreatectomy with or without splenectomy, pancreaticoduodenectomy, and central pancreatectomy can associate with many postsurgical complications and high morbidity, especially in a young patient. Wang et al. reported in their case series of ACT that 5 out of 8 patients that received surgical resection had postsurgical complications including pancreatic fistula, gastroplegia, pneumonia, and intestinal obstruction . In addi


To analyze the types and properties of cystic lesions originating from the muscularis propria of the gastric cardia (CLMPGC), explore the growth pattern and anatomical characteristics, and evaluate the safety, feasibility, and clinical efficacy of endoscopic esophageal submucosal tunnel dissection (ESTD).  From September 2013 to July 2018, we treated 6 patients with CLMPGC whom we had diagnosed using endoscopy, endoscopic ultrasound (EUS), and Computed Tomography (CT) before the operations. ESTD was the best option for treatment for all these patients. Postoperative observation and follow-ups were performed, and the operational, clinical data, and treatment results are analyzed.  The mean age of the patients was 50.67 ± 11.59 years . The only clinical manifestations the patients exhibited were upper abdominal discomfort. The diameter of the masses was 2.05 ± 0.73 (1.1–3.0) cm. The duration of the ESTD operation was 93.5 (82–256) mins, and the length of hospital stay was 7.50 ± 1.38 days. Postoperative pathology showed 4 cases of an epithelioid cyst, and 2 cases of mucocele with xanthogranuloma. There were no complications, such as hemorrhage, pneumothorax, and pleural effusion during and after the operation. No recurrence during the follow-ups was observed.  The CLMPGC were mainly mucocele and epidermoid cyst, in an expansive growth pattern, and these lesions had no distinct borders with the muscularis propria. The muscularis propria formed a complete wall of the lesion. There was no direct blood supply to the lesions from big blood vessels. Endoscopic esophageal submucosal tunnel dissection was a safe, feasible, and effective treatment for CLMPGC. The gastric cardia is the most common site of gastric submucosal tumors , most ofPreviously, open surgery or laparoscopic wedge resection were the primary treatment options for patients with cardiac lesions . The curCompared with other surgical methods, the tunnel dissection has the advantages of maintaining the mucosa's integrity above the lesion, improving surgical safety and preventing local perforation . EndoscoFrom September 2013 to July 2018, our team had treated 6 patients with CLMPGC. All these patients were diagnosed with CLMPGC by preoperative gastroscopy, endoscopic ultrasound (EUS), and CT; the lesions were confirmed to be originating from the muscularis propria of the gastric cardia. After case analysis and discussion, we chose endoscopic esophageal submucosal tunnel dissection as the best treatment method. All patients were informed in detail about the procedure's instructions, steps, and the possible complications of the operation which may require additional surgeries to handle them or to confirm postoperative pathological findings.2) insufflator was used. After the lesions had been localized by endoscopic ultrasonography, normal saline containing methylene blue and sodium hyaluronate was injected into the esophagus submucosa at 2 cm above the lesions. The submucosal space was established by the incision of the mucosa and submucosa, and the submucosa was dissected to expose the lesion along with the submucosal space. Through cutting the muscularis propria alongside the border of the lesion, we gradually dissected the lesion alongside its border. Larger blood vessels connected to the lesion were thermally coagulated, clamped with hemostatic forceps, and ligated. After that, the lesion was removed entirely using snares, baskets, and mesh bags. The removed lesion was, then, sent for pathological examination.General anesthesia was administrated using intravenous anesthetics and tracheal intubation, and a carbon dioxide .The mean age of these patients was 50.67 ± 11.59 years . The only clinical manifestations they exhibited were upper abdominal discomfort. On physical examination; no apparent signs were spotted. Gastroscopy revealed some protruding lesions at the gastric cardia mucosa. There was no significant correlation between gender and the tumor size  days. Postoperative observation showed that patients had no obvious pain after the operation. All patients were followed up at 3, 6, and 12 months after the operation with gastroscopy, endoscopic ultrasonography, and CT, and then, the following interval was after one year. The purpose of the follow-up was to observe the healing of the wound and examine whether there is a residual or recurrent tumor. Gastroscopy, EUS, and CT were performed at the follow-up visits. The examinations showed no recurrence in any of the 6 cases, patulous cardia occurred in 2 cases, and no reflux esophagitis or gastric cardiac stenosis.After searching lesions originating from the muscularis propria on PubMed ,11,15–20All our patients had no significant clinical signs related to lesions, and there was no significant correlation with their genders. Postoperative pathology proved that cystic lesions at the gastric cardia were epidermoid cyst and mucoceles, and there was no significant difference in clinical manifestations between the two kinds of cysts. However, the internal character of the cystic fluid of the two types of cystic lesions was different. The fluid in the epidermoid cyst was caseous, while the fluid in the mucocele was transparent and jelly-like. The cyst wall thickness was different between the two types of cystic lesions, and the epidermoid cyst wall was thicker while the mucocele wall was thinner.The CLMPGC needs to be differentiated from leiomyomas and stromal tumors. The first case was misdiagnosed as a stromal tumor in the initial diagnosis. Gastric foregut, on the other hand, is also likely to be misdiagnosed as stromal tumor . EndoscoSpherical mucosal protuberance is the main feature of CLMPGC observed by gastroscopy. All the lesions looked as if they were pressured from the outside. There was no mucosal bridge, the mucosal surface did not expand and dilate, and the surface mucosal blood vessels did not change correspondingly.EUS is the primary method for the diagnosis of gastrointestinal submucosal mass ,22; it sCT is an objective and definite diagnostic basis for CLMPGC and is a required preoperative evaluation method for minimally invasive endoscopic surgeries. A large prospective multicentric US study found that the diagnostic accuracy of EUS for mucinous cystic lesions of the pancreas was 51% . They coThe CT findings of the present 6 cases included the following: (1) the lesions were located in the gastric cardia, and the boundary between the lesion and the cardiac was not clear. The lesions we diagnosed and treated protruded outward in an obvious way, and they were with a clear outer boundary. The lesions were all located in the right anterior part of the gastric cardia; the location is a characteristic; (2) the cyst wall structure can be clearly visualized on an unenhanced CT scan; the CT value of cyst fluid was 5 HU. There was no significant difference in CT findings between the epidermoid cyst and the mucocele; and (3) the outer boundary of the lesions was clear, and the adjacent vessels around the lesions were clearly visible. The spaces between the lesions and the vessels were clear; no vessels were connected with the lesion; no visible direct blood supply vessels were found. The understanding of peripheral blood vessels distribution is of great significance for determining the incision site of the muscularis propria, thus preventing injury and bleeding of any large blood vessels during the operation.Endoscopic esophageal submucosal tunnel dissection (ESTD) is a safe and effective method for the treatment of CLMPGC. Endoscopic minimally invasive dissection has been proven to be a safe and effective method for treating lesions originating from the muscularis propria of the gastric cardia ,11,19. ELocalization and border determination of the lesions originating from the muscularis propria in tunnels are the main operational difficulties in ESTD. While operating on these 6 cases, the locations of lesions were challenging in 2 patients after tracheal intubation and anesthesia, while the boundary of the lesions in muscularis propria was challenging to determine in 4 patients. By switching to ultrasonography with a miniprobe, these challenges were conquered successfully.The factors related to the difficulty in determining the borders of lesions originating from the muscularis propria in the tunnel during ESTD were as follows: (1) the lesion originated from the muscularis propria, but protruded outward, and there was no visible muscle fiber hyperplasia and hyperemia, so there was no difference between its inner surface of the muscularis propria and that of the normal muscularis propria; (2) using general anesthesia with tracheal intubation and muscle relaxants led to abdominal muscle relaxation; thus, the intraperitoneal pressure was significantly reduced causing the lesions to further protrude outwardly, while the inward protruding was more weakened. They could not be clearly shown even when overinflation was performed; and (3) the lesions had outward protrusion, and all of them were located in the space beside the liver. Therefore, the CLMPGC did not protrude inwards.EUS with a miniprobe in the tunnel was used to assist in localizing and determining the border in all of the cases that were difficult to localize, which indicated that EUS with a miniprobe was a necessary auxiliary means for endoscopic minimally invasive resection of CLMPGC and a necessary condition for a safe and successful operation.It was challenging to completely take out the cyst after the resection of the lesion as there was a high chance of cyst damage and cyst fluid leakage during the operation. However, there were no recurrences in the follow-ups. In all of the cases, the cysts were removed in 3 cases without any damage ; one case  had cyst wall breakage during dissection; one case had rupture of the cyst wall during removal; and the other case was treated with preventive treatment . Therefore, the rupture of the lesion while removing the cyst and its possibility of rupture in dissection are the main factors for this difficulty, and the former had a slightly higher incidence.The main factors contributing to the rupture during removal of lesions include the narrow entrance of the esophageal submucosal tunnel, the small cavity of the esophageal submucosal tunnel, and the severe squeezing of lesions while removal using the snare. Therefore, increasing the size of the entrance of the esophageal submucosal tunnel, expanding the interspace of the submucosal tunnel, and using baskets or mesh bags to remove the lesions can effectively help to avoid the rupture. The suction of cystic lesions can reduce the lesions' diameter, thus helping their removal, which had also proven an effective means observed in treating the present patients.The rupture of the cyst wall during dissection was deemed unavoidable from the analysis of the video replay of the operations. The rupture is considered closely related to the thin cyst wall, its high tension, and the adhesions of peripheral fascia. No recurrence or dissemination was found in all cases of ruptured lesions, which was related to the following factors: (1) the submucosal tunnel of the esophagus and the wound surface after the dissection of lesions were closed spaces; the cyst fluid could not diffuse and flow; (2) in case of leakage, the cyst fluid was effectively cleaned up to avoid residual cyst fluid by using a large amount of normal saline for repeated irrigation; and (3) through continued monitoring of the damage of the cyst, the endoscope's direct suction function ensured that the cyst fluid was completely removed, thus reducing the possibility of leakage and residue.ESTD was proved to be a low-risk minimally invasive procedure without any significant complications in all the present 6 patients of CLMPGC. Neither recurrence of the tumor nor stenosis of the gastric cardia was observed in any of the follow-up visits.The main reason for no severe bleeding during operation is related to the endoscope's stability during ESTD and clear vision. No pneumothorax, abdominal cavity, and retroperitoneal pneumatocele occurred during the operation, which was related to the use of carbon dioxide ,29 as thThe CLMPGC were mainly mucoceles and epidermoid cysts, in an expansive growth pattern, without distinct borders with the muscularis propria. The lesions were without direct blood supply from big blood vessels. ESTD was proven to be a safe, reliable, and effective method for the treatment of CLMPGC. Intraoperative localization using endoscopic ultrasonography with a miniprobe was an essential guarantee for the smooth implementation of assisted surgery.


Emphysematous cystitis is a rare potentially life‐threatening condition and a distinct type of complicated lower urinary tract infection generally associated with diabetes mellitus and diagnosed radiologically. This case report presents a case of emphysematous cystitis as post hiatal hernia repair infectious complication incidentally found on CT abdomen/pelvis. Emphysematous cystitis is a rare potentially life‐threatening condition and a distinct type of complicated lower urinary tract infection generally associated with diabetes mellitus and diagnosed radiologically. This case report presents a case of emphysematous cystitis as post hiatal hernia repair infectious complication incidentally found on CT abdomen/pelvis. Other risk factors include urinary tract outlet obstruction, neurogenic bladder, immune‐deficiency, indwelling urethral catheters, and chronic UTIs.29/L  She was empirically started on Piperacillin/tazobactam 4.5 g 6 hourly. CT Abdomen/pelvis done to look for abdominal collection as source of sepsis found no intra‐abdominal collection but a gastroatmospheric fistula and extensive emphysematous cystitis  on ceftriaxone and bladder drainage with a catheter. Noncontrast CT scan done after 10 days of antibiotics demonstrated resolution of the emphysematous cystitis  was 249 mg/L  and white blood cell (WBC) count 25 × 103Escherichia coli was found to be the most prevalent microorganism followed by Klebsiella pneumonia. Other gas‐producing microorganisms include Enterococcus, Candida, and Clostridium perfringens.Emphysematous cystitis is a severe urinary tract infection characterized by build‐up of gas within the bladder wall or lumen as a result of fungal or bacterial fermentation.The majority of affected patients are female, elderly, and diabetic with clinical presentation ranging from asymptomatic to symptomatic and severe forms such as peritonitis or septic shock.2) through natural fermentation processes in diabetic patients. However, in nondiabetic patients urinary albumin acts as the favorable substrate for gas production by microorganisms within the tissue. An impaired host response, involving impaired catabolism and vascular compromise within the tissues, constitutes another suggested theory for gas production.The pathogenesis of emphysematous cystitis is still not yet fully understood hence there are numerous theories. Nevertheless, the production of gas within the affected tissues seems to be mostly associated with a multifactorial etiology of impaired host responses with sugar or protein fermentation. The presence in a tissue of gas‐producing organisms combined with a high glucose concentration and impaired tissue perfusion support the development of emphysematous infections. In addition, the high glucose concentration within the tissue acts as a substrate for pathogens to produce carbon dioxide  is more accurate in detecting non apparent cases on plain radiography, in defining the extent and severity of the disease, in differentiating emphysematous cystitis from other conditions such as colovesical fistula, intra‐abdominal abscesses, and assessing possible development of ascending infections such as emphysematous pyelonephritis.It is, however, important to be reminded that it is a potential life‐threatening disease because of rapid progression to bladder necrosis, emphysematous pyelonephritis, urosepsis, and death. Therefore, prompt evaluation and early treatment are necessary.Emphysematous cystitis is managed with aggressive broad spectrum parenteral antibiotics until the sensitivities of the isolated microorganisms are known and switched to more specific ones; bladder drainage with a catheter; tight glycemic control and treatment of any underlying comorbid disorders.In conclusion, emphysematous cystitis is a rare entity known to affect primarily patients with uncontrolled diabetes mellitus. However, nondiabetic patients can also be affected even though uncommon. This report appears to be the first of its kind associating emphysematous cystitis to post hiatal hernia repair complications. The prevalence of this condition could be underestimated as radiological assessment is required for its diagnosis which is not routinely done in all patients with urinary tract infection. We believe that Clinicians and radiologists should be aware or reminded of the importance of radiological evaluation of patients with urinary tract infection as an adjunct tool to detect emphysematous cystitis especially when there is high index of suspicion.None declared.AMM: Substantial contributions to conception and design of the case report, acquisition of data, drafting of the manuscript, critical revision for important intellectual content, and approval of final version.Written informed consent was obtained from the patient for publication of this manuscript and accompanying pictures. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal.


Laryngocele is not a common clinical entity that presents itself in a trauma setting. In the literature, there are currently two types of laryngocele, internal and mixed. Laryngocele may be congenital or acquired, and most often will present later in life. Traumatic laryngocele has only been reported three times in the literature before. Herein, we report a rare case of a 22-year-old woman who presents with bilateral laryngocele secondary to sustained direct trauma. Neck Ct-scan revealed bilateral laryngocele being responsible for her dysphagia and dysphonia. She was monitored in the hospital for further exacerbation of her symptoms with feared airway occlusion in mind. On hospital day three, her dysphagia had resolved and her dysphonia had significantly improved. A second CT, revealed resolution of left laryngocele with the right decreased in size since the initial presentation. She was followed and had complete resolution of symptoms one week after the injury. Laryngocele is a rare, benign cyst of the ventricular folds in the larynx occurring in only in one per 2.5 million people . These lWe herein present a rare case of bilateral internal laryngocele caused by direct trauma to the neck of a 22-year-old woman presenting with dysphonia and dysphagia. The onset of dysphagia and dysphonia in a patient after suffering trauma to the neck is a cause for concern, and thus this unique presentation of laryngocele is an important piece of academic discussion. A 22-year-old woman presented to the Emergency Department (ED) as an activated level two trauma. She was the rider of a motorcycle when she lost control resulting in direct trauma to her neck. She was worked up in routine advanced trauma life support (ATLS) protocol. Her primary survey was essentially unremarkable. Notably, she denied any loss of consciousness, her airway was patent and she did not have any stridor on exam. Her secondary survey showed tenderness to palpation of the anterior portion to the left side of her neck. She also complained of muffled voice and dysphagia. The vitals were within normal limits, with her blood pressure at 131/70, heart rate at 90 beats per minute, and her oxygen saturation at 100%. Because of the mechanism of injury, a trauma pan CT-scan was performed. A CT of her head showed no acute intracranial hemorrhage. CT cervical spine and CT-angiography of the neck were essentially normal. CT scan of her neck, however, showed bilateral laryngoceles in her pre-epiglottic space with the right laryngocele larger than the left . ENT serCurrently, laryngocele is reported to affect roughly 1% of the population . LaryngoLaryngocele is defined historically as internal, external or mixed. However, recent literature has described only internal, those laryngoceles that are medial to the thyrohyoid membrane and mixed, those laryngoceles that pierce through the thyrohyoid membrane . InternaSmaller internal laryngoceles are managed via microlaryngoscopy with a CO2 laser. However, for larger laryngoceles or those that are mixed in nature, surgeons use an approach through the lateral neck. This method is preferred due to superior exposure and a low recurrence rate. However, higher morbidity, longer surgery, and longer recovery time in the hospital with subsequently increased cost are the disadvantages to this approach [External approaches to management of laryngocele have also been described in the literature. The transthyroid membrane approach, thyrotomy with thyroid cartilage resection, and a V-shaped thyrotomy are three procedures that will be discussed here. Both the thyrotomy with cartilage resection and the V-shaped thyrotomy provide superior visualization of the paraglottic space  over theIn our patient, the laryngocele was diagnosed incidentally on imaging as part of the trauma workup following a direct injury to her neck. It is quite possible that our patient, based on the literature review described in this case report, had a congenitally dilated saccule that expanded upon trauma to the neck. Her symptoms improved without any intervention.In conclusion, laryngocele often present asymptomatically, incidentally on imaging or in a patient presenting as ours did with dysphagia and dysphonia. Due to the danger of possible airway compromise or underlying malignancy, laryngoceles, an uncommon entity that must be investigated further. The authors declare that there is no actual or potential conflict of interest in relation to this paper.