Objective: To report a case of iatrogenic retinal detachment due to inadvertent globe penetration during posterior sub-Tenon injectionMethods: A 65-year-old female was given posterior sub-Tenon injection of triamcinolone acetonide for pseudophakic cystoid macular oedema. The globe was inadvertently perforated with superior macula off retinal detachment.Results: She underwent immediate pars plana vitrectomy but failed to regain significant vision improvement. Conclusion: According to the literature, retinal detachment as a complication of posterior sub-Tenon injection is rare. This complication may be prevented by adhering to the standard practice of injecting slowly avoiding any undue pressure. Posterior sub-Tenon (PST) injection of triamcinolone is commonly used in uveitic conditions, diabetic macular oedema, and macular oedema secondary to retinal vein occlusions and cystoid macular oedema. First described by Nozik in 1972 [A 65-year-old female was referred to our department with pseudophakic cystoid macular oedema (CME) in her left eye (LE). According to her records, she was initially given topical non-steroidal anti-inflammatory drugs followed by steroid drops with no significant improvement in vision. On examination, the best corrected visual acuity (BCVA) in the LE was 20/120. Fundus evaluation and OCT revealed pseudophakic CME. The decision was made to give PST in LE. After topical anaesthesia, 0.5 ml  was injected on the superotemporal quadrant with a 27G needle by a trainee. Immediately after the procedure in the left eye, inadvertent globe penetration was detected via indirect signs: red reflex became white, severe shallowing of the anterior chamber and immediate profound loss of vision, and a soft eye on digital palpation. On examination, left eye fundus evaluation revealed sub-retinal triamcinolone with patchy retinal necrosis with macula off superior retinal detachment Figure 1 . The patient underwent immediate pars-plana vitrectomy (PPV) with removal of the subretinal triamcinolone along with silicon oil insertion. During vitrectomy, 1 retinal tear associated with retinal detachment was noted on the superior retina along with subretinal particles of triamcinolone over the macular area. Some triamcinolone particles were also found dispersed in the vitreous cavity. Exploration of the surgical site of the injection was done, with a puncture site detected posterior to pars plana, corresponding to the location of the insertion of the needle. However, the patient developed re-detachment at 3-month follow-up for which she underwent repeat PPV. At 6-month follow-up, the retina was attached under oil with vision of HM Figure 2 .Though PSTI is fairly safe, a sub-Tenon injection is more difficult to perform than other periocular injection techniques. To achieve an accurate approach to the sub-Tenon space, the needle has to be placed close to the sclera. This possibly increases the incidence of ocular penetration. There are very few reported cases of globe perforation with retinal detachment during sub-Tenon injection. In their retrospective review, Kuo et al. reported a case of globe perforation out of 64 injections yielding an incidence of 1.56% . RetinalIn this particular case, the procedure was done by a junior resident doctor, suggesting the importance that the technique be performed by an experienced physician or under strict supervision. State of the art is using an Atkinson retrobulbar needle which reduces the risk of inadvertent ocular penetration significantly. However, Atkinson needle is not availabe in our setup and 27/26 G needle is routinely used. Moreover, one has to inject very slowly keeping in mind the features of inadvertent globe penetration which might be missed. Kuo et al. [TA is known to be toxic to the retina and retinal pigment epithelium, particularly at high doses. This was confirmed in our case, where 20 mg (0.5 mL) subretinal triamcinolone resulted in patchy areas of retinal necrosis Figure 1 . DespiteWe report this case to make ophthalmologists aware of this vision-threatening complication of posterior sub-Tenon injection of steroids. One should adhere to the standard practice of injecting slowly to avoid excessively forceful injection and to stop the injection as soon as any undue pressure is felt during injection.The author declares that she has no competing interests.


Granular cell tumor of the pituitary stalk is an uncommon benign lesion that usually appears like a suprasellar mass with visual disturbances. This diagnosis should be considered with the discovery of neurohypophysis tumors. Histological confirmation remains essential. We describe one case of this rare entity and review the literature. No calcA surgical intervention was planned but only subtotal resection was possible because of the lesion attachment to the chiasm and optic nerves. Histological examination provided the diagnosis of granular cell tumor (GCT). The postoperative course was uneventful and the patient’s progress was satisfactory. No evidence of recurrence has been identified after two years of observation.GCT of the neurohypophysis was first described by Boyce and Beadles in 1893  revealedGenerally, this is a benign, slow growing and non-secreting tumor that does not show any space-occupying effect when it is small. For the largest lesions, symptoms of compression can appear as visual disturbances (in 70% of cases) or headaches . SurprisApart from the particular location, this lesion does not show specific characteristics. It is a well circumscribed, rounded retrochiasmatic mass, hyperdense on non-enhanced CT. MRI findings show a usual isointense signal on T1-weighted images and an iso- or hypointense signal on T2-weighted images. Heterogeneous enhancement is found in twelve of the twenty-three described cases with contrast agent use. Others enhance homogeneously , 6. RegaDepending on the lesion size, trans-sphenoidal or temporal approach is selected . The aimRegrowth after resection have been reported, therefore some authors advised postoperative radiotherapy after subtotal removal, but it is still polemic. Malignant GCTs are extremely rare and none have been reported arising from the neurohypophysis .The histological examination revealed tumors composed of large and irregularly polyhedral cells, with a round nucleus, delicate chromatin, and uniform nucleoli. The most typical feature is an abundance of periodic acid-Schiff (PAS) positive granules in the ample cytoplasm. Immuno-histochemical findings vary. Some studies report a positive nuclear reaction for S-100 protein and glial fibrillary acidic protein (GFAP) which is normally expressed in the pituityctes. Both are positive in our case. Mitotic activity is here minimal, and necrosis is not seen , 10 Fig.The cellular origin of the GCTs remains uncertain. Many possible origins have been described . Some auThe differential diagnosis of primary nonadenomatous pituitary gland tumors includes 2 other entities: pituicytoma and spindle cell oncocytoma. Pituicytoma is a purely intrasellar lesion, iso-intense to gray matter on T1-weighted images and hyperintense on T2-weighted images, and enhances homogeneously after gadolinium administration. Spindle cell oncocytoma is a mixed supra and intrasellar tumor that cannot be separated from the pituitary gland, and also presents a homogeneous enhancement after gadolinium administration. A panhypopituitarism is more common . More brIn conclusion, the lesion we described here is rare but nevertheless should be included in the differential diagnosis of a suprasellar mass, especially if well circumscribed, and in conjunction with visual disturbances.The authors declare that they have no competing interests.


Diagnosing an osteoid osteoma as a benign tumor can be challenging owing to its different presentation patterns, ambiguous radiological findings and unusual sites of involvement. The present case report involves a 30-year-old female patient with a large osteoid osteoma of the thoracic vertebrae as an uncommon site of its presentation.The patient presented with a one-year history of progressive right-sided upper back and interscapular pains. She was identified as a candidate for surgery using the whole body bone scan and a multiple detector computed tomography (MDCT) scan. A large 25-mm osteoid osteoma of the lamina of the third thoracic vertebra (T3) was also diagnosed through histopathology.As a potential cause of persistent back pain in young adults, an osteoid osteoma may be easily missed by routine radiographs. The CT scan is an effective tool in the investigation of the size and location of this tumor. Surgical excision can also be used for treating spinal lesions. An osteoid osteoma is a benign osteoblastic tumor that normally develops in long bones and rarely in the thoracic spine , 2. ThisA 30-year-old female presented with a one-year history of progressive right-sided upper back and interscapular pains with no history of fever, night sweating, trauma and radicular pains. She reported exacerbating conditions at night along with coughs and sneezes. She still complained about the pain despite using medicines such as aspirin; nevertheless, her partial response to nonsteroidal anti-inflammatory drugs had positively affected her sleep patterns. Moreover, the magnetic resonance imaging scan of her thoracic spine performed one year before was reported as normal. Different evaluations ultimately diagnosed her with myofascial pain syndrome. Depo-Medrol plus lidocaine injected into a right rhomboid muscle failed to relieve the symptoms. Four months after the injection, she presented to the physical medicine clinic with severe upper back pains and anorexia-associated weight loss. She reported no history of serious health conditions, including chronic infections, metabolic diseases and malignancies, in either herself or her family. Furthermore, examinations suggested neither deformities nor apparent abnormalities. Her muscle bulk and tone were also found to be normal. A point of tenderness was, however, detected in the midline thoracic spine at the level of T3. Neurological examinations were also unremarkable. Moreover, routine laboratory tests suggested no abnormalities. The patient was then referred to an infectious disease specialist for further workup for mycobacterium tuberculosis, and all the results were reported as normal. The whole body bone scan showed an increased uptake at T3 . In the An osteoid osteoma is a benign tumor that is commonly found in young patients. The lesion was first described by Jaffe in 1935 as a true neoplasm and histologically as a dense sclerotic overgrowth of bone with a highly-vascularized nidus containing varying levels of lymphocytic infiltration . In addiThe condition often remains undiagnosed for at least six months after the emergence of the symptoms. The small size of the lesion, the complexity of spinal anatomy and the overlapping areas of soft tissue shadows usually cause routine radiographs to fail to pick up spinal osteoid osteoma. A CT scan is the best visualization technique for the nidus, and can exactly delineate the origin, size and location of the tumor, and helps with planning surgical excision , 9. HistAs a potential cause of persistent back pain in young adults, a spinal osteoid osteoma may be easily missed by routine radiographs, and a high degree of clinical suspicion is required if it is not associated with scoliosis or neurological deficit. The CT scan is an effective tool in the investigation of the size and location of this tumor. Surgical excision can also be used for treating spinal lesions.


Neurological exam was normal with no motor weakness and sensation was intact. Plain radiographs showed no evidence of abnormality, including instability and other pathologic findings. Magnetic resonance imaging (MRI) revealed an epidural mass posterior to the L5 vertebral body that was isosignal to subcutaneous fat and it compressed asymmetrically on the right side of the cauda equina and the exiting right L5 nerve root on sagittal (A) and axial (B) T2 weighted images. There was no evidence of spinal stenosis. The result of electromyography was normal. We recommended surgical intervention to relieve pain but the patient declined. Opioid analgesia has been prescribed and her symptoms became much improved. Weight reduction by physiotherapy and exercise resulted in complete loss of lumbar pain (the patient lost 30kg in 6 months) and MRI control showed a complete disappearance of the mass.Spinal epidural lipomatosis (SEL) is defined as normal adipose tissue that is pathologically overgrown in the epidural space of the spinal canal. It usually occurs in obese people, patients with history of corticosteroid use or endocrinopathy. They usually present with gradually progressing symptoms and are rarely associated with rapidly aggravated neurologic deficits. Radiologic assessments are mostly conducted by using MRI. A 65-year-old woman presented with isolated low back pain. She had no history of corticosteroid use, endocrinopathy or radicular pain. On examination, she was obese  with a body mass index (BMI) of 56.1 kg/m


A 38-year-old man with longilinear shape, smoker (38 packs/year) and no other relevant medical history was referred to our department due to the finding of left pulmonary hyperlucency on a chest x-ray. A computed tomography (CT) was performed and a giant emphysematous bulla with thin-walled partitions inside was shown that replaced almost the entire left upper lobe, The patient underwent an exploratory thoracoscopy. Intraoperatively a giant bulla was seen that initially impressed to replace the entire upper lobe. Despite the large size we decided to attempt thoracoscopic resection preserving the remaining healthy parenchyma. Bullectomy was done using linear endoscopic stapling devices. To our knowledge this is the only case with such a large bulla resected entirely by VATS. Giant bullous emphysema (GBE) was first described by Burke in 1937 . SurgeryA 38-year-old man with longilinear shape, smoker (38 packs/year) with no other relevant medical history was referred to our department due to the finding of left pulmonary hyperlucency on a chest x-ray done  because GBE, sometimes referred to as Vanishing Lung Syndrome (VLS) as a clinical syndrome, was first described by Burke in 1937. It typically presents in young males cigarette smokers as in our patient and also can be associated with other conditions . Development of multiple large lung bullae (termed GBE or VLS) is a rare and progressive disease with chest radiographs showing peripheral  bullae in contrast to the more uniformly distributed bullae of centrilobular emphysema shown in smokers. High resolution computed tomography (HRCT) typically shows extensive paraseptal emphysema coalescing into giant bullae and is the best imaging to determine the extension of the disease. Surgery is indicated to treat complications related to GBE or in asymptomatic patients who have a bulla that occupies more than one-third of the hemithorax compressing healthy adjacent lung tissue and when in the clinical follow-up an increase in the size of the bulla is observed. Different thoracoscopic techniques are reported in literature and almost all are nowadays abandoned . The VATWe presented the only case with a bulla of such size resected completely by videothoracoscopy. To obtain satisfactory results, both postoperative and operative care are essential. As we mentioned, the most frequent complication is persistent air leakage and the lack of pulmonary expansion in the postoperative period. The use of adequate mechanical sutures, some type of pleurodesis and mechanical and respiratory kinesiology are key points in this type of interventions. Despite there is not enough evidence published with similar cases resolved entirely by VATS, we consider that it's a safe and feasible procedure in experienced centers.The authors declare no competing interests.


Colorectal cancer (CRC) is the 2nd most common type of cancer in females and the 3rd in males, worldwide. It occurs rarely during pregnancy and is often associated with poor prognosis, due to the unspecific manifestations until advanced stage. Majority of CRC are localized in the rectum (63%) and the sigmoid colon (20%) during pregnancy.In thisstudy, we report the case of a pregnant woman who was diagnosed with adenocarcinoma of the ascending colon at her 33rd gestational week. She was referred to our department from local hospital with low fever and right-sided flank pain, which had lasted for nearly half a year and severely aggravated for 5 days. Previous prenatal examinations contributed the pain to kidney stones or uterine contractions.After a caesarean section and tumor resection of a mass at the hepatic flexure of colon, tumor histology of frozen section confirmed the diagnosis of ulcerative adenocarcinoma of the ascending colon with a diameter of 10 cm. Final pathologic evaluation showed a grade 1 adenocarcinoma with negative lymph nodes (16/0), R0 resection, pT4b pN0 M0 and Dukes B stage.A healthy female infant was delivered by caesarean section, right after which a right hemicolectomy and ileostomy was performed. Pathology examination proved an early stage adenocarcinoma with no lymphatic metastasis. Patient received chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX) after recovery smoothly and got discharged 1 month after surgery.Patient showed no relapse or progression during the follow-up time of 2 years after operation and chemotherapy.Rare occurrence of CRC during pregnancy and limited experience concerning its diagnosis and treatment bring obstacle to both patients and physicians. Symptoms as constipation and abdominal pain must be inspected carefully. With a perfect coordination between different disciplines, CRC with pregnancy can be ideally treated with better prognosis. Reported incidence in pregnant women is 0.002% and the majority of tumors were localized in the rectum (63%) and the sigmoid colon (20%), which is contrary to the general population, and Dukes stage at presentation was B or higher in all patients.Colorectal cancer (CRC) is the 2nd most common type of cancer in females and the 3rd in males worldwide,Typical symptoms of CRC include nausea, vomiting, abdominal pain, and altered bowel movements. All the symptoms above can be misdiagnosed as common symptoms of normal pregnancy. Considering the potential risks of further diagnostic tests to the fetus such as colonoscopy or computed tomography (CT), physicians and patients tend to ignore the underlying risks. Perhaps due to the immunotolerance which accompanies pregnancy, colon obstruction, perforation, and metastatic spread seem to occur more frequently in these patients, which leads to the advanced development of malignancy and poorer prognosis.Because of the rare occurrence of CRC during pregnancy, there is limited experience concerning its diagnosis and treatment, which requires more knowledge and clinical experience to support both patients and physicians. To the best of our knowledge, we present the rare case of adenocarcinoma of the ascending colon during pregnancy in this study. The patient was successfully treated surgically and a healthy female infant was delivered by caesarean section.2A 31-year-old woman  was referred to our department from local hospital at 33rd weeks gestation with low fever and right-sided flank pain, which had lasted for nearly half a year and severely aggravated for 5 days. As the patient recalled, previous prenatal examinations in local hospital contributed the pain to kidney stones or uterine contractions without any further inspection. After local outpatient treatment with antibiotics, progesterone and Nonsteroidal Antiinflammatory Drugs (NSAIDs), she was admitted to our department as the pain aggravated. She denied any vomiting, hematochezia, or difficulty with urination.Moderate iron deficiency anemia, occasional dyspepsia, and diarrhea were present during the whole gestation period. At the time of presentation, patient had no family history of gynecologic or CRC. Physical examination revealed right-sided abdominal pain on palpation and normal bowel sounds. Vital signs are normal. Body mass index 24.8. Obstetric examination showed no abnormalities. Initial laboratory results included a mildly elevated white cell count and hemoglobin 7.6 g/dL and a mean corpuscular hemoglobin 26.7 pg. Her serum potassium was 4.0 mmol/L. Liver function tests showed the serum albumin was 20 g/L. Urinalysis and routine excrement examination remained normal with no occult blood. Tumor markers serum carcinoembryonic antigen (CEA) was elevated to 70.68 ng/mL. Abdominal ultrasound showed a large heterogeneous cystic mass located below the hepatic flexure of colon. Considering the extremely low risk of radiation teratogenicity in late pregnancy, an abdominal CT scan without contrast was obtained, which revealed incrassation of the ascending colon wall and exudative change around it Fig. . MultiplAfter a detailed discussion in a multidisciplinary medical team, a planned delivery by caesarean section and tumor resection during the same operative procedure was performed, following the induced fetal lung maturation by dexamethasone. Intraoperatively, a palpable tumor mass at the hepatic flexure of colon with a diameter of 15 cm was identified, with the right lobe of the liver and perirenal adipose tissue involved. Mucopurulent discharge could be found through the rupture on the necrotic mass. Further abdominal exploration revealed paracolic lymph nodes, intermediate lymph nodes, and middle lymph nodes pathologically enlarged, with none metastatic lesions on pancreas or duodenum. Both adnexa and the rest of the peritoneal cavity also appeared normal. A 1550-g live female infant with an Apgar score 10-10-10 was delivered at 33rd of gestation. A right hemicolectomy and ileostomy were performed right after the cesarean section. Tumor histology of frozen section confirmed the diagnosis of ulcerative adenocarcinoma of the ascending colon with a diameter of 10 cm. Final pathologic evaluation showed a grade-1 adenocarcinoma with negative lymph nodes (16/0), R0 resection, pT4b pN0 M0, and Dukes B stage. The postoperative course was uneventful while patient received chemotherapy with folinic acid, fluorouracil, and oxaliplatin (FOLFOX) after recovery smoothly and got discharged 1 month after surgery. Patient showed no relapse or progression during the follow-up time of 2 years.Written informed consent was obtained from the patient for publication of the present case report and any relevant images.3–10 which possess a peak incidence during the woman's reproductive period. CRC presents in only 1 in 13,000 pregnancies. There has been much controversy on the role of estrogens and progestogens in malignancy during pregnancy. Neoplastic cell cultures in vitro can be stimulated by elevated estrogens and progestogens. On the contrary, recent report showed the incidence of CRC is not influenced by the number of gestations or contraceptive use. Experimental data reported a lack of estrogen/progesterone receptors in CRC. However, a prospective study showed that parity may reduce the risk of colon cancer among women as a result of modifications of hormone profiles. Possible mechanisms include hormonal effects on bile acid metabolism,13 and immunologic influences of ABO-incompatible fetal antigens.The most common malignancies complicated with pregnancy are breast cancer, cervical cancer, lymphoma, ovarian cancer, and melanoma, During pregnancy, CEA levels are inevitable increased but within normal range. But elevated CEA value before surgery can be used as a prognostic factor for recurrence and disseminated disease. Colonoscopy is the most definite diagnostic tool which can provide precise biopsy and pathologic examination in general patients with CRC. However, during pregnancy colonoscopy possess the potential risks of uterine pressure, placental abruption, and fetal injury. Abdominal ultrasound is a rather safe diagnostic method compared to CT, which is the standard imaging technique used for determining CRC. Magnetic resonance imaging (MRI) is the imaging tool of choice as abdominal CT is contraindicated in pregnancy for its radioactive teratogenic and carcinogenic effects on the fetus. Unenhanced MRI is preferred because safety of contrast agents during pregnancy has not been proved. In this case, a plain abdominal CT is obtained instead of MRI because the contraindications during this gestational period is relatively negligible. Meanwhile a CT scan is more detailed on the depth of carcinoma tissue infiltration, lymph node metastasis, and birth canal obstruction. There has been researches showing that CRC pose no threat to the fetus. It is reported that 25 patients delivered normal infants among 32 cases of pregnancy complicated by colon carcinoma. Metastasis to the placenta or embryo is extremely rare as only 1 case has been reported till now, and the infant proved to be normal in the follow-up of 8 months.Diagnosis of CRC during pregnancy is quite challenging and often delayed because the symptoms  are unspecific and usually attributed to general manifestations of pregnancy without further diagnostic tests considering the potential fetal risks. Therefore, pregnant women are diagnosed with locally advanced or metastatic CRC more often than general population and have a substantially poorer prognosis. Artificial abortion should be considered on personal wishes. Adjuvant chemotherapy or radiotherapy depends on the stage of the cancer. Three cases have been reported of chemotherapy use during pregnancy without any observable adverse effect on the fetus.–23 Gestational weeks ≥20 weeks: the operation is recommended to be delayed until a viable fetus is delivered (28–30 weeks), with certain drugs administered to induce fetal lung maturation. Choice between vaginal delivery and caesarean section has been controversial among authors. Resection of tumor should be performed usually 1 to 2 weeks after vaginal delivery when the involution of the uterus and resolution of vascular congestion of pelvic structure completes. In this case, we chose cesarean section to avoid high pressure or trauma to the tumor during vaginal delivery and reduced the harm to the patient by performing tumor resection at the same setting.To optimally treat the mother and minimize the side effect on the fetus, treatment of CRC during pregnancy must be considered thoroughly from many aspects, including the gestational stage, elective or emergency presentation, the progression of the disease, and the wishes of the patient. Gestational weeks ≤20 weeks: surgical resection is recommended right after diagnosis to minimize the progression of malignancy. The incidence of premature delivery and low birth weight followed operation is reported to be double that of the general normal pregnancies.,26 Visual inspection and biopsy of ovaries are highly recommended in the operation, but ovariectomy should not be performed unless metastasis is detected or hysterectomy is unavoidable. Chemotherapy is recommended in patients of Dukes C stage or incomplete excision of the tumor. The 5-fluorouracil-based chemotherapy is relatively safe during the 2nd and 3rd trimester of gestation with lower risk of abortion or malformation (2–3%) compared to the first trimester (15–25%). However, growth retardation and premature labor can still be found, which leaves the decision-making process to the patient herself about whether to apply chemotherapy. Radiotherapy is abandoned during pregnancy and not recommended with the patient willing to bear again since colon cancer is not sensitive to radiotherapy and ovarian function can be devastated.Incidence of metastasis to ovaries in CRC is reported to be 3% to 8% among general population but 25% during pregnancy. In conclusion, early diagnosis, active treatment and more attention to unspecific symptoms from clinicians during pregnancy is the key to reverse this unfavorable situation.The prognosis of CRC is about the same at each stage for both pregnant and general patients. However, gravid women are usually delayed in diagnosis, which leads to more advanced and malignant disease and poorer prognosis. In a research of 39 cases of CRC during pregnancy in United States, 16 were diagnosed at Dukes B stage, 17 at Dukes C, and 6 at Dukes C.Investigation: Youzheng Xu.Supervision: Beihua Kong, Keng Shen.


Developmental defects in the Mullerian ducts can result in several uterine anomalies including a unicornuate uterus with a rudimentary horn. Pregnancy in a rudimentary horn is extremely rare occurring in 1:76,000-1:160,000 pregnancies. We present a case of an 18-year-old primigravida with a ruptured rudimentary horn pregnancy (RHP) presenting as acute abdomen at 17 weeks of gestation. Hemodynamic instability led us to perform a life-saving emergency laparotomy. A 1.5 liters hemoperitoneum was encountered with a ruptured non-communicating rudimentary horn. Excision of the horn and unilateral salpingectomy was performed. In addition to ectopic pregnancy and appendicitis, rare uterine anomalies must also be considered in patients presenting with an acute abdomen especially after 10 weeks of gestation. Basic diagnostic facilities may not be available in developing countries. Therefore, clinicians must be aware of this rare entity in order to manage such patients efficiently. Several uterine anomalies occur due to developmental defects in the Mullerian duct, the incidence of which ranges from 0.1%-3% .th week of gestation by last menstrual period, presented to the emergency department with complaints of severe abdominal pain and two episodes of syncope since last three hours. The pregnancy followed spontaneous conception in a non-consanguineous marriage of six months and was confirmed by a urine pregnancy test at home.She developed acute, severe, lower abdominal pain, stabbing in nature and associated with shoulder tip pain. There was no history of dysmenorrhea prior to pregnancy. Past medical and surgical history was insignificant. She was an unbooked case, hence no records of routine pregnancy scans or investigations were available.On arrival, the patient was conscious, well-oriented, and afebrile. General examination revealed severe pallor and hypovolemic shock. Blood pressure was 50/30 mmHg and pulse rate was 120 beats per minute. The abdomen was found to be tense, tender, and mildly distended. Pelvic examination demonstrated a healthy vagina. The cervical os was closed with no evidence of bleeding. The size of the uterus could not be determined due to intense guarding. Cervical excitation was found to be positive. Tenderness and fullness were present in both fornices.Her investigations showed hemoglobin of 7.6 g/dl and raised total leukocyte count of 22.5 x103 while serum electrolytes, urea, creatinine, and coagulation profiles were normal. She was immediately managed with two intravenous cannulas for fluid resuscitation and was catheterized. Blood was sent for cross match and four units of blood were arranged. A provisional diagnosis of ectopic pregnancy was made and she was transferred to the operation theatre for emergency exploratory laparotomy.The abdomen was opened by a Pfannenstiel incision and a hemoperitoneum of 1.5 liters was encountered along with an extrauterine 17-week fetus floating in the peritoneal cavity. Further exploration revealed a right-sided ruptured non-communicating rudimentary horn (5 cm x 4 cm) attached to the uterine cavity with a 2.5 cm fibrous band (Figure An 18-year-old primigravida, at 17Intravenous urography was performed which revealed no urological abnormalities. Histopathologic examination of the specimen confirmed the diagnosis of a unicornuate uterus with a non-communicating rudimentary horn. Following an uncomplicated recovery, the patient was discharged on the fourth postoperative day.Pakistan has had limited success in reducing maternal and neonatal deaths with a maternal mortality ratio of 276 per 100,000 pregnancies . PreviouThe diagnosis of RHP is particularly difficult in developing countries such as Pakistan. Substandard antenatal care and lack of access to basic diagnostic services such as ultrasonography and MRI may cause delayed recognition and management of several clinical anomalies contributing to maternal and perinatal mortality. Therefore, clinicians must be aware of this rare entity in order to achieve timely management.


We report a case of meningioma with both secretory and lipomatous features in an advanced middle aged female patient with a 3-month history of headaches and convulsions. Radiological findings are revised and compared to other reported cases in the literature. Meningioma is a central nervous system tumor arising from the arachnoid cells present in the arachnoid mater. It is the most common primary tumor of the brain; 33.8% of all primary central nervous system tumors are reported in the United States between 2002 and 2006 . SecretoA 65-year-old female patient was admitted to the hospital complaining of headaches and convulsions over the previous three months. The patient was conscious and alert with stable vital signs. Computer tomography (CT) scan showed a well-defined left-temporal extra-axial lesion of mixed density, predominantly hypodense (fat density), causing calvarian bone hyperostosis with a localized mass effect on the adjacent temporal lobe. Significant vasogenic edema with associated effacement of the left hemispheric sulci, compression of the ipsilateral ventricle, early left uncal herniation, and a rightward midline shift also were noted. MRI showed a dural-based focal mass in the left-temporal lobe exhibiting a mass effect on the adjacent parenchyma and a large area of perifocal edema (delete vasogenic) causing compression of the ipsilateral ventricle and approximately 6mm midline shift towards the right. Evidence of a high fat component (high T1 and T2 mass) showing avid enhancement with a dural tail sign was present Figures . As a reUpon examination in our laboratory, we found a firm, well-circumscribed, white/tan mass attached to the dura. The cut surface showed yellowish fatty tissue interwoven with firm fibrous tissue. Microscopically, the tumor was composed of meningotheliomatous tumor cells with classic whorls in addition to hyaline inclusion bodies scattered throughout the examined tissue, representing the secretory component Figures . These hAlthough meningothelial meningioma is quite common, the presence of secretory and lipomatous features in the same tumor is exceptional and deserves studying and reporting. Secretory meningioma is identified radiologically by predominantly hypo-to iso-signal T1 weighted and hypersignal T2 weighted (T2 flair) MR images. These findings have been related to soft tissue consistency and the severe peritumoral brain edema. The predominant finding on MR images is a strongly enhanced, homogeneous tumor. Dai-Jun Wang and his colleagues call this enhancement, “xenon light” like enhancement comparable to the enhancement of secretory meningiomas . HistoloOur case demonstrates both secretory and lipomatous elements within conventional meningioma, as demonstrated by both radiological and pathological studies. It shows mixed density on CT scan. MRI revealed evidence of both peritumoral brain edema and fat components. The key features of our case in comparison with the previous reported cases are summarized in the table . Each of


First described in 1945 by Morehead and Bowman, uterine tumors resembling ovarian sex-cord tumors (UTROSCT) are rare tumors of the uterine body that tend to occur in menopausal women presenting with abnormal vaginal bleeding, abdominal pain, and increased uterine volume. UTROSCT are usually diagnosed from incidental histological findings following hysterectomy performed due to a suspected endometrial polyp or uterine fibroids. To report on a 46-year-old patient with abnormal vaginal bleeding. At physical examination, a pediculated nodular lesion was found protruding from the external cervical os. Histopathology of the resected lesion led to a diagnosis of UTROSCT. Total abdominal hysterectomy with bilateral adnexectomy was then performed. The patient is currently undergoing regular outpatient follow-up, with no evidence of disease after one year. Data were retrieved from the patient's records, and macroscopic and microscopic images of the tumor were obtained. Reports of metastasis or recurrence are rare. UTROSCT are considered of uncertain malignant potential and no particular form of treatment is formally recommended, with hysterectomy currently being the treatment of choice. This patient will be followed up for five years during which clinical examination and tomography of the chest, abdomen, and pelvis will be performed annually. Uterine tumors resembling ovarian sex-cord tumors (UTROSCT) represent a rare form of tumors that affect the uterine body . Up to tMorehead and Bowman published the first descriptions of UTROSCT in 1945 . In 1976Clinically, these tumor types generally occur in menopausal women, who may present with symptoms of abnormal vaginal bleeding, abdominal pain, and increased uterine volume . TreatmeThis paper describes the case of a 46-year old patient with abnormal vaginal bleeding. She presented with a pelvic mass, identified at histopathology as a UTROSCT. Her follow-up and treatment after diagnosis are discussed.A 46-year-old, brown-skinned woman with regular menstrual cycles and one child presented at the gynecology department of a philanthropic hospital in Vitória, Espírito Santo, Brazil, reporting a 6-month history of intense vaginal bleeding associated with abdominal pain. She had suffered vaginal discomfort over the previous week. She had no prior history of allergy, comorbidities, use of medication, or surgery. There was no family history of gynecological cancer. At physical examination, she was found to be in good general health, alert, pale, with a flaccid abdomen, and no signs of peritoneal irritation. A hypogastric mass was detected. There were no vulvar lesions. Speculum examination showed no lesions in the vagina but revealed the presence of a bleeding mass extruding from the external cervical os and associated with intense bleeding at manipulation. At bimanual pelvic examination, it was possible to palpate the pedicle of the lesion through the cervical os.In view of the initial diagnostic hypothesis of a prolapsed fibroid, vaginal myomectomy was performed. There were no complications following surgery and the patient was discharged from hospital the following day in good clinical conditions.Macroscopically, the pinkish-colored nodule measured 3.5 x 3 x 4 cm . MicroscImmunohistochemistry confirmed the diagnostic hypothesis of a UTROSCT, with positive expression for CD56, smooth muscle actin, CD10, desmin, and pan-cytokeratin. The immunohistochemical markers for calretinin and inhibin were negative .The patient was readmitted to the department and metastatic screening was performed using computed tomography (CT) of the abdomen and chest. No abnormalities were found in the chest CT results. However, abdominal imaging showed the uterus to be greatly increased in size, with heterogeneous enhancement, an image resembling a cyst, probably of ovarian origin, in the left parauterine region, and a small amount of free fluid in the pelvis. No other abnormalities were found.Serum levels of carcinoembryonic antigen (CEA) and CA 125 were <50 ng/ml and 15.50 U/ml, respectively.Once the possibility of implantation metastasis had been ruled out, it was decided to submit the patient to a total abdominal hysterectomy with bilateral salpingooophorectomy. When accessing the abdominal cavity, a small amount of ascites was found and the left ovary was increased in volume, with a cystic appearance. The cecal appendix was normal. There were no complications following surgery and the patient was discharged from hospital the following day.Histopathology performed on the surgical specimen obtained during the latest surgical procedure revealed uterine fibroids and focal adenomyosis, an endometrium with simple hyperplasia and no atypia, and a cervix with chronic cervicitis and squamous metaplasia. The right ovary was normal, while a hemorrhagic corpus luteum cyst was found on the left ovary. There was no sign of any residual UTROSCT.The patient has been followed up regularly at the gynecological oncology outpatient department and remains asymptomatic one year after the second surgery. She will continue to be followed up as an outpatient for five years, with clinical examination and tomography of the chest, abdomen, and pelvis performed annually. At the end of the follow-up period, she will continue to undergo annual gynecological and clinical examination.A 46-year-old patient with abnormal vaginal bleeding underwent a surgical procedure to remove a pediculated nodular lesion protruding from the external cervical os. Histopathology led to a diagnosis of UTROSCT. Total abdominal hysterectomy with bilateral adnexectomy was then performed. Uterine fibroids and focal adenomyosis were identified in the surgical specimen, with no findings of residual UTROSCT. The patient is currently undergoing regular outpatient follow-up, with no evidence of disease after one year.In 1976, Clemente and Scully classified these tumors into two groups: Group 1: ESTSCLE and Group II: UTROSCT. In ESTSCLE, less than 50% of the total tumor mass is composed of structural areas resembling sex cords and the tumor behavior is malignant in around 15% of cases , 5. On tAs in the case reported here, UTROSCT are more common between the fourth and sixth decades of life, with the principal symptoms being abnormal uterine bleeding and pelvic pain. Because of the rarity of this type of tumor, its incidence and mortality rates remain unknown .Diagnosis can only be confirmed by histology after tumor resection, in most cases incidentally following hysterectomy performed because of a suspected endometrial polyp or uterine fibroids. Up to the present time, no noninvasive diagnostic tests such as specific serum markers or imaging findings have become available . AlthougMicroscopically, these tumors are well demarcated; however, in rare cases they can be infiltrated between muscle fibers and may present with different microscopic forms such as sheets, tight nests, thin cords, trabeculae with wide interconnections, irregular islands, and hollow or solid tubules, with varying amounts of fibrous or hyalinized stroma. Cells with small amounts of clear or foam eosinophilic cytoplasm remaining from Sertoli and granulosa cells may be present. Typically, mitotic indexes are low with this type of tumor. It should also be emphasized that neoplastic endometrial stroma should not be found in the histological analysis of UTROSCT . DiffereThe tumor site varies and it may be submucous, intramural, or subserous. In the present report, the tumor was submucous, since pathological analysis of the uterine body showed no sign of the tumor after it had been removed . ImmunohThere are few reports of metastasis and recurrence in the literature. In a systematic review published in 2018 that evaluated prognostic factors of recurrence in UTROSCT, recurrence rates of 6.3% were found for the 79 patients evaluated. Disease-free survival is high and is associated only with the type of surgery: 86% for patients submitted to resection of the tumor alone and 96% for those submitted to total hysterectomy, both for a five-year period . The UTRAlthough there is currently no consensus with respect to the follow-up regimen for cases of UTROSCT, the patient in the present report is undergoing annual outpatient follow-up, with no signs of metastasis or tumor recurrence twelve months after surgery. She will continue to be evaluated for five years, with clinical examination and tomography to assess for metastases in abdominal and pelvic organs.This is the first reported case of a UTROSCT in a prolapsed fibroid protruding into the vagina through the cervix. The initial surgical procedure performed  would have been sufficient to completely resect the tumor in this case, since histopathology following the second procedure  failed to detect any signs of residual UTROSCT, confirming the low malignant potential of this type of tumor.


An 8-year-old female spayed Dachshund presented with an acute onset of dysuria, dyschezia, and painful perineal protrusion. A perineal hernia was ruled out on digital rectal examination, and blood work was unremarkable. An extremely dilated vagina was identified on computed tomography, and hydrocolpos was suspected. Endoscopic vaginal exam confirmed the diagnosis of imperforate hymen. The membrane was ruptured digitally and remnants were removed endoscopically, resulting in resolution of clinical signs. Imperforate hymen is a rare congenital abnormality that can result in extensive fluid accumulation within the vagina and subsequent compression of local structures or secondary infection. Treatment of hydrocolpos includes membrane perforation and removal.  Congenital abnormalities of the female canine reproductive tract are uncommonly seen in veterinary practice, with reported occurrence in 0.02–0.05% of the canine population . An impe Staphylococcus organism were grown from the culture, and treatment was changed to marbofloxacin. The dog also had a 2-day history of tenesmus associated with the appearance of the perineal protrusion. The dog had been spayed 2 years prior to presentation after multiple types of unsuccessful breeding.An 8-year-old female spayed Dachshund weighing 7.45 kg was presented to the University of Tennessee Veterinary Medical Center with a large, firm, bilaterally symmetrical, painful protrusion in the perineal region that had appeared acutely 2 days before presentation. The dog had a one-month history of dysuria and pollakiuria that was suspected to be a urinary tract infection; when the dog did not respond to amoxicillin-clavulanic acid, a free catch urine sample was submitted for culture. A few colonies of aPhysical exam abnormalities revealed an otherwise normal dog with an approximately 5 × 4 × 2 cm firm, painful protrusion on midline of her perineal region, ventral to the anus. A fluid-filled structure was noted ventral to the rectum and distal colon on digital rectal exam; no pelvic diaphragm weakness was palpable, making perineal hernia unlikely. Serum chemistry and complete blood count were unremarkable.The dog was anesthetized for computed tomography (CT) and vaginoscopy. On abdominal and perineal CT Figures , a largeOn digital vaginal exam, a large, thin-walled, fluctuant structure was palpably filling the vaginal lumen just cranial to the urethral meatus. Digital pressure was used against the wall of the structure to perforate it; approximately 200 mL of brown, mucoid fluid was immediately released from the vulva. A sample was collected for cytology and culture. Within a minute, the drainage had ceased, and vaginoscopy was performed, revealing remnants of an imperforate hymen just cranial to the external urethral orifice. No fluid remained in the distended vagina, and no other abnormalities were seen. The remainder of the hymen was removed endoscopically with grasping forceps and submitted for histopathology.On cytology, the fluid was moderately cellular, primarily consisting of neutrophils with rare clusters of epithelial cells. No bacteria were seen on cytology, and no organisms were cultured from the fluid. Histologically, the tissue was composed of a dense band of fibrous connective tissue covered by a nonkeratinized stratified squamous epithelium. It contained a medium-sized blood vessel and several smaller blood vessels that were surrounded by rare neutrophils. Findings were consistent with the hymen of a nonpregnant mammal. After recovery, the dog's dysuria, pollakiuria, and perineal swelling resolved. The dog was discharged with instructions to complete the previously prescribed course of marbofloxacin. At follow-up 2 months later, the dog was clinically normal.Hydrocolpos secondary to imperforate hymen has been described in several case reports –6. In thBecause of the acute appearance of a mass in the perineal region in this older bitch, computed tomographic imaging was performed to rule out neoplasia, perineal herniation with organ entrapment, and other causes of local swelling, such as infection or hemorrhage. In previous reports, hydrocolpos has been diagnosed with survey radiographs and ultrasonography –5. PotenVarious treatments of imperforate hymen have been described, including fenestration ; ovarioh


Duodenal fibrolipoma and duodenum-jejunum intussusception are both rare occasions in clinical practice. The diagnosis of duodenal fibrolipoma mainly depends on endoscopy examination, supplemented by CT and MRI. As the tumor grows, some severe symptoms need surgical intervention. As the development of endoscopic techniques, the operation plan should be made individually.A 47-year-old female with the complaint of upper abdominal pain and melena was reported. Abdominal examination revealed upper abdomen lightly tender and blood test showed severe anemia. Image and endoscopy examination exhibited “a giant mass” in the descending (D2) part of duodenum, dragged by the tumor into the distal intestinal canal and causing intussusception. Intermittent blood transfusion treatment, enteral and parenteral nutrition were adopted to adjust her general state. Two weeks later, the mass was resected together with the basement intestinal wall via the jejunum incision and then the intussuscepted D2 part was restored. The paraffin pathological diagnosis correlated with the preoperative judgment of fibrolipoma and the patient was discharged healthy on POD 14.Duodenal fibrolipoma is a rare disease, infrequently causing intussusception and severe upper GIB. Duodenoscopy and endoscopic ultrasound contribute to making an appropriate diagnosis, and for patients with severe symptoms needed surgical intervention, operation plan should be individualized depending on the size and location of the lesion. Gastrointestinal fibrolipoma, especially occurring in duodenum, is a kind of benign tumor of extremely low morbidity and detection rate, accounting for only 5–6% of all gastrointestinal tumors . Giant dThe patient, a 47-year-old female, was admitted to our hospital with the complaint of upper abdominal pain and melena for 1 month. After once eating oysters 1 month ago, the patient developed a cold feeling with pain in the upper abdomen. One week later, she gradually developed acid reflux, melena and reduced stool volume, whose frequency of melena was 2–3 times a day. In terms of physical examination, the whole abdomen was soft, no gastrointestinal type and peristaltic wave were seen, the upper abdomen was lightly tender, no mass was touched, and the bowel sounded normal. Admission test showed severe anemia (HGB 47 g/L), with liver and kidney function and tumor markers normal. Intermittent blood transfusion treatment, enteral and parenteral nutrition were adopted along with the appearance of nearly complete intestinal obstruction.99mTc-RBC gastrointestinal bleeding site determination was performed, which showed the 6th group of intestine would be the bleeding site and no abnormal radioactive elevation was observed in duodenum and proximal jejunum.The upper digestive tract radiography showed a mass-like filling defect in the D3 and D4 part of duodenum, and no obvious damage of mucosa was observed, considering the possibility of a submucosal lesion Fig. a. AbdomiAn Elective laparoscopic exploration was performed. Intraoperatively, a mass, about 5 × 4 cm in diameter, was found in the jejunum near Treitz ligament, and after opening the duodenal collateral ligament, the D2 part of duodenum was found incarcerated into the D3 part, D4 part and jejunum, which presented the “vortex sign” (Fig. Duodenal fibrolipoma is a rare benign tumor of the small intestine, accounting for 28.6% of small intestinal fibrolipoma . On accoThe combination of endoscopic orthoptic findings and endoscopic ultrasonography findings, the clinical diagnosis of duodenal fibrolipoma can be basically confirmed . BecauseIn this case, the duodenal fibrolipoma was characterized that the lesion originating from the D2 part gradually drove the local intestine sheath into the D3 part at the beginning of occurrence. As the lesion grew, the tumor was “incarcerated”, which made the D2 part difficult to be restored and formed duodenum-jejunum intussusception finallly. Because the duodenum is a retroperitoneal organ and the duodenal mesentery is short, its position is relatively fixed and less intussusception occurs. Once it is intussuscepted, it usually combines with a large mass inside or congenital small intestine dysplasia. Duodenum-jejunum intussusception previously reported often involved the D3 and D4 part of duodenum and our case shoule be the first report of D2 part-jejunum intussusception .99mTc-RBC gastrointestinal bleeding site determination, both failed in detecting the real bleeding site. For endoscopy, its body was blocked by the tumor in the D2 and D3 part and the “mass” we saw was in fact the adjacent mucosa. Then for nuclear scan, as the tumor bled intermittently, the residual blood affected the accuracy of the result.Moreover, the patient was combined with severe anemia which was difficult to be corrected by blood transfusion. As a matter of fact, our preoperative examination, duodenal endoscopy and In summary, duodenal fibrolipoma is a rare disease, which should be considered when encountered with the unexplained upper gastrointestinal bleedind. Duodenoscopy and endoscopic ultrasound should be conducted to confirm the diagnosis, and for patients with severe symptoms, surgeons should take surgical intervention and individualize the surgical plan.


Although craniopharyngioma (CP) and pituitary adenoma (PA) are common tumors of the parasellar lesions, the coexistence of CP and PA is very rare. A 48-year-old male visited our hospital because of consciousness disturbance. The neuroimaging revealed a sellar tumor contact with a massive suprasellar cyst including calcification. Preoperative diagnosis was CP, and the patient underwent craniotomy to resolve the suprasellar mass effect. The histological examination disclosed adamantinomatous CP, and subsequently a transsphenoidal approach was chosen for the residual intrasellar tumor. Against expectations, the histological diagnosis was not CP but PA. The patient underwent gamma knife surgery for the residual tumor, and the postoperative course was good. After a 10-year follow-up, both lesions were still completely controlled. If we had suspected and diagnosed the tumor involved as not only CP but also PA at the first operation, the second operation could have been avoided because we would have chosen gamma knife surgery for the residual tumor. We should draw attention to this rare situation for differential diagnosis of parasellar tumor to avoid unnecessary surgery and to decide the best strategy for treatment. In addition, the biological behavior of collision tumors composed of CP and PA is probably the same as solitary CP or PA based on a long-term follow-up of our case. Although craniopharyngioma (CP) and pituitary adenoma (PA) are common tumors of the sellar or suprasellar lesions, the coexistence of CP and PA is very rare. The lack of attention on this rare condition may occasionally bring unnecessary surgery to the patients. To the best of our knowledge, there have been 14 reports involving a CP and a concomitant PA. Herein, we present 15 cases of collision tumors composed of CP and PA with a 10-year follow-up. The clinical features and treatment strategy of these collision tumors are discussed along with a literature review.A 48-year-old male visited our hospital because of remissness and memory disturbance lasting up to several weeks. First, he had been suspected of suffering from sleep apnea syndrome and was psychiatrically hospitalized. Intracranial magnetic resonance images (MRI) for screening revealed an intra- and suprasellar mass in contact with a large cyst, and he was referred to our division.Neurological examination demonstrated mild memory disturbance and right homonymous hemianopsia. A computerized tomography (CT) scan and MRI revealed a massive sellar tumor in contact with a massive suprasellar cyst extending beyond the bilateral cavernous sinus and into the body of the left lateral ventricle. The midline structures  were severely displaced by the cyst. Part of the cyst wall was calcified on the CT scan . The selμU/ml), luteinizing hormone (LH): 2.6 , follicle-stimulating hormone (FSH): 2.8 , and prolactin (PRL): 22.0 ), the pituitary responsiveness was disturbed for LH, FSH, GH, PRL, and cortisol.Although the baseline values of the pituitary glands were almost within the normal range (growth hormone (GH): 2.2 , adrenocorticotropic hormone (ACTH): 43 , thyroid-stimulating hormone (TSH): 4.09  to both the residual intra- and suprasellar tumors. After a 10-year follow-up at our outpatient clinic, both lesions were still completely controlled Figures .There have been 14 reports involving a CP and a concomitant PA. Their clinicopathological features are summarized in As for radiological findings, it is very difficult to detect the coexistence of CP and PA. In fact, all reported 14 cases failed not only to detect but also to suspect the coexistence of CP and PA before the surgery. In particular, in 8 cases for which the tumors were “encased” with each other, it was all but impossible to prove their coexistence until a precise pathological examination was done. On the other hand, there were 7 cases for which the tumors were “separated” and existing side-by-side. In these cases, it might be possible to suspect the coexistence of CP and PA radiologically if we bear in mind the possibility of collision tumor at parasellar lesion.The prognosis of collision tumors composed of CP and PA had been very poor, particularly before 1990, because patients were forced to undergo multiple surgeries and experienced severe postoperative complications. Since then, a favorable prognosis has been reported. However, Jin et al. reported a case of a patient who was forced to undergo two surgeries because the coexistence of CP was not detected even after the first surgery . They coIn summary, we report a very rare collision tumor composed of a large cystic CP and nonfunctioning PA. It could be suspected that this case was CP concomitant with PA by preoperative MRI retrospectively. We should draw attention to this rare situation for differential diagnosis of a parasellar tumor to avoid unnecessary surgery and to decide the best strategy for treatment. Finally, this is the first case of collision tumors composed of CP and PA with a very long 10-year follow-up period. Based on the clinical course of our case, the best choice of an individual treatment plan for CP or PA is certain to lead to good control for collision tumors composed of CP and PA. The biological behavior of a collision tumor composed of CP and PA is probably the same as solitary CP or PA.


Cavernous hemangioma of the rib is extremely rare benign vascular tumor. It is difficult to diagnose in time because both invasive and noninvasive examinations usually fail to distinguish it from other tumors of the rib and other bones.We described an asymptomatic 44-year-old woman with cavernous hemangioma of the rib that was incidentally discovered in the bathing. The tumor was completely resected by minithoracotomy through posterolateral incision. The pathological tissue was diagnosed as a cavernous hemangioma composed of thin-walled blood vessels and red blood cells.We reported this case of giant cavernous hemangioma of the rib for its extremely rare occurrence. The preoperative diagnosis is a challenge both clinically and radiologically, and difficult to distinguish this tumor from other tumors of the rib or long bones. Hemangioma is not a neoplasm, but rather a congenital venous malformation with the potential to develop in all part s of the body. They are predominantly found in the spine and skull and are uncommonly observed in the ribs or long bones , 2. CaveHowever, we describe an extremely rare case of a cavernous hemangioma of the rib which was found accidentally in a female patient, the preoperative investigations, and the surgical treatment.An asymptomatic 44-year-old female with no medical history or history of trauma to the chest wall was admitted due to a right chest wall mass which was incidentally discovered in the shower. Chest computed tomography (CT) demonstrated a tumor, measuring 8.5 cm in diameter. Osteosclerosis was present on the top of the lesion along with calcification in different places and thickening on the nearby parietal pleura and diaphragm Fig. a,b.Fig. The laboratory investigation including serum tumor marker levels and routine hematologic, blood biochemistry results were normal. The patient underwent right lateral minithoracotomy in which a partial excision of the rib was performed, the intraoperative exploration showed the diaphragm was closely adhered to the giant mass. The large chest wall defect caused by rib resection was reconstructed by performing a polyester patch draft Fig. a,b. WhenThe patient had an uneventful recovery and discharged on the sixth postoperative day. Five months after the operation, she was doing well, without any evidence of local recurrence. A definite diagnosis of cavernous hemangioma was made based on histopathology examination results of the resected mass Fig. . The masMost cases of bone hemangiomas develop in the vertebral body or the skull. Hemangioma of the rib is rare, both as a rib tumor and as a bone Hemangioma . It is mHemangioma is a benign neoplasm of blood vessels that can occur throughout the body. Histologically, there are four types of hemangiomas: cavernous, capillary, venous, and mixed type . CavernoBone hemangiomas can present with different features on scans obtained by using varying imaging techniques. 18 F-FDG PET can detect the elevated glucose metabolism of cells, which is widely used for differentiation between benign and malignant neoplasms. Malignant lesions tend to be 18 F-FDG avid, however, benign lesions generally show lower 18F-FDG avidity . Choi etPreoperative diagnosis is not always possible due to overlapping radiological features between benign and malignant lesions. It is difficult to make a preoperative definite diagnosis of the chest wall tumors by imagery alone. Therefore, most of the patients with a rib hemangioma undergo rib resection. However, if CT scans show an osteolytic expansive lesion containing sunburst calcifications with low 18F-FDG avidity, a diagnosis of rib hemangioma should be considered .It is the treatment of choice to make a surgical excision of the rib while the histological examination reveals the diagnosis. Excision of rib hemangiomas is a safe procedure with no reported complication after removal or recurrence. Generally, needle biopsy should be avoided because of the risk of life-threatening bleeding or seeding the needle tract unless multiple myeloma or metastatic disease is highly suspected .In addition, temporary embolization using gel foam in rib hemangioma causes shrinkage in size and vascularity of the lesion drastically further easing the excision of the lesion.We have reviewed 36 cases of rib hemangiomas available in the literature from August 1994 to November 2018 (Table We reported this case of cavernous hemangioma for its extremely rare occurrence in the eleventh rib, which is the false and floating rib and relatively small and delicate. Preoperative diagnosis remains a challenge both clinically and radiologically. It is still difficult to distinguish the disease from other tumors in the rib. Furthermore, surgical resection provides materials for histopathologic diagnosis.In the future, we hope more cases of rib hemangiomas will be investigated and explored to find out reasons for gender and location differences of rib hemangioma.


To the best of our knowledge, only 2 cases of Creutzfeldt-Jakob disease demonstrating nigrostriatal dopaminergic deficits in vivo using DaTSCAN have been published in the literature.Sporadic Creutzfeldt-Jakob disease (sCJD) is a type of progressive, subacute encephalopathy associated with spongiform degeneration of the central nervous system. sCJD includes a broad and heterogeneous spectrum of clinical variants, but extrapyramidal symptoms and signs at disease onset were rarely reported. We describe a case of unilateral parkinsonism associated with pathological  Parkinsonism as the first symptom of sporadic Creutzfeldt-Jakob disease (sCJD) is rarely described –3. The aWe present the case of a patient with sCJD manifesting with gait abnormality and right-side bradykinesia and hypokinesia, associated with presynaptic dopaminergic deficits. Our case supports the hypothesis of nigrostriatal pathway alterations in CJD.123I-ioflupane SPECT (DaTSCAN), which revealed asymmetrical tracer uptake in the caudate nuclei (decreased uptake in the left caudate nucleus) and a near-complete lack of activity in the putamina, particularly on the left side . The examination revealed no further abnormalities. With the clinical suspicion of parkinsonism, we performed a complete blood test performed at baseline, with either normal or negative. A brain MRI scan revealed increased signal intensity in the left putamen with diffusion restriction, suggesting lacunar infarction . By the eft side . On disceft side . PRNP gene; the study of codon 129 polymorphisms revealed methionine/valine heterozygosity (M129V). The probable diagnosis of sporadic CJD was reached based on the World Health Organization (WHO) diagnostic criteria iodophenyl) nortropane. This cocaine analogue has a high binding affinity for and acceptable sensitivity to dopamine transporters (DAT), making it an excellent marker of viability and function of nigrostriatal neurons. Numerous studies of Parkinson's disease have evaluated the use of this technique to confirm clinical diagnosis. In the context of Creutzfeldt-Jakob disease, in contrast, DaTSCAN may be useful for in vivo confirmation of the presence of striatal dopaminergic degeneration.Further, lesions to the nigrostriatal pathway have never been studied in detail . To our Although our patient was admitted due to pseudoictal symptoms of language impairment, his gait disorder had appeared a month previously. In our case, the DaTSCAN revealed abnormal tracer uptake in the left caudate nucleus and reduced tracer uptake in the putamina ; these findings were coherent with the patient's symptoms of right-sided bradykinesia. It may be argued, however, that the patient had mixed parkinsonism  based on functional neuroimaging results and the presence of a lesion to the left putamen on diffusion-weighted MRI sequences; this lesion may reflect the spongiform changes typical of sCJD. These findings were consistent with anatomical pathology results from the postmortem studies, which revealed dopaminergic neuron loss in the substantia nigra, caudate nucleus, and putamen . This suIn conclusion, parkinsonism in CJD may be caused by lesions to the basal ganglia affecting the lenticular nucleus, or by nigrostriatal pathway degeneration. Much remains to be understood about DaTSCAN as an in vivo functional technique for the study of basal ganglia motor circuits and their role in the pathogenesis of this symptom in CJD. In any case, DaTSCAN seems to be a promising, noninvasive method for identifying lesions to the dopaminergic pathway; combined with MRI, it may help in the diagnosis of CJD.


An appendiceal mucocele is a dilatation of the appendix and it is the result of benign or malignant diseases, which cause the obstruction of the appendix and the consequent accumulation of mucus secretion. The preoperative diagnosis is difficult due to non-specific clinical manifestations of the disease. We present a case of an 83-year-old female patient with a history of breast cancer that was referred to our hospital for an evaluation of a right adnexal mass discovered during her yearly follow-up. The patient underwent an exploratory laparotomy with a provisional diagnosis of a right adnexal mass. A perioperative, appendiceal mucocele was diagnosed. She underwent a formal appendectomy and histopathology of the specimen revealed a low-grade mucinous neoplasm. Appendiceal mucinous neoplasms represent a rare form of pathology among all appendectomy specimens. A preoperative diagnosis is difficult due to the lack of specific symptoms and it is often misdiagnosed as an adnexal mass. The perforation of the appendix and subsequent extravasation of its contents into the abdominal cavity may lead to pseudomyxoma peritonei, which has a very poor prognosis if not treated properly. A mucocele of the appendix is a rare entity contributing to 0.2%-0.7% of appendiceal pathologies and is more frequent among individuals aged 50 years or more -2. RokitThe clinical presentation varies with more than a half of them being asymptomatic. The patient may present as acute appendicitis, a nonspecific abdominal pain, or a pelvic mass. Therefore, it may rarely receive a definitive diagnosis before surgery or it may be encountered during abdominal surgery performed for another indication . Early rIn this study, we present a case of a postmenopausal woman diagnosed with a pelvic mass. The patient underwent laparotomy, which revealed an appendiceal mucocele, and a formal appendectomy was performed. We also refer to the various classification systems that have been recently proposed for appendiceal mucinous neoplasia and the recent guidelines published by the Peritoneal Surface Oncology Group International (PSOGI) and American Joint Committee on Cancer (AJCC) 8th edition -6.An 83-year-old female patient, with a history of breast cancer diagnosed at the age of 68, for which she underwent lumpectomy followed by radiotherapy and chemotherapy, was referred to the ob-gyn department of our hospital for an evaluation of the right adnexal mass discovered during her yearly follow-up. On physical examination, a palpable mass was found in the right hypogastric area without tenderness. Tumor markers were within normal rates, with a mild elevation of serum carcinoembryonic antigen (CEA) 5.3ng/ml  and of serum cancer antigen 15-3 (CA 15-3) 31.4U/ml . An abdominal ultrasound showed a hypoechoic formation, sized 80.0 x 36.6 mm, below the uterus. An intravaginal ultrasound revealed a mixed texture mass, sized 8.7cm, with a solid and a cystic part in the right ovary. No free fluid was seen in the Douglas pouch. An abdominal magnetic resonance imaging (MRI) scan was carried out, which identified a cystic mass, sized 9 cm, in the right iliac fossa. The mass was in contact with the right ovary, uterus, and intestines. It was described as thin-walled without a disturbance in its molecular diffusion and with low-grade heterogeneity in its upper part, as can be seen in Figure The patient underwent an exploratory laparotomy under the diagnosis of a pelvic mass. The perioperative bilateral adnexa and uterus were found normal during the abdominal exploration. An appendiceal mass was revealed and a formal appendectomy was performed Figure .A frozen section of the appendix specimen diagnosed cystadenoma. The postoperative course was uneventful. A pathological examination of the surgical specimen revealed a low-grade mucinous neoplasm of the appendix Figure .After a year of follow-up, the patient is asymptomatic, with no pathological imaging findings.The term appendiceal mucocele refers to a dilated appendix with an increased intraluminal accumulation of mucus. It may be caused by a primary disease, which could range from an innocuous hyperplastic process  to a clinically benign neoplasm (mucinous cystadenoma), ending with a truly malignant tumor (mucinous cystadenocarcinoma) . The incThe clinical presentation is usually non-specific and the final diagnosis is intraoperative and based on the histopathological evaluation. A study done by Stocchi and coworkers found that of patients with symptoms, 27% had abdominal pain, 14% had an abdominal mass, 13% lost weight, 9% had nausea, vomiting, or both, and 8% presented with acute appendicitis . A compuMisdraji et al. classified appendiceal mucoceles into two groups based on architectural and cytologic features: low-grade appendicular mucinous neoplasms (LAMN) characterized by villous or flat-mucinous epithelial proliferation with low degree atypia, and mucinous adenocarcinoma (MACA), characterized by tumoral invasion of the bowel wall, complex epithelial proliferation, and high-grade nuclear atypia . These lGiven these unique issues with appendiceal mucinous neoplasia, the AJCC 8th edition has made significant and necessary changes to the staging of LAMN and created a new T category specifically for LAMN, termed the Tis-LAMN ,15. Tis-For lesions with the low-grade architectural features of LAMN but with high-grade cytologic features in the absence of an infiltrative invasion within the appendix, the term high-grade appendiceal mucinous neoplasm (HAMN) was proposed by the PSOGI consensus on the diagnostic terminology of mucinous appendiceal neoplasia. The term “low-grade appendiceal mucinous neoplasm” was supported by the PSOGI consensus while the term “mucinous adenocarcinoma” should be reserved for lesions with an infiltrative invasion. It was also agreed that the term “cystadenoma” should no longer be recommended ,15. The The treatment of an appendiceal mucocele is surgical resection. The surgical approach depends on the specific circumstances of the tumor and on clinical presentation. One of the cardinal principles in surgical management is that an intact mucocele presents no future risk for the patient. Many authors prefer the open surgical approach for the excision of a mucocele because it gives the ability for safer manipulations of the lesion. However, some authors reported that the laparoscopic and certain, minimally invasive techniques approaches are also appropriate ,17. In tThe five-year overall survival for patients with disseminated low-grade  mucinous neoplasms ranges from 60% to 90% with an estimated 10-year overall survival of 50% ,15. HoweAppendiceal mucinous neoplasms represent a rare form of pathology among all appendectomy specimens. A preoperative diagnosis is difficult due to its lack of specific symptoms and signs and the final diagnosis is mainly achieved intraoperatively. It is important for gynecologists and general surgeons to consider appendiceal mucinous neoplasms in cases where an elderly woman is observed to have a mass in the right iliac fossa. Furthermore, it is important for pathologists to be aware of the recent significant changes in the diagnostic terminology, histologic criteria, and staging of appendiceal mucinous neoplasms proposed by the PSOGI and AJCC eighth edition, as they can significantly affect patient management.


Keloid following circumcision has been described in the literature despite the rarity of its occurrence in penile skin. In this paper, we review the literature and report the successful management of post-circumcision keloid scarring in a 2-year-old boy. After circumcision a 2-year-old boy of African origin developed keloid scarring at the circumcision site. This was treated with three intralesional injections of triamcinolone acetate over 3 months, followed by surgical excision. There was no recurrence at 6 months after excision. To our knowledge this is the 12th case of keloid following paediatric circumcision described in the literature. There is a wide range of techniques described but all are recurrence free at 6 months following repeated intralesional triamcinolone acetate injection and surgical excision. While there is no current consensus in treating post-circumcision keloid, we find that intralesional injection followed by surgical excision provides an acceptable aesthetic result, which is recurrence free. Keloid scars result from an interrupted wound healing process and as such form a raised, red scar extending beyond the original wound to invade healthy skin. They are typically described as occurring in the upper chest, shoulders, upper back, and the head and neck. The ear is the most common site, accounting for just under half of all keloid scarring, closely followed by the chest and trunk . The leaA young boy of African origin underwent a religious circumcision at the age of 8 months. Around 7 months later he was referred to the paediatric surgery team by the GP with keloid scarring of the penile skin . This waWhen keloid scarring occurs there is clearly a disruption in the normal wound healing process, which has both cellular and genetic origins. The cellular mechanism is an over expression of growth factors leading to increased fibroblast and collagen synthesis. Poorly regulated vascular endothelial growth factor, connective tissue growth factor and TGF-β, have all been implicated in keloid development . The latThe genetic basis of keloid remains elusive. It is more likely to occur in people of African or Asian descent  and therKeloid of the penile foreskin was originally described by Parsons  in 1966 A differential diagnosis in this case should include hypertrophic scarring, where the scar does not extend beyond the original site of trauma. Such scars often regress with time, are limited to the area of injury, have fewer thick collagen fibres  and scanty mucoid matrix. They also present around 1 month and show regression. In comparison, keloid scars present at ~3 months following trauma and are described as elevated and extending beyond the wound, with thick collagen (type I) and mucoid matrix ,21,22. IFrom the above literature , none haKeloid formation has also been reported in penile surgery after operations for hypospadias. Recently, Alyami et al.  reportedSeven of the 11 cases in literature report no recurrence by combining intralesional triamcinolone injection with surgical excision. Triamcinolone acetate is a corticosteroid, which at a concentration of 10–40 mg/mL flattens a keloid scar by diminishing collagen synthesis and inhibiting fibroblast proliferation. In the papers listed in This case reports the successful treatment of a post-circumcision keloid scar with repeated monthly intralesional triamcinolone acetate followed by surgical excision. These are rare lesions to encounter and so optimal treatment is difficult to determine. The literature and our own experience suggest that a combination of intralesional injection and surgical excision provide the best outcome with no reported recurrence.


We describe an asymptomatic case of PJS in a six-year-old boy with café au lait spots in several parts of his body, a large gastroduodenal polyp, two polyps near the ampulla of Vater, and another in the jejunum. This patient shows some unique aspects of PJS. No other such large gastric polyp in a Peutz-Jeghers child is reported in the literature. The large size of the gastric polyp with lack of symptoms is unusual and poses a unique challenge in terms of management and surgical resection. Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder distinguished by hamartomatous polyps in the gastrointestinal tract and pigmented mucocutaneous lesions. Coexistence of multiple café au lait spots is rare , 2.We describe an asymptomatic case of PJS in a six-year-old boy with café au lait spots in several parts of his body, a large gastroduodenal polyp, two polyps near the ampulla of Vater, and another in the jejunum.An asymptomatic 6-year-old boy was referred by a dermatologist because of lesions on the inner side of his lower lip that firstly appeared 4 years ago.He was a skinny boy, light-coloured skin, blond, and green-eyed that was always eating small meals. He had no previous family history of PJS. On clinical examination, we found seventeen café au lait spots ranging from 0.3–3 cm on the anterior and posterior body surface and extremities .Blood tests showed mild anemia. Abdominal ultrasound and computed tomography showed a large polypoid gastric mass in the antrum and the beginning of the duodenum .A large, 8 × 5 cm in size, multilobed polypoid gastric mass situated in the antrum was found in gastroscopy. The mass was hemorrhagic, wide-based, and seemed to enter duodenum but moved back to the antrum with peristaltic movements. Two smaller polyps, 0.5 cm in size, were found at the 2nd part of the duodenum near the ampulla of Vater.The operation was scheduled for polyp removal. Under general anesthesia, a hard epigastric mass was palpated. We made a midline supraumbilical incision. The hard mass could be palpated at the lower third of the stomach. Palpation also revealed one lesion at the second part of the duodenum and another in the jejunum. We did a gastrotomy on the anterior surface of the pyloric antrum. The polyp was wide-based , occludiSTK11/LKB1 gene identification (a gene encoding a serine/threonine kinase that is responsible for the appearance of the syndrome)  showed the splicing mutation: c290 + 1 G > A, in intron 1, which results in aberrant splicing. No family history was reported, so it is highly likely that this mutation was a de novo event. This could not be confirmed, as the patient's parents did not consent to genetic testing.Postoperative results were excellent. We advised for clinical examination and ultrasound of testis yearly and capsule endoscopy, colonoscopy, and gastroscopy biannually.At a second look gastroscopy, six months later, we managed to endoscopically remove two smaller polyps near the ampulla of Vater. Colonoscopy was clear. Histology verified the diagnosis of PJS. All 4 polyps showed findings suggestive of hamartomas .So far, one polyp was detected in the duodenum and another in the sigmoid colon. Polyps were removed by gastroscopy and colonoscopy, respectively. The duodenal polyp was found to be histologically a Peutz-Jeghers polyp, whereas sigmoid polyp was found to be of a hyperplastic type. The gastric polyp was also found to have abnormal (resembling neoplastic) growth in muscularis mucosae where smooth muscle fibers followed the growth of exophytic gastric pits. Biopsies of the esophagus were normal, and gastric biopsies revealed only signs of mild chronic gastritis.Primary tumors of the gastrointestinal tract in children are estimated at 1.2% of all pediatric malignancies. They are usually benign. The literature is mainly limited to case studies , 4.The prevalence of gastric polyps in the pediatric population is low compared with that in adults 0.7% vs. 6.35%). The most common pathological types in children are hyperplastic polyps, and most are asymptomatic and do not require removal. Gastric polyps are being encountered in less than 1% of upper gastrointestinal endoscopies performed in children [.35%. ThePJS is an autosomal dominant disease characterized by mucocutaneous pigmentation and hamartomatous polyps of the gastrointestinal tract. The most common location of these polyps is in the small intestine, colon, and stomach, respectively , 2.Our patient shows some unique aspects of PJS. At first, the large size of the gastric polyp with lack of symptoms is unusual and poses a unique challenge in terms of management and surgical resection. No other such large gastric polyp in a Peutz-Jeghers child is reported in the literature. Polypectomy or partial resection was impossible due to its size. The polyp obstructed the view and precluded initial endoscopy of the duodenum. Resection was the only way to inspect the duodenum and first part of the jejunum. Moreover, a Billroth I anastomosis was deemed preferable so that future endoscopies may be facilitated.Multiple café au lait spots on his body in addition to the classic mucocutaneous macules around the mouth and the buccal mucosa was another unusual finding. Café au lait spots are more often associated with syndromes such as neurofibromatosis type 1 and McCune-Albright syndrome . UnfortuSurveillance of PJS patients is of critical importance because of the increased risk for malignancies , 8. We aPolyps beyond the reach of conventional endoscopy have been difficult to manage. Until recently, barium contrast upper-gastrointestinal series with a small-bowel follow-through has been recommended. However, recent advances allow better diagnosis and eradication of small-bowel polyps. Video capsule endoscopy (VCE), magnetic resonance enterography (MRE), and double balloon enteroscopy (DBE) are the modern ways of small bowel surveillance . In our PJS can present with café au lait traits and hyperpigmented macules of lipsUnusual and classic hyperpigmentation in children may indicate a “clinically silent” syndromePeutz-Jeghers gastric polyps in children are very rareThey may become very large in size in small children but still be asymptomaticPrompt diagnosis may avoid complicated operations and prevent any possibility for malignant transformationFollow-up of children with PJS is necessary for early diagnosis and management of possible tumors


Isolated splenic sarcoidosis is difficult to diagnosis due to its rarity. Laparoscopic splenectomy has become the gold standard for therapeutic diagnosis in patients presenting with solid splenic lesions because needle biopsy can lead to bleeding and tract seeding.A 59-year-old female was referred to our hospital due to abnormal accumulation in the spleen on abdominal ultrasonography. Enhanced computed tomography showed three heterogeneously enhanced nodules. Magnetic resonance imaging showed hypointense nodules on T2-weighted images. The initial diagnosis was a fibrous hamartoma or an inflammatory pseudotumor. At follow-up 4 months later, the splenic nodules had increased in size, and diagnostic laparoscopic splenectomy was performed without complications. Histopathologically, the splenic nodules contained noncaseating granulomas comprising epithelioid cells, multinucleated giant cells, and asteroid inclusion bodies. Postoperatively, examinations found no other organ involvement, and the final diagnosis was isolated splenic sarcoidosis. There was no evidence of recurrence at 2 years postoperatively, and systemic treatment was not required.Radiological imaging studies are insufficient for the differential diagnosis of splenic lesions in sarcoidosis from other diseases, whereas laparoscopic splenectomy is less invasive and useful as part of the diagnostic approach. One of 2A 59-year-old female was referred to our hospital with abnormal nodules in the spleen on abdominal ultrasonography during a routine health screening. Her past medical history included an abscess in the fallopian tube and bilateral ovaries 7 years ago. Baseline laboratory tests, including complete blood count, serum levels of electrolytes , renal and liver function tests, soluble interleukin-2 receptor (sIL-2R) level, and levels of the tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), were within normal limits. Abdominal ultrasonography revealed a normal-sized spleen with three small hypoechoic nodules of different dimensions. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen confirmed the presence of multiple lesions in the spleen. The three splenic nodules exhibited heterogeneous enhancement with a hypointense signal on T2-weighted images and measured 22, 17, and 9 mm in diameter , Fig. 2.18F-fluorodeoxyglucose (FDG) uptake with a maximum standardized uptake value (SUVmax) of 2.89 was observed by positron emission tomography (PET)-CT, and the patient finally underwent diagnostic laparoscopic splenectomy.The initial differential diagnosis included a fibrous hamartoma and an inflammatory pseudotumor, and a follow-up imaging was planned. An enhanced CT scan performed 4 months later revealed an increase in the diameters of all nodules to 27, 22, and 16 mm. Aberrant ™  or by clipping. After full mobilization of the viscus, the splenic artery was exposed until the peripheral parts, and the peripheral artery to the pancreas (pancreatic tail artery) was preserved. The spleen was removed through a small 3-cm opening in the umbilical region. There was no significant bleeding, and the total surgery time was 148 min. The patient recovered uneventfully and was discharged on postoperative day 5 with adequate oral intake, normal vital signs, and no complaints.The 4-trocar technique was used, and ligaments and vessels were dissected using a LigaSureGross examination revealed that the resected spleen contained poorly demarcated, white nodules . Histopa3The diagnosis of sarcoidosis, relies on clinical and radiological imaging findings associated with the histology of epithelioid granulomas; however, granulomas are not pathognomonic for sarcoidosis. Sarcoidal granulomas can involve any organ, but clinical sarcoidosis manifests as intrathoracic lymph node enlargement, pulmonary involvement, skin or ocular signs and symptoms, or a combination of these findings in more than 90% of the patients. Conversely, splenic sarcoidosis in the absence of specific clinical or radiographic signs of pulmonary sarcoidosis is extremely rare, with few noteworthy reported cases ,7,8. LabIn the present case, abdominal ultrasonography revealed small hypoechoic nodules of different sizes, which were confirmed by CT, whereas MRI yielded no diagnostic advantage. The initial diagnosis was a benign tumor such as a fibrous hamartoma or an inflammatory pseudotumor. After 4 months of follow-up, diagnostic laparoscopic splenectomy was performed due to tumor size progression and aberrant uptake of 18F-FDG on PET-CT.Laparoscopic splenectomy has been extensively employed as an effective approach for diagnosis and treatment of diseases and determination of malignancy involving the spleen . The proThe current case highlights the diagnostic approach for splenic lesions and the outcome of laparoscopic splenectomy as an effective and safe procedure for diagnosis and treatment. The present case was an extremely rare form of sarcoidosis. Isolated splenic involvement in sarcoidosis is a precursor for systemic disease. Although the current patient did not show recurrence of additional lesions of sarcoidosis at 2 years of follow-up, further monitoring is necessary to identify potential recurrence.All authors declare that they have no conflicts of interest in relation to this study.None of the authors has any conflicts of interest or any financial ties to disclose.This study has been approved by the ethics committee in the Osaka Police Hospital. The ethical approval number is No. 912.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on requestConception and design of study: Manabu Mikamori, Masahiro TanemuraAcquisition of data: Manabu Mikamori, Kenta FurukawaDrafting the manuscript: Manabu MikamoriRevising the manuscript critically for important intellectual content: Masahiro Tanemura, Kenta Furukawa, Takuro Saito, Masahisa Ohtsuka, Yozo Suzuki, Mitsunobu Imasato, Kentaro Kishi, Hiroki AkamatsuNo registration of research studies.On behalf of all author, Manabu Mikamori is guarantor for this paper.Not commissioned, externally peer-reviewed.


We report a rare case of an epiploic appendage twisted through an omental defect, resulting in an epiploic appendagitis at a distance to the colonic wall. The 59-year-old women complained of low abdominal pain and alguria, progressively increasing following a total colonoscopy 4 days earlier. A 59-year-old women was referred to our emergency department with low abdominal pain and alguria, progressively increasing following a total colonoscopy 4 days earlier. There were no other gastrointestinal complaints or fever. The relevant medical history revealed only an appendectomy. Physical examination showed (rebound) tenderness in the lower abdomen. Laboratory tests revealed a mildly elevated white blood cell count (10330/mL) and elevated C-reactive protein (47 mg/L). Urinary infection was excluded.Ultrasound showed a large suprapubic mass that was tender when pressure was applied. Contrast-enhanced computed tomography (CT), with peroral and retrograde contrast filling, showed a large fat-containing suprapubic mass of 9.1 × 4 × 5.3 cm Figures  and 1B. Exploratory laparoscopy revealed a fatty mass, being a giant epiploic appendage of the transverse colon, herniated through a defect in the greater omentum Figures  and 2C. Adhesiolysis was performed, the greater omentum was transected and the strangulated fatty mass was resected. Histopathology confirmed a fatty mass of 101 g with fat necrosis surrounded by congestive changes and inflammation, confirming to the diagnosis of a complicated epiploic appendagitis.Epiploic appendages are pedunculated fatty structures (on average 1–2 cm of thickness and 2–5 cm of length) protruding from the serosal surface of the colon into the peritoneal cavity. Approximately 50–100 appendages are present; most are localized in the caecum and sigmoid along the taenia libera and taenia omentalis. The transverse colon has a smaller number of appendages, as the greater omentum attaches to the taenia omentalis 12.A limited blood supply—consisting of a small artery and vein passing through a narrow pedicle—in combination with an excessive mobility makes the appendages prone to torsion, resulting in ischemic or hemorrhagic infarction. Spontaneous thrombosis of the draining vein, resulting in a vascular occlusion, is another cause of primary appendagitis 23458. Vo23451Most patients suffering from epiploic appendagitis are between 20 and 60 years of age and complain of pain in the lower abdomen (right or left iliac fossa), as appendages of the caecum and sigmoid are most commonly involved 28. There212Ultrasound typically shows a tender oval-shaped or rounded hyper-echoic mass, surrounded by a hypo-echoic rim and hyper-echoic fat infiltration 37. CT fi323523In most cases, epiploic appendagitis is a self-limiting condition 348. Howe34122Epiploic appendagitis should always be included in the differential diagnosis of a patient presenting with acute abdominal pain. In this case report, we described a rare presentation of torquated epiploic appendagitis at a distance to the colonic wall, secondary to a transomental herniation.


Schwannomas represent only 5% of all soft tissue tumors. As a variant of this tumor, the plexiform schwannoma is rare accounting for less than 5% of all schwannomas. Herein, we report a rare case of a 49-year-old athlete who suffered from a pain in the posterior aspect of the right leg one year before his presentation. Initially, a radiograph of his right leg showed no abnormality, and so, the emergency physician discharged him on analgesics and anti-inflammatory medications, and rest was advised. The persistent pain obliged the patient to consult our orthopedic department. On examination, we found a firm mass in the proximal medial aspect of his right leg. The neurovascular exam was normal. Sonography of the leg was not conclusive. Therefore, magnetic resonance imaging was performed, and a hemangioma or schwannoma was suspected. The patient underwent surgery in which the entire tumor mass was shelled out in one piece with no damage. The histopathological finding was concomitant with a plexiform schwannoma. Follow-up evaluation, sixteen months later, showed no evidence of recurrence, and the patient has regained his previous level of sportive activities. So, given the case described here, despite the rarity of the schwannoma, it should be taken into consideration as a possible diagnosis in such situation to promote early diagnosis and appropriate treatment. Schwannomas, also known as neurilemomas, are benign peripheral nerve sheath tumors composed exclusively of Schwann cells; they account for only 5% of all soft tissue tumors , 2. ThesA 49-year-old athlete suffered from pain localized in the posterior aspect of the right leg since one year, with no reported history of trauma or prick injury. He consulted initially an emergency physician who has requested a radiograph of the right leg which showed no pathology, and so, the patient was discharged on analgesics and anti-inflammatory medications, and rest was advised.At home, the patient did well, but he continued to experience intermittent pain in the same localization, which prevented him from carrying out his activities. One month later, he consulted our orthopedic department for further evaluations. On admission, he reported a localized moderate pain in the proximal medial side of his right leg, burning in type with no radiation, and it increased slightly with active and passive dorsiflexion of the foot. In this localization, the clinical examination found a firm mass measuring 2.5 cm/2 cm mobile transversely and slightly longitudinally. The neurovascular examination was normal.On investigation, he had a hemoglobin of 12 g/dl and normal white blood cell counts, platelets, and D-dimer. Since the sonography of the leg was not conclusive, we performed, a few days later, a magnetic resonance imaging of the leg that was in favor of hemangioma or schwannoma , promptiAt the last follow-up of sixteen months, he did not present any evidence of recurrent pain and he regained his previous level of sportive activities.For orthopedic surgeons taking care of athletes, chronic leg pain in athletes is a common complaint , 13. TheAlthough Schwannomas are uncommon, they should be considered as a possible cause of chronic leg pain. Its diagnosis is suggested by clinical and MRI examinations and is confirmed by histopathological analysis.