Although inguinal hernia repair is one of the most common surgical procedures, finding a retroperitoneal structure, such as the ureter, is a rather rare occurrence. Ureteroinguinal hernias may arise in the presence or absence of obstructive uropathy, the latter raising difficulties in diagnosis for the general surgeon performing a regular inguinal hernia surgery. This study aims to collect the relevant literature describing the diagnosis and management of ureteroinguinal hernias and update it with a case encountered in our clinic. The following study was reported following the SCARE guidelines. The relevant literature describes less than 150 cases of ureteroinguinal hernias overall, considering the 1.7% prevalence of inguinal hernias in the general population. With only 20% of these hernias being described as extraperitoneal, such an encounter becomes an extremely rare finding. Our clinical experience brings a case of a 75-year-old male with frequent urinary tract infections and a large irreducible inguinoscrotal hernia of about 20/12 cm located at the right scrotum. The patient underwent an open inguinal hernia repair technique under general anesthesia, incidentally finding an extraperitoneal ureteral herniation. Segmental ureterectomy was performed with uneventful recovery. Intraoperatively, finding an incidental ureteroinguinal hernia raises concerns about probable urinary tract complications during regular hernia repair surgery and whether the diagnosis is likely to happen prior to surgical intervention. Although imaging is rarely indicated in inguinal hernias, the case reports show that a pelvic CT scan with urography in symptomatic patients with urinary symptoms will provide accurate confirmation of the diagnosis. The relevant literature is limited due to the rarity of respective cases, thus making standardized management of such cases unlikely. Inguinal hernias are classified as direct and indirect based on the relationship of the herniation sac with the inguinal canal , while bInguinal hernias containing a ureteral segment are an extremely rare finding in patients with native kidneys when there is no ectopic or transplanted kidney involved. To date, fewer than 140 cases of ureteral inguinal hernias have been described , and aroThe first documented case of ureteroinguinal hernia was in 1880 during an autopsy , while, Ureteroinguinal hernias are most frequently found in obese patients or people who have undergone a kidney transplant . In contA tortuous ureter is often described in imaging studies and might suggest a ureteroinguinal hernia associated with the patient’s clinical picture. Tortuous ureters are usually found in ectopic kidneys ,53, the Although trapping the ureter in the inguinal canal is a rare possibility , when coA 75-year-old Caucasian male was brought to the emergency room complaining of gradually increasing high-intensity pain involving the right inguinal region and the scrotum, onsetting a week prior to admission. Anamnesis revealed a history of high blood pressure, chronic venous insufficiency, grade III obesity, chronic gastritis, and type II diabetes mellitus. The patient underwent multiple surgical interventions, including a trans-urethral resection of the prostate, varicocelectomy, umbilical hernia repair, cholecystectomy, and right total hip arthroplasty eight years prior to the respective hospital admission. A small size inguinal hernia was first noticed by the patient a short time after the hip replacement surgery. It was followed by multiple episodes of severe unilateral and colicky flank pain associated with urinary tract infections.E. coli, which indicated antibiotic therapy. There was a slight distension of the pelvis and right ureter on ultrasound, without ultrasound-visible stones.A review of systems showed a normal gastrointestinal tract with regular intestinal habits and no emetic or nauseous symptoms until hospital admission. The patient presented with abnormal genitourinary with dysuria, urinary frequency, urgency with weak urinary flow, and right flank pain, and no hematuria. The patient’s vitals were stable on clinical examination, and a large, irreducible inguinoscrotal hernia of about 20 cm located at the right scrotum was identified, having the superior pole at the deep inguinal ring descending into the right scrotum. The scrotum was swollen and painful spontaneously and on touch, having an increased consistency. Additionally, tight phimosis was observed. A complete blood test was within normal ranges, and urinalysis showed leukocyturia and microbial flora growing An open surgery incision for repairing the inguinal hernia was performed under general anesthesia. On inspection, we identified a bulky fatty mass originating from the retroperitoneum. It protruded through a considerably large defect at the lateral inguinal fossa down to the right scrotum, tightly adherent to the external spermatic fascia. While dissecting the herniated adipose tissue, a white tortuous loop of about 10 cm long was discovered. Showing signs of peristalsis on stimulation, the first intention was to guide a 3F ureteral catheter on the right ureteral meatus. Due to the impossibility of completely reducing the herniated part of the ureter back into its anatomical position in the retroperitoneum, we decided to perform an 8 cm distal segmental ureterectomy with end-to-end anastomosis on the JJ tube . On furtWe identified eight case reports describing the diagnosis and surgical management of extraperitoneal ureteroinguinal hernias. In 2001, Giglio et al.  treated In 2016, Di Nicolo et al.  reportedAlthough most of the reported cases of ureteroinguinal hernia are diagnosed intraoperatively, under classic hernia repair and a high rate of ureteral damage due to unrecognizable diagnosis, the recent advances in imaging and surgical techniques allow for more precise diagnosis, preferably before surgical intervention for inguinal hernia, and facile management of these occurrences. Such was the case reported by Smith et al.  involvinAs was the case in our report, ureteral hernia might occur with or without obstructive symptoms, such as hydronephrosis. Even when hydronephrosis is present, the clinical picture may or may not show symptoms, such as ipsilateral flank discomfort. If the bladder is also implicated, the blockage of the bladder outlet may develop, producing symptoms of the lower urinary tract, such as frequency, urgency, and difficulty emptying. We believe the broader access and use of imaging techniques resulted in a greater number of ureteroinguinal hernias being diagnosed preoperatively. However, in the absence of evident bladder involvement or a urography phase highlighting the urinary system, the existence of ureteral herniation may be difficult to detect completely in the absence of hydronephrosis. Thus, when a hernia is discovered intraoperatively or when the repair is planned, surgeons should maintain a high index of suspicion that critical structures, including the ureter, may be present within the hernia or sac, especially in the setting of ipsilateral flank pain, renal failure, or hydronephrosis on the ultrasound.On the contrary, a review published in 2021 argued the rarity of ureteral inguinal hernia and proposed a management algorithm . The ureIt is critical to emphasize that most case reports depict a patient with symptoms of urinary obstruction ,78,79,80Compared to the existing literature, our case is remarkable as an inguinal hernia involving extraperitoneal ureteral elements in a patient with native kidneys located in their anatomical position, as the condition is prone to occur after renal transplant . Most ofSummarizing the data available in the literature, the ureteroinguinal hernia is a rare occurrence. Recently, this pathology has been diagnosed more frequently, secondary to kidney transplantation as an obscure cause of hydronephrosis. In such cases, abdominal repositioning is advisable. Primary ureteroinguinal hernia is so uncommon that less than 10 cases have been reported in the adult population. In the presence of urinary symptoms, urographic CT usually confirms the diagnosis. On the other hand, although rare in incidence, the possibility must be considered while operating on a massive sliding hernia on the right side. If the ureter is identified under such circumstances, the resection followed by the aureteral reconstruction on a JJ stent is considered as a safe decision.


It is characterized by visceral pleural fibrosis and adjacent lung parenchymalfibroelastosis with striking upper lobe predominance. Because of its rarity and the lack of clear diagnostic criteria, the prevalence of the disease is still unclear. We report the first case of IPPFE in Lebanon and the second one in the Arab World. A 37-year-old Iraqi man was admitted to the hospital with progressive dyspnea on exertion occurring since 2 years and associated with dry cough. Histo-pathologic results reported a prominent interstitial fibrosis mainly in upper parts, and no granulomatous tissue was detected. Therefore, the diagnosis of IPPFE was made. The IPPFE is a distinct entity that requires meticulous clinico-pathological correlation for an adequate diagnosis and a close follow-up as this entity can progress into more advanced stages.Idiopathic pleuroparenchymal fibroelastosis (IPPFE) was initially described by Amitani  In the et al. reported a bimodal age onset ranging from 13 to 87 years of age with a first peak in the third decade and a second one in the sixth decade and with a mean age of 53 years of age [Because of its rarity and the lack of clear diagnostic criteria, the prevalence of the disease is still confusing. Cheng s of age . The coms of age . We repoA 37-year-old Iraqi man was admitted to the hospital with progressive dyspnea on exertion occurring since 2 years and associated with dry cough. Patient was afebrile. The patient reported two episodes of severe dyspnea and low oxygen saturation occurring 1 month and 2 years ago. In both exacerbations, patient’s chest X-ray revealed left pneumothorax, and a tube thoracostomy was performed subsequently . The patThe differential diagnosis of the disease is wide and includes: usual interstitial pneumonia (UIP) due to idiopathic pulmonary fibrosis (IPF), nonspecific interstitial pneumonitis (NSIP), hypersensitivity interstitial pneumonitis, pleuropulmonary fibroelastosis and advanced fibrosing sarcoidosis. UIP typical computed tomography (CT) pattern consists of honeycomb stage with basal-predominant distribution . Additioet al. considered chest flatness as a constitutional symptom for IPPFE [The definitive diagnosis of PPFE relies on the histological and radiological findings in surgical lung biopsy and includes pleural thickening with subpleural fibrosis in the upper lobes , 5. Amitor IPPFE . The exaor IPPFE . Additioor IPPFE . Being aN-acetylcysteine has been reported with limited effects [There is no effective treatment for IPPFE; however, therapy with steroids, pirfenidone, immunosuppressants and  effects , 8. Ther effects .The IPPFE is a distinct entity that requires a meticulous clinico-pathological correlation for an adequate diagnosis and a close follow-up as this entity can progress into more advanced stages. Further cohort studies assessing available treatment modalities and the development of anti-fibrotic treatment are now warranted.


Angiomatoid fibrous histiocytoma (AFH) are rare soft tissue mesenchymal neoplasms that commonly affect children and young adults. They are classified as “intermediate tumours of uncertain differentiation”. We present a case of an 8-year-old child with a left thigh AFH and antecedent history of minor trauma showing perilesional oedema and enhancement at MRI, leading to an initial working diagnosis of infected haematoma that contributed to the challenge in reaching the final diagnosis. Although most of the imaging features of AFH previously described in the literature are demonstrated in this case, the presence of arterial vascular channels within the tumour and feeding branch from the left profunda femoris artery is unusual and to our knowledge the first to be published in the literature. The lesion appeared after suspected trauma with an unknown object (possibly a nail or piece of wood). Growth was most marked over the preceding 2 months. The patient had intermittent low-grade fever, usually at night, with weakness and fatigue. Examination revealed dark brownish skin discolouration (approximately 5×5 cm), with a central hypopigmented area where the skin scaled off and underlying mobile subcutaneous firm non-tender swelling feeling mildly warm to touch. Initial laboratory findings revealed low haemoglobin level of 7.9 gm dlPlain radiographs demonstrated subtle soft tissue opacity in the lateral aspect of the left mid-thigh with no radiopaque foreign body or soft tissue gas . UltrasoThe initial differential diagnosis was post-traumatic infected haematoma with underlying vascular malformation or vascular tumour not excluded. The patient was followed closely and given antibiotics with only minimal improvement of the local symptoms. Follow-up ultrasound after 2 weeks revealed no significant interval change. Left femoral digital subtraction angiogram was performed and confirmed the presence of the vascular lesion in the left mid-thigh along the lateral aspect supplied by a prominent branch arising from the terminal part of profunda femoris artery ; howeverUltimately, the patient underwent surgical resection with gross specimen appearances showing a solid non-haemorrhagic lesion 3×3 cm attached to tensor fascia lata of left lateral thigh, and no infiltration to underlying muscles or bone, the vascular pedicle was posterior and intact.Histopathological examination  revealedCranial MRI and staging contrasted CT of the chest, abdomen and pelvis performed confirmed no evidence of metastasis or satellite lesion. Repeat thigh MRI 1 month after resection demonstrated minimal postoperative oedema and seroma without evidence of residual lesion. Ipsilateral prominent inguinal lymph nodes were re-demonstrated. Selective excisional nodal biopsy was performed showing follicular hyperplasia with no evidence of malignancy.1,2AFH is a rare soft-tissue mesenchymal neoplasm of uncertain histogenesis and line of differentiation that most commonly affects children and young adults. AFH was described initially as “angiomatoid malignant fibrous histiocytoma” by Enzinger in 1979. Currently, it is no longer regarded as “malignant” because of its benign microscopic appearance and favourable prognosis. In the 2013 World Health Organization (WHO) classification, AFH are classified as “intermediate tumours of uncertain differentiation”.3–5 A small proportion of patients experience systemic signs and symptoms including pyrexia, anaemia, and malaise suggesting tumoural cytokine production. Symptoms of pain and tenderness are rarely encountered.6 In this case, the clinical presentation with suspected history of trauma was misleading, leading to a working diagnosis of infected haematoma, and it contributed to the challenge of reaching the final diagnosis.No well-organized clinical reports exist for AFH because it is a very rare soft tissue tumour. AFH often presents as a slowly growing painless mass in the deep dermis or subcutis in children and young adults with a median age of 13 years but may also occur in middle-aged patients. Some tumours invade deep structures such as skeletal muscle and rarely in other sites such as the lung and bone.6–15More than 400 cases of AFH have been reported in the pathology literature. By comparison, the imaging features of AFH are less well established. A few series of well-documented cases of soft tissue AFH with comprehensive accompanying MRI and several with limited MRI have been published in the radiology literature. AFH typically occur in the extremities but may occur anywhere in the body.6,16Clinical and radiological differentiation of AFH from haematoma or vascular tumours such as haemangioendothelioma and angiosarcoma is challenging. The imaging findings of AFH are often non-specific. When originating in the soft tissues, radiographs are of limited value and contrast-enhanced computed tomography with its limited soft tissue contrast resolution may show a heterogeneous mass, and possibly hint at cystic and enhancing components.17US and MRI are preferred to evaluate soft-tissue masses. US findings in AFH have been described in very few cases. One case report in a 77-year-old female with a temporal region lesion showed an irregular-shaped hypoechoic cystic lesion with peripheral flow, US elastography revealed high elasticity centrally.9A case series of four children undergoing US showed a predominantly solid appearing mass in three of which there were tiny cystic changes in two, and in one the mass had a multi-cystic appearance with fluid-fluid levels of mixed echo-texture with septal and peripheral colour Doppler flow.In our case, the latter described sonographical findings were also noted in addition to the presence of vascular channels showing arterial spectral flow pattern which is to best of our knowledge have not been previously reported in literature for histopathologically proven AFH.6–10,12,15,16,18 The presence of a rim of high signal intensity and adjacent inner rim of low signal intensity which can be observed on both T2W and post-contrast images, referred to as the ‘double rim sign’ is considered a novel-specific sign for AFH.15 The double rim may be partial or not clearly delineated as in this case where only a peripheral low signal rim was seen representing a fibrous pseudocapsule.Some MRI features of AFH previously described in the literature may help in the diagnosis although none are considered specific, the most helpful finding is the presence of intralesional cystic spaces with fluid-fluid levels. In general, AFH show homogeneously isointense T1 signal and heterogeneously hyperintense foci on T2W imaging, with peripheral nodular and variegated internal pattern of gadolinium enhancement. Additional reported features include the presence of a pseudocapsule, haemosiderin and in some cases perilesional oedema.A unique imaging finding which was not previously described as features of AFH was present in this case, which is the presence of a feeding arterial branch directly to the lesion. Conventional angiography excluded the presence of AV malformation and revealed blood supply to the lesion as a prominent terminal branch of the profunda femoris artery .19 Nodal metastases are uncommon from soft tissue neoplasms.20MRI is indicated for local staging. Accurate staging of nodal and distant metastases is mandated, fluorodeoxyglucose positron emission CT (FDG PET-CT) has been used for staging but caution is required in interpreting nodal involvement as biopsy of suspicious nodes seen on PET-CT have subsequently been found to be benign on histopathological analysis.9The lesion in our patient showed the typical histopathological findings of AFH, which have been well-described in the literature, including fibrous pseudocapsule, peritumour lymphoplasmacytic infiltrate, cystic spaces containing blood products surrounded by tumour cells and stromal haemosiderin deposition, and aggregates of histiocytoid and spindle-shaped tumour cells in a whorled or fascicular distribution.21The management of AFH includes surgical wide local excision with imaging surveillance for recurrence. With unrespectable or metastatic disease, adjuvant chemotherapy and/or radiation therapy may be used.16The prognosis of patients AFH does not appear poor; however, local soft tissue recurrence is seen in up to 15% of cases with metastases in under 1%.Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue tumour with intermediate malignant potential that most commonly affects children and young adults. It usually occurs as a painless mass in an extremity but can occur anywhere.We present a case of AFH with misleading antecedent history of trauma, initially leading to a working diagnosis of infected haematoma which contributed to the challenge of reaching the final diagnosis on diagnostic imaging alone.While the imaging features of AFH are not well established in the literature and typically non-specific, a mass with cystic areas, pseudocapsule, internal fluid-fluid levels and variable enhancement in the extremity of a child or adolescent should prompt the consideration of AFH in the differential diagnosis. A unique imaging feature was present in this case, the presence of a feeding arterial branch directly to the lesion, which is to the best of our knowledge, the first to be published in literature.


Background: Biliary cystadenomas are rare cystic tumors of the bile duct system that are mostly benign but also have the possibility of malignant transformation. Biliary cystadenomas mostly occur in the intrahepatic bile ducts and are more common in middle-aged women. Due to non-specific radiology, preoperative diagnosis is difficult and is usually performed by postoperative pathology. Complete resection is the best treatment option, and the postoperative prognosis is good.Case Description: This study reports a case of a patient with biliary cystadenoma who was diagnosed with simultaneous chronic hepatitis B and colon (hepatic flexure) adenomatous polyps. The patient presented to the doctor because of abdominal pain, and a blood test showed hepatitis B. Computed tomography revealed both right liver and colonic lesions. Colonoscopy revealed polyps, and the postoperative pathological diagnosis was adenomatous polyps. Laparoscopic resection of the right liver tumor was performed, and it was diagnosed as hepatobiliary cystadenoma by postoperative pathological analysis combined with immunohistochemistry.Conclusion: In patients with chronic hepatitis, the shape of biliary cystadenoma may not be very typical, and it is necessary to combine this with immunohistochemistry for diagnosis. When multiple lesions are detected in the painful area, the diagnosis of each lesion and its treatment sequence are worthy of consideration. Under normal circumstances, the prognosis of biliary cystadenoma is good; however, in patients with chronic hepatitis B, more cases need to be observed for verification. Biliary cystadenomas are rare cystic tumors of the biliary system, most of which are benign but may also be malignant . BiliaryTo date, it has not been reported that patients with chronic hepatitis B were diagnosed with biliary cystadenoma at the same time and, more particularly, combined with colonic (hepatic flexure) adenomatous polyps. This study reports on such a case.Due to dull pain in the right upper abdomen for ~1 month, a 46-year-old woman was admitted to a local hospital, in which computed tomography (CT) revealed space-occupying lesions of the liver. She was then admitted to our hospital for further treatment. The patient reported that pain in the right upper abdomen did not radiate to other areas, with no headache, dizziness, chest tightness, shortness of breath, nausea and vomiting, diarrhea, black stool, frequent urination, urgency, and other discomforts. She had no history of any major diseases, and her family and social histories were non-significant.Her physical examination showed no abnormalities. The admission blood test showed that the indirect bilirubin level was 3.2  μmol/L, activated partial thromboplastin time was 23.6  s, and carcinoembryonic antigen and carbohydrate antigen levels were within the normal range. The following were also noted: quantitative hepatitis B virus DNA (HBV DNA) level, 1.12 × 107 (positive) IU/mL; quantitative hepatitis B surface antigen (HBsAg-C) level, 2,675.000 cut-off index (COI) ; quantitative hepatitis B e antigen (HBeAg-C) level, 1,430 COI ; and quantitative hepatitis B core antibody (HBcAb-C) level, 0.007 COI , which were suggestive of chronic hepatitis B.Ultrasound examination of the abdomen showed cystic liver lesions, ~38 × 28 and 13 × 8 mm in sizes, and separated light bands could be seen in the larger ones . CT of tUnder electronic colonoscopy, three flat polyps sized 2–4 mm were found in the liver flexure of the colon , all of Postoperative CT showed resection of the posterior lower segment of the right liver lobe; a small amount of fluid, blood, and gas in the residual cavity; drainage tube indwelling; and a small amount of fluid around the gallbladder fossa . Re-examMost patients with biliary cystadenoma are asymptomatic, and such patients are usually diagnosed incidentally during imaging examinations or surgical exploration . PatientHowever, our examination was not comprehensive regarding the cause of the patient's upper abdominal pain. Upper gastrointestinal endoscopy should be performed to rule out other causes of right upper abdominal pain.Biliary cystadenoma is usually a multilocular, isolated lesion with liquid content . Under lThe diagnosis and differential diagnosis of cystadenoma mainly rely on abdominal ultrasound, CT, and magnetic resonance imaging (MRI). CT and enhancement have advantages in displaying the anatomy and blood vessels of the lesion, but ultrasound shows that the internal separation of the cyst is more obvious, which also proves that ultrasound and CT are complementary . CompareDifferential diagnoses include simple liver cysts, parasitic cysts , hematomas or post-traumatic cysts, liver abscesses, congenital cysts, and other cystic liver diseases, while biliary cystadenoma and cystadenocarcinoma can only be accurately distinguished by postoperative histopathological evaluation . The conComplete resection is the first treatment for biliary cystadenoma. Other treatment options such as internal drainage, aspiration, marsupialization, sclerosis, Roux-en-Y cyst-bowel anastomosis, or partial resection are associated with complications and the risk of tumor recurrence or deterioration . A complIn fact, as early as 2010 in the WHO classification of digestive system tumors (5th edition), BCA is no longer a disease type, but is divided into intraductal papillary neoplasms of the bile duct (IPNB) and mucinous cystic tumor (MCN) . But in IPNB is a rare tumor that was classified as a unique pathological entity in the WHO Classification of Digestive System Tumors (5th Edition) . IPNB caThe patient's liver function before the surgery was normal, but HBsAg(+), HBeAg(+), HBcAb(–), and HBV DNA levels  were in line with the immune tolerance period of chronic hepatitis B . ChronicThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.GH and TL provided cases and constructed a framework for reporting. YT sorted out the context of the case, summarized the characteristics of the case, and conducted a literature review. CW organized the images and participated in the literature review. SF provided new laboratory test results for this case. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Primary renal angiosarcoma (AS) encompasses only 1% of soft tissue sarcomas, and it is seldom seen in literature. Because of its rarity, few risk factors for its development have been established. Due to lack of screening guidelines for kidney cancer, it is often found late when patients become symptomatic. We present the case of a male patient who presented with gross hematuria and flank pain and was discovered to have a large renal mass. Following successful resection, pathology showed it to be AS. The patient had a post-operative course complicated by two separate COVID-19 infections and expired 200 days after surgery. This case not only highlights an extremely rare renal cancer but also illustrates the challenges patients with complex medical issues faced in the era of COVID-19. Angiosarcoma (AS) is a rare, endothelial cancer that forms in the linings of blood vessels and lymphatics and comprises <1% of all soft-tissue sarcomas . AS primA 52-year-old, previously healthy, Caucasian male presented to the emergency department (ED) with chief complaints of gross hematuria, abdominal pain, vomiting, diarrhea and left flank pain for 3 days. He had neither family history of cancer nor history of exposure to ionizing radiation, arsenic, thorium dioxide or vinyl chloride. He reported exposure to chemical tankers 10 years prior and had recent occupational exposure to paint-thinning agents. Urinalysis on admission showed large blood with later cytology significant for atypical epithelioid cells concerning for neoplasm of the kidney or bladder. Subsequent contrast-enhancedcomputed tomography (CT) of the abdomen revealed an 11-cm left renal mass, 2-cm para-aortic lymphadenopathy and possible invasion of the tail of the pancreas . He was After discussing options for treatment, surgical management was deemed most appropriate. He subsequently underwent open left radical nephrectomy and adrenalectomy with partial ureterectomy and left para-aortic lymphadenectomy. Intraoperatively, the pancreas was found to be uninvolved. There were no intraoperative or immediate post-operative complications.The resected tissue was stained with routine hematoxylin–eosin (H&E) and was immunostained with CD31 . HistoloTwo weeks post-resection, the patient was recovering as expected. At 4 weeks post-resection, radiation oncology recommended 7 weeks of intensity-modulated radiation therapy to both the surgical site and at-risk nodes identified on CT. Six weeks post-resection, the patient presented to the ED with nausea and vomiting. Abdominal CT revealed a retroperitoneal effusion at the surgical site . At thisSerial CT scans at 10 and 12 weeks post-resection revealed reduction of the retroperitoneal abscess and appearance of liver lesions concerning for metastasis . The patFourteen weeks post-resection, the patient presented to the ED for symptoms of pneumonia and again tested positive for COVID-19. Chest X-ray showed evidence of small, right-sided pleural effusion. He was discharged for home quarantine. Ten days later, he returned to the ED with worsening shortness of breath and chest pain. CT showed a nonmalignant effusion filling the entire right hemithorax as well as significant enlargement of liver lesions . He was Over the next 2 weeks, his respiratory distress worsened, requiring increased oxygen supplementation. Oncology recommended starting Taxol for concern of liver metastasis, but this was not started due to the patient’s rapid deterioration. He subsequently required intubation due to cardiopulmonary arrest and was discharged to inpatient hospice. He expired the following day, surviving a total of 200 days from the day of tumor resection.The overall survival for AS is reported to range from 6–16 months after diagnosis, with a median age of diagnosis of 60–71 years [Most of the knowledge surrounding primary renal AS originates from case reports, which suggest the most important factors in predicting survival are tumor size and metastasis at presentation. Tumors <5 cm may have better odds of long-term survival following resection, but further studies are necessary to create a more reliable cut-off point . This hyRoutine screening for renal cancers is not recommended for most, apart from patients who have heritable disorders which increase their risk . Thus, rLastly, this case highlights the barriers to care which patients faced during the COVID-19 pandemic. Many patients with multiple co-morbidities were unable to receive adequate or continuous care due to concerns surrounding COVID-19. Positive tests often prohibited patients from receiving hospital admission or outpatient treatment in favor of home quarantine. For this case, positive COVID-19 testing delayed care on two occasions; it caused a delay of radiation treatments and in the treatment of pleural effusion which could have prevented its subsequent progression. Although this patient’s overall survival was likely minimally affected, given his tumor size and presence of metastasis, this case provides examples of how care for many patients across the world may have been compromised because of the COVID-19 pandemic.


Pneumorrhachis (PR) is a rare phenomenon, which consists in the presence of air in the spinal canal. There are various aetiologies, being the most common traumatic, non-traumatic and iatrogenic. The diagnosis is primarily done through radiographic findings and it is necessary to understand the mechanism behind its origin. PR secondary to decubitus ulcer (DU) infection is rare. PR is associated with great morbidity and mortality. In selected cases, surgical intervention may be necessary.A 67-year-old woman, dependent, was admitted to the emergency room (ER) and diagnosed with an infected sacral DU, later discharged with antibiotics. She was readmitted to the ER two weeks later, with prostration and fever. On examination, she scored five points on the Glasgow coma scale, had bilateral Babinsky sign and a deep sacral ulcer with bone exposure. A cranial computerized tomography (CT) demonstrated “high cervical and endochannel emphysema in the upper slope of the cervical segment” and the CT scan of the spine showed “endochannel air along the cervical-dorsal and lumbar rachis in an epidural location and inside the dural sac (evoking laceration of the dura mater) (…) and densification of the sacrococcygeal soft tissues (diagnosis of PR secondary to DU infection)”. Broad-spectrum antibiotics were started and the patient was evaluated by General Surgery, which described a large sacral ulcer with signs of the previous debridement and bone exposure, with no indication for surgical debridement, only for chemical debridement. Despite all the measures instituted, the patient died in the ER. Pneumorrhachis (PR) is a rare phenomenon that consists of the presence of air in the spinal canal. The air can be present in the entire length of the spinal canal, from the lumbar to the cervical region, or only in the region of dissection/injury. Being so rare, it is important to understand the mechanisms and pathologies involved in its origin -3.PR may be of iatrogenic, traumatic and non-traumatic aetiology ,4,5,6. IAs to aetiology, we have iatrogenic manipulation during surgical, diagnostic (lumbar puncture) and anesthetic procedures, traumatic or penetrating injuries of the spine, cancer and spontaneous . There aPR is normally asymptomatic and therefore the diagnosis is mainly imagiological ,6,7. RadPR is associated with high mortality and morbidity. There are no guidelines for the treatment of PR due to its rarity .There may be a loss of cerebrospinal fluid in PR, leading to a decrease of intracranial pressure and surgical intervention for its correction may be needed ,3. In tuThe causes of PR should be identified and treated accordingly.coccos - Streptococcus anginosus.A 67-year-old female, dependent on her daily activities, with a history of Alzheimer’s disease, type 2 diabetes mellitus, arterial hypertension and dyslipidemia was observed in the ER two weeks before admission and diagnosed with an infected sacral decubitus ulcer and was discharged with antibiotic (cefolosporin). Two weeks later she was admitted in the ER with prostration with one week of evolution and fever with four days evolution, which resolved with paracetamol. On admission, she was apyretic, normotensive, tachycardic, hyperglycemic, scored five points on the Glasgow Coma Scale, had bilateral Babinsky sign and a deep sacral ulcer with bone exposure. Analytically she presented leukocytosis 15,200/uL, with neutrophilia 93%, glucose 469 mg/dL, urea 58 mg/dL, creatinine 1,30 mg/dL, sodium 153 mEq/L, albumin 2,1 g/dL, C-reactive protein 517mg/L and blood cultures (4 samples) which posteriorly isolated a gram-positive A cranial CT demonstrated “high cervical and endochannel emphysema in the upper segment of the cervical rachis (…) Figure .”A spine CT was performed showing “the presence of endochannel air along the cervical-dorsal and lumbar rachis in an epidural location and inside the dural sac (evoking laceration of the dura mater), apparently insufficient to cause spinal cord compression; as well as air bubbles in the paraespinal soft tissues of the lumbar region and “densification” of the sacrococcygeal soft tissues muscles (possible infection with origen in the ulcerated lesion) Figure , showingBroad-spectrum antibiotics were initiated.She was evaluated by General Surgery, which described a large sacral ulcer, with signs of the previous debridement and sacral bone exposure, without indication for surgical debridement, only chemical debridement.Despite all the measures instituted, the patient died in the ER.Clostridium subterminale and Streptococcus anginosus [Streptococcus anginosus, with gas production in the surrounding tissues and structures.Infectious pneumorraquis can be secondary to hematogenous dissemination or extension of a local infectious process, such as vertebral osteomyelitis, caused by gas-producing microorganisms . PR seconginosus . In the Given the rarity of PR, a high degree of suspicion is important for diagnosis. The exam of choice is CT and the treatment depends on the type of lesion that led to the PR and the clinical manifestation. In some cases, surgical treatment is necessary ,3.Infectious PR is extremely rare. The treatment of decubitus ulcers in regions overlapping the spine should not be neglected, given the possibility of infection by gas-producing microorganisms affecting the spinal canal. When an infectious PR is suspected, broad-spectrum antibiotics should be empirically initiated. PR is mostly asymptomatic, but when symptomatic it is associated with high morbidity and mortality, which was the outcome of this case.


If a child has abdominal pain, it is important to evaluate the possibility of intestinal perforation caused by foreign objects such as fishbone. If a foreign agent is present, laparoscopic surgery is an effective method to remove the foreign objects. If a child has abdominal pain, it is important to evaluate the possibility of intestinal perforation caused by foreign objects such as fishbone. If a foreign agent is present, laparoscopic surgery is an effective method to remove the foreign objects. A case of fishbone perforation in a boy was misdiagnosed as appendicitis. The case we present is rare in children. A 5‐year‐old boy presented with right lower abdominal pain, mild fever, and constipation. He was diagnosed with acute appendicitis and was sent to the operating room for laparoscopic surgery. During surgery, the appendix was normal, and we discovered that a fishbone pierced the ileum wall. We removed that foreign object and sewed the intestine. He recovered well and was discharged after 7 days of treatment in stable condition. It is often difficult to diagnose intestinal perforation caused by a fishbone because the patient and family cannot remember the history of fishbone ingestion. Depending on the lesion location, children have different clinical characteristics, including constipation, abdominal pain, and anal pain. When a child has abdominal pain, a detailed history of eating and drinking, as well as a thorough physical examination and diagnostic imaging, is needed to make an accurate diagnosis.Fishbone perforation has been described by several authors in the medical literature.29/L, neutrophils accounted for 75.8%, and serum C‐reactive protein (CRP) was 21 mg/L. The abdominal ultrasound result showed that his intestines contained fluid and increase motility. The abdominal X‐ray did not show abnormal images (See Figure A 5‐year‐old boy with normal past medical history was admitted to Haiphong Children's Hospital with abdominal pain around the navel after having symptoms for 5 h. He also had a mild fever and an inability to pass stool or gas. On physical examination, the boy was conscious, able to communicate but tired, with a temperature of 37.5°C. His pulse rate was 100 beats per minute; his blood pressure was 90/60 mmHg; and the respiratory rate was 30 breaths per minute. His height was 100 cm, and he weighed 18 kg. All of these numbers were in the normal range for his age. The abdominal examination noted that he had abdominal distension and obvious abdominal muscle guarding in the right iliac and umbilical region. His complete blood count: the number of white blood cells was 14.8 × 10He was diagnosed with acute appendicitis and had had laparoscopic surgery. We saw little fluid around intestines through the laparoscopic camera, with no pseudomembrane, no Douglas fluid, and a normal appendix. While examining the ileum, we did not find Meckel's diverticulums but a sharp foreign object that punctured the intestine from the lumen of the intestine to the outside, about 35 cm from the ileum—cecum (See Figures The boy made a full recovery and was discharged in a satisfactory condition following 7 days of treatment3Fishbone perforation is rarely seen, especially in children. Although most foreign objects can be excreted within a week of entering the gastrointestinal tract,Depending on the perforation's location, patients may have various clinical symptoms, including constipation, abdominal pain, and anal pain. A study reported that 95% of patients presented with abdominal pain, which is the most crucial symptom, 81% having a fever, and 39% having local peritonitis.Patients do not often think they could suffer from intestine perforation due to a fishbone. Therefore, it is hard for doctors to take a medical history of the disease. The fishbone is often only found during an imaging examination or surgical exploration.This child's most essential symptoms were abdominal pain, clear abdominal muscle guarding in the right iliac region with constipation, and fever in our patient. Diagnostic imaging results were not sensitive. Therefore, this patient's symptoms are somewhat close to those of a patient with acute appendicitis, perhaps leading to a misdiagnosis of abdominal pain caused by acute appendicitis.Gastroscopy and enteroscopy are popular methods to remove the gastrointestinal foreign bodies. Only 1% of cases need surgical excision. However, depending on the perforation site and clinical symptoms, treatment could be chosen through suture perforation site, bowel resection, or Hartman procedure.The boy recovered very well and was discharged after 7 days of treatment in stable condition. Nevertheless, after all of this, his family still cannot remember clearly that whether their son ate fish that day or not. All they can make sure that their family regularly ate fish for dinner.4Identifying a case of fishbone ingestion is difficult because patients often do not remember when they ate fish, especially children. Therefore, it is critical for parents to recall their children's food and drinking history. In the case of a child with acute abdomen, doctors have to ask carefully about eating and drinking histories, if they ate fish, chicken, and so on, or not. A clinical examination together with imaging diagnosis is necessary to make the most accurate diagnosis. When performing an inflammatory appendectomy, the abdomen should also be carefully examined.5When dealing with a child having an abdominal pain, it is important to evaluate the possibility of intestinal perforation caused by a foreign object such as a fishbone, in addition to appendicitis. If a foreign agent is present, laparoscopic surgery to remove the foreign objects and suture the gastrointestinal perforation is a common and effective method.Families should not feed their children with fish that still has its bones inside. Parents need to remove all the bones from the fish before their child consumes it.The authors declare that they have no competing interests.SNN, TDN, LTV, and CNBH participated in the study design, protocol development, and performance, data analysis, interpretation of data, writing the manuscript, carrying out the clinical data collection and data analysis, and observing the patient during the treatment. TDN and CNBH performed laparoscopic surgery. All authors read and approved the final manuscript.Approval for the study was obtained from Medical Ethics Council of Haiphong University of Medicine and Pharmacy, and informed consent was obtained according to the Declaration of Helsinki.Written informed consent was obtained from the patient and his parent for publication of these data and the accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Pancreatic tail cystic lesions are increasingly encountered in clinical practice, however, it is difficult to make a correct diagnosis preoperatively because there are many types of pancreatic neoplastic and non-neoplastic cysts. Epidermoid cyst in an intrapancreatic accessory spleen (ECIPAS) is a rare non-neoplastic cyst locating in the pancreatic tail, and it is commonly misdiagnosed as another cystic neoplasm.A 51-year-old man was admitted for investigation of abdominal pain. The physical examination and laboratory tests found no abnormalities, except for an elevation of carbohydrate antigen (CA)19-9. Imaging revealed a cystic lesion within the pancreatic tail, and the solid component surrounding the cyst was enhanced similarly to those of the splenic tissue.ECIPAS was diagnosed based on the pathology after surgery. The mass was composed of a cyst and brown solid spleen-like tissue. The microscopic analysis demonstrated that the solid component was accessory splenic tissue, and the cyst wall was lined with a thin stratified squamous epithelium.Laparoscopic spleen-preserving distal pancreatectomy was performed.The patient was discharged on day 5 postoperatively after an uneventful recovery. CA19-9 returned to normal after surgery. During a 2-years follow-up, there was no evidence of tumor recurrence.Although rare ECIPAS should be considered in the differential diagnosis of pancreatic tail cystic lesions, and the typical imaging features might facilitate the preoperative diagnosis. Laparoscopic distal pancreatectomy is a safe and effective approach for treating ECIPAS. It is difficult to diagnose ECIPAS preoperatively using conventional imaging, thus it is commonly misdiagnosed as another cystic neoplasm, such as a mucinous cystic neoplasm (MCN), solid pseudopapillary tumor (SPT), intraductal papillary mucinous neoplasm (IPMN), or cystadenocarcinoma.–9 ECIPAS was thought to be benign until recently when it was found to develop into a malignant tumor during 6-years follow-up, which highlights its malignant potential. Thus, it would be necessary to make a definitive diagnosis of this disease as well as to differentiate it from other potentially malignant pancreatic tail cystic neoplasms. We describe a case that was speculated to be ECIPAS, treated by laparoscopic spleen-preserving distal pancreatectomy.Although pancreatic tail cystic lesions are being increasingly encountered in clinical practice, it is difficult to make an exact diagnosis preoperatively.2A 51-year-old man was admitted to our hospital with a history of abdominal pain for 6 months. The patient had no symptoms of fever, nausea, vomiting, or weight loss. The patient's symptoms started 6 months ago, with recurrent episodes of abdominal pain that could relieve spontaneously. No history of trauma or pancreatitis was recorded. The physical and laboratory examinations were normal, except for elevation of carbohydrate antigen (CA)19-9 to 55 U/mL . Contrast-enhanced computed tomography (CT) found a cystic lesion measuring 2.6 cm within the tail of the pancreas, and the thick solid wall surrounding the cyst was enhanced similarly to those in splenic tissue . Although most cases of ECIPAS were benign, it was necessary to differentiate it from other potentially malignant pancreatic tail cystic neoplasms, including MCN, SPT, pseudocyst, IPMN, and cystic pancreatic neuroendocrine tumor (p-NET).ECIPAS is an extremely rare entity. ECIPAS was thought to be benign until recently malignant transformation was found during a 6-years follow-up.,13 hence increasing the difficulty to distinguish ECIPAS from malignant tumors preoperatively. It has been reported that the squamous epithelial lining of ECIPAS expressed CA19-9 in immunohistochemical analysis, and serum CA19-9 levels markedly decreased to normal levels postoperatively in patients. These findings suggest that serum CA19-9 is secreted by the epithelial lining cells of ECIPAS. In the current case, although ECIPAS was speculated, the symptoms and high CA19-9 level encouraged us to perform surgery.Elevation of serum CA19-9 level was common in ECIPAS patients. Hu et al reported that nearly 40% of ECIPAS showed high levels of CA19-9,–18. Including the present case, only 6 (10.7%) among the 56 reported cases were correctly diagnosed preoperatively.,19–22 Most cases of ECIPAS were diagnosed after surgery based on pathological findings. Advances in imaging techniques facilitated the diagnosis of ECIPAS as compared with previously; however, few studies have reported the imaging characteristics of ECIPAS. ECIPAS is a well-defined, unilocular, or multilocular cystic mass located in the tail of the pancreas on multimodality imaging. The well-defined boundary is a differentiating morphological feature suggestive of a benign tumor. The cystic wall of ECIPAS showed contrast enhancement similar to that of the spleen during multiphasic CT or MRI. Therefore, the accessory spleen surrounding the cyst was a key component for correct diagnosis. However, only a few cases of ECIPAS had a sufficient solid component that allowed splenic tissues to be detected through radiological imaging. Fortunately, there was a large amount of solid tissue present in our case; therefore, a correct preoperative diagnosis of ECIPAS was achieved. Including the present case, 4 of 56 cases were diagnosed as ECIPAS preoperatively based on the similar density on enhanced CT and intensity on MRI between the solid component and the spleen.,20,21 The cystic component of ECIPAS usually appears to be hypodense on nonenhanced CT, hypointense on T1-weighted imaging, and hyperintense on T2-weighted imaging. However, it sometimes appears hyperdense on nonenhanced CT and hyperintense on T1-weighted imaging, in the presence of hemorrhage or keratinized materials within the cyst.,24,25 In the present case, the cystic component was hyperdense on nonenhanced CT and hyperintense on T1-weighted imaging, and remained unenhanced during multiphasic scans. Thus, the cystic content was considered to be mucinous or bloody liquid that was confirmed by the resected specimen following surgery.Preoperative diagnosis of ECIPAS is difficult. MCN, cystadenocarcinoma, pseudocyst, cystic p-NET, or potential malignant tumor is suspected in most cases. In the only case of ECIPAS diagnosed postoperatively, the FNA sample revealed only predominant macrophages and proteinaceous debris; therefore, no pathological evidence of ECIPAS was acquired prior to surgery. Among the remaining 5 cases of ECIPAS reported in the English-language literature, 1 was correctly diagnosed by EUS-FNA.,21,27–29 Matsumoto et al reported a case of ECIPAS that was accurately diagnosed by EUS-FNA. Their histological findings showed that sinusoids and abundant polymorphous lymphocytes were consistent with an intrapancreatic accessory spleen. Therefore, acquiring pathological evidence of ECIPAS using EUS-FNA seems to be difficult. This is mainly because the amount of splenic tissue surrounding the epidermoid cyst was too small in most cases to be successfully aspirated by FNA. In the present case, although leukocytes were found, we failed to reveal splenic sinusoids and endothelial cells within the acquired specimen.EUS-FNA is a commonly used technique to evaluate pancreatic masses, and it has been investigated for diagnosis of ECIPAS. In Tatsas et al report, 3 of 6 cases of intrapancreatic accessory spleen were diagnosed successfully; however, 1 case of ECIPAS failed to be diagnosed by EUS-FNA. reported that laparoscopic distal pancreatectomy could be a useful, minimally invasive surgical approach for treating ECIPAS with additionally decreased postoperative pain, length of stay, and associated mortality and morbidity. In the present case, the symptoms and serum CA19-9 level encouraged us to perform surgery on this patient. The patient recovered uneventfully and had no evidence of tumor recurrence during a 2-years follow-up, suggesting laparoscopic spleen-preserving distal pancreatectomy is effective and safe for ECIPAS.Treatment of ECIPAS consists of surgical resection and follow-up. As most cases of ECIPAS are reported not to have malignant potential, unnecessary surgery can be avoided with a correct preoperative diagnosis. However, in cases of ECIPAS with symptoms, or in those in which it is difficult to completely exclude malignancy, laparoscopic spleen-preserving distal pancreatectomy is suggested since this procedure has been commonly used to treat benign or low-grade malignant tumors of the pancreatic tail. Fujii et alIn conclusion, it is difficult to make an exact diagnosis of pancreatic tail cystic lesions preoperatively. ECIPAS is an exceedingly rare entity, and all cases reported so far have been found in the pancreatic tail. Therefore, although rare, ECIPAS should be considered in the differential diagnosis of pancreatic tail cystic lesions. Imaging and endoscopic evaluation may be helpful in the diagnosis, but preoperative diagnosis is still challenging. A similar enhancement between the solid component of the cystic lesions and the splenic parenchyma is critical for correct diagnosis. Treatment of ECIPAS by laparoscopic distal pancreatectomy is an effective procedure with the advantages of minimal invasiveness.The patient signed a written informed consent form for the purpose of publication of the results of this case study.XZ reviewed the literature, acquired the data, and contributed to manuscript drafting; BZ analyzed and interpreted the pathological and immunohistochemical findings, and contributed to manuscript drafting; QJS and MJ analyzed and interpreted the imaging findings and contributed to manuscript drafting; SY acquired the data and was responsible for the revision of the manuscript for important intellectual content; all authors issued final approval for the version to be submitted.Conceptualization: Sheng Yan.Data curation: Xiang Zheng.Writing – original draft: Xiang Zheng, Ming Jin.Writing – review & editing: Bo Zhou, Qing jing Sun.


Uterine adenosarcoma is a rare variant of mixed Mullerian tumors comprised of neoplasticglands with the benign appearance and sarcomatous stroma. The epithelium most oftenconsists of endometrium-like cells, while the sarcomatous component usually showslow-grade homologous uterine sarcoma. These tumors present as a pelvic mass or an enlargeduterus with abnormal vaginal bleeding. Here, we present a case of 61 years oldpostmenopausal female patient with chief complaints of excessive vaginal bleeding andurine retention. Predisposing factors attributed to adenosarcoma are a history of pelvicradiation, breast cancer, hypertension, obesity, and treatment history withtamoxifen.A 61-year-old female patient came with chief complaints of intermittent, excessive vaginalbleeding for two months. She also complained of vaginal discharge along with burningmicturition and retention of urine for two days.She had menopause five years back and uterine prolapse for one year. There was no historyof hypertension or diabetes mellitus. Her general and systemic examinations were within thenormal limit, but the per speculum examination revealed a polypoidal mass into the vagina,and the mass was protruding from the cervix.Ultrasonography of abdomen and pelvis revealed bulky uterus measuring 13.7 x 9.3 x 5.5 cmwith thickened endometrium and large heterogeneous mass in the cervix. MRI pelvis revealedlarge heterogeneously enhancing lesion with cystic areas involving cervix measuring 14 x 8 x8.5 cm. The lesion was extending up to the left lateral uterine wall displacing thethickened endometrium (14.8 mm) to the right. An inferior lesion was reaching up to thevaginal introitus. No parametrial infiltration was seen. MRI impression was given ascarcinoma cervix.During surgery, a huge submucosal fibroid extending up to the vagina was noticed. Adhesionswere present over the posterior surface of the uterus and to the bowel mucosa. Massincluding the uterus and bilateral adnexa could not be removed intact. Tissues were sent forhistopathological examination with a provisional diagnosis of carcinoma cervix.On gross examination, the uterine mass was received in multiple bits and altogether weighed400 grams and measured 9.5 x 7.5 x 3 cm. The endometrial cavity showed multiple exophyticmasses extending into the endometrial cavity, the largest measuring 2 x 1 cm. Friableirregular areas measuring 4 x 4.5 cm was noted protruding from the cervix . The cutMicroscopic examination showed biphasic proliferation of tumor with glands and stroma. Thestroma was cellular with mild to moderate atypia and was seen cuffing around the glands. Theglands were distributed throughout the tumor and were lined by columnar epithelium. Glandswere cystically dilated with luminal secretion . The foc3 It occurs in women of allages.1 The majority occur inpostmenopausal women, but about 30% are found in premenopausal patients, includingadolescents. The median age for the tumor is 50-59 years.4 Here, we report a case of adenosarcoma in 61 years oldpostmenopausal female who presented with abnormal vaginal bleeding, discharge, urinaryretention, and cervical growth.Adenosarcoma is a rare variant of mixed Mullerian tumors, consisting of neoplastic glandswith a benign appearance and a sarcomatous stroma.1Extrauterine adenosarcoma occurs in younger women and is more aggressive than its uterinecounterpart. It most often occurs in the endometrium but is also found in the cervix and inextrauterine pelvic locations, such as the fallopian tube, ovary, and para ovariantissues.1 Risk factors for uterine adenosarcoma includeunopposed estrogen stimulation,5long-term oral contraceptive use6 andprolonged use of tamoxifen for breast cancer.8 Our patient had none of theserisk factors. These tumors can present as a pelvic mass (37%), uterine polyp (22%), or anenlarged uterus (22%).9 Abnormal vaginalbleeding is the most common presenting symptom. Vaginal discharge, pain, nonspecific urinarysymptoms, a palpable pelvic mass, and a tumor protruding from the cervix are other commonsigns and symptoms.1 There may be ahistory of the uterine polyp.4Association of adenosarcoma with obesity or hypertension is not seen.10At low power, the architecture is of a phyllodes tumor, with leaf-like architecture.Stromal projections can be lined by any benign or mildly atypical Mullerian-type epithelia,with or without squamous metaplasia. Intraglandular stromal protrusions arecharacteristic.4 The stroma is usuallylow-grade and of endometrial stromal or fibroblastic type.10 Histopathologically, this case also had similar findingslike phyllodes appearance and cuffing of stromal cells around glands. WHO definesadenosarcoma as having a stromal mitotic activity of two or more mitotic figures/10 highpower fields, as suggested by Clement and Scully.2 Histopathological examination in this case also showed 2-3/10 HPF.The stroma is typically more cellular and condensed ("collaring") around theglands.1 Uterine adenosarcomas arecapable of local recurrence, but lymph node and distant metastases are rare. Radiotherapy isnot recommended, and there is only limited evidence for the use of neo-/adjuvant or adjuvantchemotherapy and hormonal therapy.4 Ourpatient also underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy.Uterine adenosarcomas can recur locally in up to 30% of cases, particularly in the vagina;recurrences can be early or late. The presence of deep myometrial invasion is a risk factorfor recurrence. Metastatic disease is usually associated with tumors exhibiting sarcomatousovergrowth, and the prognosis is poor.4Management is usually done by total hysterectomy and bilateral salpingo-oophorectomy.Negative prognostic factors include the presence of myometrial invasion, sarcomatousovergrowth, lymphovascular invasion, necrosis, and the presence of heterologouselements.In conclusion, uterine adenosarcoma is a rare biphasic malignant mesenchymal tumor mostlyseen in postmenopausal women, which may be confused as carcinoma of the cervix bothclinically and radiologically if the tumor protrudes from the cervix.


A spontaneous intraperitoneal bladder rupture is a rare, serious and life-threatening surgical emergency of various etiologies, with unspecific clinical presentation, and difficult diagnosis. Surgical treatment is the standard therapy for intraperitoneal bladder rupture; however, there is an increasing tendency toward conservative management in selected patients with favorable characteristics. Herein, we report a rare case of a 65-year-old male patient presented to the emergency department with intraperitoneal bladder rupture following an episode of acute urinary retention due to benign prostatic hyperplasia, and which was successfully managed conservatively with urinary bladder catheterization and antibiotic therapy, without any complication. A spontaneous intraperitoneal bladder rupture is an extremely rare urologic emergency, potentially life-threatening with significant morbidity and mortality rate reaching up to 50%, and mostly occurs in men . EtiologA 65-year-old male patient, with a past medical history of benign prostatic hyperplasia (BPH) not followed for 3 years, presented to the emergency department with generalized malaise, painful abdominal distension, and absence of urine outflow, following an episode of acute urinary retention for 1 day. On examination, he was apyretic, his abdomen was distended and painful, especially in the hypogastric area, without guarding or rebound tenderness, with empty bladder, and absence of urine outflow. Digital rectal examination revealed an enlarged prostate, with firm consistency with no palpable nodule. Vital parameters were normal, with blood pressure of 123/72 mmHg, heart rate of 78 beats/min, and respiratory rate of 18 breaths/min. Urinary bladder catheterization allowed to drain approximately 60 ml of clear urine. Computed tomography (CT)-urography revealed large amounts of intraperitoneal fluid, leaking from the bladder through a small defect in the anterior bladder wall, associated to free intraperitoneal air, with an infiltrated perivesical fat, and empty bladder , late exth day in good health with indwelling bladder catheter, and a transurethral resection of the prostate (TURP) was planned after 4 weeks.Given the patient's stable clinical status, early diagnosis, the absence of sepsis or associated comorbidities, conservative management has been decided, it consisted of intravenous antibiotic with close observation and maintenance of bladder catheterization. Abdomen distension has slowly abated over the next day. Laboratory testing revealed hemoglobin of 12.7g/dL, with normal serum creatinine and urea level, negative C-reactive protein (CRP), and negative urine culture. On the seventh day, cystogram revealed no evidence of any contrast leak, the cystoscopy did not show any suspicious bladder lesions, with enlarged obstructive prostate. The patient was discharged from the hospital at the 8A spontaneous urinary bladder rupture is an extremely rare pathological entity, with an incidence of 1: 126,000, and a mortality rate of around 50% . PredispClinical presentation is non-specific and vague, and the diagnosis has been described as challenging in most of cases, it manifests by haematuria, abdominal distension, diffuse tenderness in abdomen, associated with decreased urine output and voiding complaints, or sometimes it takes the clinical picture of acute peritonitis with sepsis, oliguria and acute renal failure due to reabsorption of urine through the peritoneum, especially when the diagnosis is delayed or missed , 4. ThisCT-cystography is the investigation of choice for a suspected urinary bladder rupture, with sensitivity and specificity of 78% and 99%, respectively, it offers the advantage of exploring the whole abdominal cavity and etiological research in the same examination. CT-urography with excretory phase can also make diagnosis, it is less invasive than CT-cystography and provides a complete overview of the entire excretory system, but it can sometimes miss the diagnosis .Once urinary bladder rupture is diagnosed, treatment depends on type of bladder perforation as well as the nature of an underlying pathology which can require additional treatment, this treatment is not codified and there are still no clear guidelines in the available literature . SeveralThese findings highlight that bladder rupture can be a serious complication of benign prostatic hyperplasia, which is the most common pathology in elderly man, and must be treated effectively before the occurrence of irreversible complications. Conservative management may be a valid treatment option for patients diagnosed with a spontaneous intraperitoneal bladder rupture. However, further research is needed to determine the best candidates for such approach.Spontaneous intraperitoneal bladder rupture is a rare urological emergency. Prompt and accurate diagnosis is the key for appropriate management. Non-operative treatment with bladder drainage, and antibiotic therapy could be a valid option in carefully selected patients.


Rosette-forming glioneuronal tumor (RGNT) is a rare variety of slow growing mixed glioneuronal tumor involving primarily fourth ventricular region. This is a comprehensive analysis of a 22-year-old woman with RGNT composed of mainly cystic components. In addition, the case showed multiple lesions located in brain parenchyma which mimicked cerebral cysticercosis. Here, we analyzed this case and listed some characteristics of RGNTs in reported literature which occurring in atypical locations for further understanding it.A 22-year-old woman presented with a history of transient dizziness, nausea, and vomiting. Magnetic resonance imaging (MRI) showed multiple cystic lesions in brain parenchyma and then the patient was diagnosed with cerebral cysticercosis possibility. Empirical anti-infective therapy in addition to a follow-up post 2 weeks of MRI examination showed the lesions unchanged. Finally, a biopsy of the right cerebellar hemisphere lesions verified RGNT.RGNT is an uncommon tumor classified as grade I glioma by World Health Organization (WHO) with slightly longer course. The imaging findings of RGNT are not specific especially in atypical areas. RGNT is rare, but we should also consider the possibility in diagnosis and differential diagnosis. The rosette-forming glioneuronal tumor (RGNT) was first described by Komori et al. in 2002. As it was initially thought as dysembryoplastic neuroepithelial tumor (DNT) of the cerebellum . In 2007A 22-year-old woman presented with a history of transient dizziness, nausea, and vomiting. No neurological deficits were apparent; however, on further evaluation, initially with computed tomography (CT) scan, revealed multiple cystic hypo-dense mass lesions in bilateral cerebellar hemisphere, brain stem, and left thalamus with unclear boundary Fig. . MagnetiBased on the above radiological findings, the woman was initially diagnosed with cerebral cysticercosis most possibly. Naturally, primary tumors of the central nervous system and metastatic tumors were differential diagnoses. Subsequently, she was admitted to the infectious diseases department to conduct empirical anti-infective therapy in addition to a follow-up post 2 weeks of MRI examination. Over the course of 2 weeks, she underwent further laboratory examinations, including serologies ); however, the results were negative. Meanwhile, eosinophilic cells and lymphocytes were neither found in cerebrospinal fluid (CSF). Other parasite antibodies were not discovered either. Most importantly, there were no significant changes in the MRI findings after 15 days Fig. . FinallyRGNT is an unusual disease, and it is considered an independent entity of glioma, which is categorized as grade I by World Health Organization (WHO) due to its characteristics of containing both neural and glial components . It is gWith regards to the English literature through a comprehensive search of Web of Science and PubMed using the search term “the rosette-forming glioneuronal tumor” nearly a decade, more than 100 articles have been published to date. After full text screening, excluding articles that were less relevant to the characteristics of RGNTs, nearly 70 articles were included by December 2020 finally. In general, 101 cases of RGNTs were reported located in the fourth ventricle, while 51 cases were located in atypical site. However, the imaging manifestations of RGNTs occurring outside the fourth ventricle are not specific; so, they are often misdiagnosed. Here, the characteristics of RGNTs located outside the fourth ventricle in 51 published cases were listed  Fig. . After eRGNT is an uncommon low-grade neuroglial tumor which is generally considered benign with slightly longer course . Headach


Hepatic inflammatory pseudotumor (IPT)-like follicular dendritic cell (FDC) sarcoma is a very rare disease. Till now, only 19 cases were reported in the English literature. However, the coexistence of IPT-like sarcoma and non-Hodgkin lymphoma (NHL) in the same patient has never been reported. In this report, we presented a case of hepatic IPT-like FDC with hepatic NHL history of which both were successfully resected.We reported a case of a 47-year-old male patient who presented with right upper abdominal discomfort. Nineteen years ago, he underwent liver resection of segment VII for hepatic NHL (B-cell lymphoma). He had a history of chronic hepatitis B virus infection. Serum alpha fetoprotein level was normal. However, imaging studies revealed a well-circumscribed, solid mass in the right hepatic lobe, he came back to the clinic because he was worried about a recurrence of the B-cell lymphoma.Based on the patient's past medical history and magnetic resonance imaging results, and he was diagnosed as hepatocellular carcinoma or hepatic NHL preoperatively.Right hemi-hepatectomy was performed on this patient.Histological report showed features of a mixture of chronic inflammatory cells and variable amounts of spindle cells. Also, immuno-histo-chemical studies demonstrated that all the tumor cells showed strong nuclear in situ labeling for EBV-encoded small RNAs and strongly positive stainings with CD21 and CD35. The patient tolerated the surgery well, recovered smoothly and he was discharged on postoperative day 7 (day 7). The patient is still disease free after a follow-up of over 50 months.To our knowledge, this is the first report demonstrating hepatic IPT-like FDC sarcoma in a patient with primary hepatic NHL history. In regards to treatment, complete surgical resection should be performed and would acquire excellent long-term outcomes. IPT-like FDC sarcoma contains a few spindle cells with prominent lymphocytes and plasma cell infiltration with some neoplastic cells resembling Hodgkin cells. Hepatic IPT-like FDC sarcoma has been rarely reported in recent years, even though it has been receiving increased attention since its first description in 1996 by Selves et al. Clinico-pathological characteristics of hepatic IPT-like FDC sarcoma have not been fully understood.,5 So far, <20 cases of hepatic IPT-like FDC sarcomas have been published in the literature.,4,6–17 Due to these morphologic features, IPT-like FDC tumors are commonly misdiagnosed as inflammatory lesions and occur almost exclusively in the liver or spleen with a slight female predominance. Recent studies indicated that these tumors had a risk of recurrence and metastases.,5 The origin of tumor cells, causes of the disease, and the ambiguity of diagnosis are still unknown. Hepatic IPT-like FDC sarcomas, which is different from other extra-hepatic FDC tumors, have always been shown to be associated with the Epstein-Barr virus (EBV) infection. EBV infection is considered as one of the most important etiologies of this tumor. Almost 100% of the IPT-like FDC tumors have always been proven to be associated with the EBV infection. Although hepatic IPT-like FDC sarcoma is extremely uncommon, most published cases showed typical histological characteristics, consistent with EBV infection and had a good prognosis after surgical resection of the tumor.,19Follicular dendritic cell (FDC) sarcoma is a very rare disease with more than half of the cases occurring in lymph nodes. Extra-nodal follicular dendritic cell tumors mainly arise from intra-abdominal organs such as liver and spleen, which display an aggressive clinical course.,21 The tumor had no enhancement in all 3 phases after the injection of contrast materials in contrast-enhanced ultrasonography. Central septations, calcification, necrosis, or hemorrhage may be present. Some atypical hepatic IPT-like FDC sarcomas may present with arterial enhancement and are hard to differentiate from hepatocellular carcinomas (HCCs). The definite diagnosis of hepatic IPT-like FDC sarcoma should rely on histopathology. The tumor is a mixture of lymphocytes, storiform, and fascicular arrangement of spindle cells which are positive for at least one of the markers for FDCs including CD21, CD23, CD35, Fascin, Clusterin, CXCL13, and epidermal growth factor receptor.The distinction of IPT-like FDC sarcoma from other tumors is very challenging and such tumors are commonly misdiagnosed as inflammatory lesions. The regression of the tumor size, either spontaneously or after treatment with anti-inflammatory agents may increase the likelihood diagnosis of IPTs.Primary malignant lymphoma of the liver is also a rare disease. In addition, the occurrence of hepatic IPT-like FDC sarcoma and non-Hodgkin lymphoma (NHL) in the same patient has never been reported. In this report, we presented a case of hepatic IPT-like FDC sarcoma with hepatic NHL history, both of them received liver resection.2We evaluated a 47-year-old man with right upper quadrant abdominal pain and no other associated symptoms. He had a history of Hepatitis B virus (HBV) infection and no Hepatitis C infection. Abdominal magnetic resonance imaging (MRI) scan from the First Hospital of Yi Chang revealed a 19 × 15 × 13 cm tumor in the right lobe of the liver. The right portal and hepatic veins were not visualized, inferior vena cava (IVC) was compressed  staining procedures. Immuno-histo-chemical (IHC) and in situ hybridization analyses were performed on a 4-μm thick section. The patient did not receive any adjuvant therapy, and was still alive without tumor recurrence for >50 months after liver resection.3The excised mass measured 20 × 18 × 15 cm, which was well delimited from the surrounding liver parenchyma. The surgical margins were free of tumor, with areas of necrosis and hemorrhage in the center of the tumor , and inflammatory pseudo-tumor.,26,27 According to IHC analyses, FDC sarcoma shows spindle tumor cells arranging in fascicular or storiform patterns, which are immuno-reactive for one or more FDC markers: CD21  and CD35 . Other quite specific markers used are: R4/23 (63%), Ki-67 (5–50%), EMA (41%), Vimentin (61%), HLA-DR (57%), CD45 (21%), and S-100 protein (31%). The tumor cells typically lack expression of CD1a, CD 68, and Desmin.,14FDC tumors are very rare neoplasms that mainly arise in lymph nodes and about one-third of the cases develop in extranodal sites, which have a heterogeneous histology with storiform and fascicular arrangement of plump spindle cells. Hepatic IPT-like FDC sarcoma is an extremely uncommon tumor and only 20 cases have been reported till now in English literature, including the present patient , the mean tumor diameter was 11.9 cm (3–20 cm), and the mean reported survival was >30 months (follow-up ranging from 6 to 108 months). The histology is similar to that of the conventional FDC tumor and it is generally considered to be a distinctive variant which is characteristically restricted to the abdomen and seems to be a separate clinico-pathologic entity. Comparing to the conventional FDC sarcoma, hepatic IPT-like FDC sarcomas have a marked female predominance , whereas conventional FDC sarcomas are not more prevalent in only one sex. Hepatic IPT-like FDC sarcomas have prominent inflammatory component, which makes them challenging to differentiate from inflammatory pseudo-tumors. IPT-like FDC sarcomas are strongly associated with the presence of EBV (85% in our review) infection, which is rare in conventional FDC sarcomas. Both the IPT-like FDC sarcomas and conventional FDC sarcomas generally show an indolent clinical behavior. Nevertheless, conventional hepatic FDC sarcomas can be more aggressive than IPT-like FDC sarcomas, and may recur or metastasize and even lead to death.Primary hepatic sarcomas are very rare, representing <0.1% of all primary hepatic tumors. reported a case of hepatic IPT-FDC tumor which was initially misdiagnosed as an inflammatory pseudo-tumor. The tumor recurred 30 months after complete liver resection. The definite diagnosis of hepatic IPT-like sarcoma relies on histopathologic findings. Furthermore, CD21 and CD35 have been widely used as the preferred FDC markers which were expressed in almost IPT-like FDCs. Moreover, EBV infection was identified as a key role in the genesis of IPT-like FDC sarcomas. Almost all the hepatic IPT-like FDC sarcomas exhibited positive EBV-encoded small RNAs by in situ hybridization  in 1999 (no data available due to long time). IHC studies demonstrated that all the tumor cells were strongly positive stainings with CD20 and CD45. A diagnosis of hepatic NHL was confirmed at that time . Several studies indicated that chronic hepatitis C virus (HCV) infection may be associated with the pathogenesis of NHL. However, the present case has HBV infection and no HCV infection. The detailed mechanism of HCV-mediated lymphomagenesis remains unclear. Our search of the literature found no such cases. This is the first report to demonstrate hepatic IPT-like FDC sarcoma in a patient with a history of primary hepatic NHL.Primary NHL of the liver has rarely been reported and there are no typical laboratory or image diagnostic findings. Therefore, pathological analysis is the standard diagnostic method. reported that even if complete resection had been achieved for hepatic NHL, postoperative chemotherapy was necessary. The patient in our report did not receive chemotherapy after the first hepatectomy. Tsunemine et al suggested that transarterial chemoembolization (TACE) was useful for the management of hepatic FDC sarcomas and the patient was still alive 27 months after the diagnosis of hepatic FDC sarcoma, which was favorably controlled by repeated TACE. Shinagare et al reported a case whereby the patient was not determined to be a surgical candidate due to large tumor mass and small residual liver volume. The patient received 4 cycles of standard-dose of chemotherapy comprising of cyclophosphamide, doxorubicin, vincristine, and prednisone therapy and portal vein embolization in an attempt to cause hypertrophy of the residual liver which made him a surgical candidate. Seven months later, the patient underwent a successful resection of the 12-cm nodular mass. In our review, 19 of the patients (95%) with hepatic IPT-FDC sarcomas only underwent partial hepatectomy and had a relative good long-term outcomes.Surgical resection is an acceptable choice for primary hepatic IPT-like FDC sarcomas and hepatic NHL whenever possible. The efficacy of chemotherapy and radiotherapy is unclear. Daniel et al6In conclusion, we reported a unique case of hepatic IPT-like FDC sarcoma with hepatic NHL history. IPT-like FDC sarcoma is receiving growing attention and the diagnosis may be correct with the aid of immuno-histochemical analysis being CD21 and CD35 the most reliable FDC markers. IPT-like FDC sarcoma should be considered in differential diagnosis when confronted with a liver tumor in a patient with primary NHL or HBV infection history. Complete resection remains the preferred method for the management of hepatic IPT-like FDC sarcomas which could get a better prognosis. In analyzing the reported cases, we brought forth differential diagnosis and provided evidence for further exploration of the pathogenesis of the tumor. Continued accumulation of characteristics of hepatic IPT-like FDC sarcomas would help in future patient care.Conceptualization: Er-lei Zhang.Data curation: Jiang Li.Formal analysis: Jiang Li, Hai-su Tao, Dong Chen.Funding acquisition: Erlei Zhang.Investigation: Jiang Li, Hai-su Tao.Methodology: Zhiyong Huang.Project administration: Erlei Zhang.Resources: Jiang Li, Dong Chen, Hai-Su Tao.Supervision: Er-lei Zhang, Zhiyong Huang.Writing – original draft: Jiang Li.Writing – review & editing: Er-lei Zhang, Jiang Li.All authors read and approved the final manuscript.


Aortoenteric fistula is a life-threatening emergency and is associated with high morbidity and mortality. Prompt surgical intervention before the aneurysm ruptures lowers the mortality rate to about 50%. Potential imaging mimics for aortoenteric fistula include retroperitoneal fibrosis, mycotic aortic aneurysm, and infectious aortitis. Secondary aortoenteric fistula has relative higher incidence compared to primary and is more common with open aortic repair versus endovascular stent graft repair. Ectopic gas in the aneurysm sac and extravasation of enteric contrast into the aneurysm sac is diagnostic for aortoenteric fistula. However, enteric contrast is not recommended for routine evaluation of aortoenteric because the aforementioned finding is extremely rare. More common imaging findings include bowel loop appearing adherent to aneurysm sac with associated inflammatory stranding and foci or ectopic gas within the aneurysm sac or interposed between the bowel and aneurysm sac. Here we present a case of 52-year-old male who presents with incidental primary aortoenteric fistula. Aortoenteric fistula is defined as an abnormal communication between the aorta or aortoiliac tree with the gastrointestinal tract and presents as catastrophic gastrointestinal bleeding with annual incidence of primary aortoenteric fistula reported at 0.007 per million (with 250 cases reported in literature) Aortoenteric fistula present as minor "herald" gastrointestinal bleeding followed by later catastrophic life-threatening gastrointestinal hemorrhage Here, we present a case of aortoenteric fistula who underwent open resection of abdominal aortic aneurysm with a right axillary to bifemoral bypass graft.A 52-year-old Caucasian male presented to the outside facility emergency department following a syncopal episode and dysthymia. On arrival his vital signs were within normal limits. No leukocytosis. Chest radiograph and unenhanced CT brain were normal. CT abdomen and pelvis with contrast was performed which showed infrarenal abdominal aortic aneurysm measuring 8.9 × 10.3 cm .Fig. 1CTAdditionally, on retrospect, the loop of jejunum appeared adherent to aneurysm sac, with ectopic air within the partially thrombosed aneurysm sac tracking to and in continuity with intraluminal bowel gas. Findings compatible with primary aortoenteric fistula .Fig. 2AdPatient underwent endovascular aortobiiliac stent graft placement on the same day at outside facility . FluorosFive days following the procedure patient reported bright red blood per rectum with stable vitals and hematocrit. CT angiogram of the abdomen and pelvis was performed which showed normal positioning of aortobiiliac stent graft and no evidence of endoleak. The size of the excluded aneurysmal sac was stable from prior exam. There was interval worsening of ectopic air within the excluded aneurysmal sac. Findings were compatible with known aortoenteric fistula .Fig. 4FiAdditionally, prior to transfer at our facility, CT abdomen and pelvis without intravenous contrast was performed which showed enteric contrast into the excluded aneurysmal sac, confirming known aortoenteric fistula .Fig. 5PrPatient was transferred to our facility for further management. Patient underwent resection of abdominal aortic aneurysm with a right axillary to bifemoral bypass utilizing bifurcated ringed Polytetrafluoroethylene, Aortoenteric fistula was first described in 19th century by a British surgeon Sir Astley Cooper CT findings of primary aortoenteric fistula includes presence of ectopic gas within the excluded aneurysmal sac and/or presence of enteric contrast in the aneurysm sac. Lack of fat plane between the vessel and bowel lumen may be early sign for developing aortoenteric fistula. Ancillary findings for secondary aortoenteric fistula includes peri-graft soft tissue inflammation, and adjacent bowel wall thickening Potential imaging mimics of aortoenteric fistula includes retroperitoneal fibrosis, mycotic aortic aneurysm, and infectious aortitis No patient identifiers are disclosed in current report.


Intradural disc herniation (IDH) is usually diagnosed during surgery when a herniated mass is found to have penetrated the ventral dura. We experienced a case of IDH that entered the dura from the lateral side with no penetrating hole. A 61-year-old man presented to our institution with left leg pain of two months' duration. Plain x-ray imaging showed degeneration of the lumbar spine, and a magnetic resonance imaging (MRI) scan revealed a suspected tumor at the L3-L4 level. Two weeks later, the patient suffered from acute cauda equina syndrome. A gadolinium-enhanced MRI showed an enlarged lesion with no enhancement visible, and emergency surgery was performed. The lesion originated from the left side of the dura. Despite the white debris suggesting a herniated disc, no penetrating hole was found in the dura. Pathologically, the lesion was found to be an intervertebral disc and was diagnosed as an intradural lumbar disc herniation. The patient’s neurological symptoms improved, but he did not recover his left ankle dorsiflexion. In a degenerated lumbar spine, IDH may not always originate from the ventral dura and may not be accompanied by a penetrating hole. Intradural disc herniation (IDH) is a rare condition that is difficult to diagnose on preoperative magnetic resonance imaging (MRI). It is usually confirmed at the time of surgery when a herniated mass is found to have entered the ventral dura. Herein, we report a case of an intradural prolapse of a herniated disc from the lateral side, rather than the ventral dura, with no apparent penetration hole.A 61-year-old man presented to our institution complaining of intermittent left leg pain that had begun two months earlier. The patient had a history of lung cancer and type 2 diabetes mellitus. Walking caused pain from the left buttock to the outside of the left thigh, which dissipated when he rested. Muscle strength and deep tendon reflex tests were normal, and there was no bladder or bowel dysfunction. Plain x-ray images showed degeneration of the lumbar spine, and an MRI found stenosis at the L3-L4 level due to a suspected tumor (Figure A contrast-enhanced MRI scan was therefore planned for further evaluation. However, two weeks later, the pain in the patient’s left leg became severe with worsening low back pain, and at the same time, the left ankle joint became impossible to dorsiflex, despite none of the usual triggers. This was followed by difficulty walking due to an inability to move both ankles a few hours later. He also had urinary retention. An urgent MRI scan with no gadolinium enhancement showed an enlarged lesion Figure . No abnoAn acute cauda equina syndrome was diagnosed, requiring emergency surgery. An L3-L4 laminectomy was performed, followed by ultrasonography to confirm the lesion, which was located at the L3-L4 disc level but was not continuous with the disc (Figure When the dura was incised, white debris was observed. This led us to assume a herniated disc Figure . The lesPostoperatively, the patient gradually recovered his muscle strength but did not recover his left ankle dorsiflexion. His bladder regained its function. Histologically, there were no findings of neoplasm, and fibrocartilaginous tissue that could be considered as intervertebral disc was identified Figure . The diaIDH is a rare condition that accounts for 0.26%-0.30% of lumbar disc surgeries ,2. TherePreoperative diagnosis of IDH is often difficult ,7,8. IDHWe have reported a case of IDH with cauda equina syndrome that could not be definitively diagnosed intraoperatively because of its atypical nature. At the level of the degenerated lumbar spine, IDH may not always originate from the ventral dura and may not be accompanied by an obvious penetration hole. Yet, regardless of how much is known about the lesion, prompt surgery is always necessary for acute-onset cauda equina syndrome.


Chylous ascites is caused by an accumulation of lymphatic fluid in the peritoneal cavity secondary to a rupture or obstruction of the abdominal lymphatic ducts. It has a milky appearance and is rich in triglycerides. The most frequent etiologies are neoplasms, liver cirrhosis, and ruptured lymphatic vessels after abdominal surgery. Clinically, it manifests as abdominal distention and increased abdominal girth. The presence of triglycerides in ascites fluid is the most useful diagnostic criterion. Treatment consists of a high-protein diet with fat restriction and medium-chain triglyceride supplements. Surgery is reserved for refractory cases. We present the case of a 66-year-old patient with a diagnosis of chylous ascites secondary to retroperitoneal lymphadenectomy. Chylous ascites is caused by an accumulation of lymphatic fluid in the peritoneal cavity . It is aThere are a series of cases described, although no large clinical series have been published. The objective of the present case is to describe the report and carry out a review of the current bibliography on the management of chylous ascites.We present a 66-year-old woman diagnosed with locally advanced cervical cancer, FIGO IIB stage (2018), undergoing follow-up by the Gynecologic Oncology Unit. After the presentation to the tumor committee, it was decided to perform a staging retroperitoneal para-aortic lymphadenectomy before the radical treatment (concomitant chemotherapy and radiotherapy). Following the recommendations of the tumor committee, a laparoscopic retroperitoneal para-aortic lymphadenectomy was carried out without incident, with negative results for malignancy of all nodes removed. The immediate postoperative period was uneventful, with hospital discharge at 48 hours.One month after the surgery, the patient came to the emergency room with generalized abdominal pain, distension, diarrhea, early satiety, and increased girth that had evolved over a 48-hour period. On examination, she presented with visible abdominal distension and a positive ascites surge. A thoracic-abdomino-pelvic CT scan Figures , 2 was pDuring her stay, an evacuating paracentesis was performed with the extraction of 5500 cc of bloody milk-like ascites fluid Figure , with thThe patient was diagnosed with chylous ascites secondary to ruptured lymphatic ducts that had occurred as a result of the previously performed para-Aortic lymphadenectomy. She was treated with a high-protein diet with fat restriction, medium-chain triglyceride supplements at 20 ml/day, and subcutaneous octreotic 100 µg every eight hours. The evolution was satisfactory. She was discharged after four days. She continued the treatment as an outpatient. Octreotide was discontinued one month after the diagnosis, and the evolution was favorable. Subsequently, the patient received external radiotherapy, brachytherapy, and sensitizing chemotherapy as treatment for cervical cancer, presenting no complications. Twelve months after discharge, the patient remains on a low-fat, high-protein diet, supplemented with medium-chain triglycerides, and is making good progress.In our center, over a period of 13 years, a total of 239 staging para-Aortic lymphadenectomies have been performed on locally advanced cervical cancer patients, with only one case of chylous ascites during this entire period, which represents 0.42% of the sample.Chylous ascites is the accumulation of lymphatic fluid in the peritoneal cavity . Its milThe present case is a chylous ascites secondary to surgery. Its appearance varies according to the type of surgery, with interventions related to oncological processes, specifically retroperitoneal lymphadenectomy, the procedure with the highest risk .Complications can be present early (during the first week) if there has been a rupture of the lymphatic vessels, or late (weeks or months) because of adhesions or extrinsic compression of the lymphatic vessels. This was most likely in our case due to the presence of a lymphocele, which could have caused the rupture of the lymphatic vessels.Clinically, abdominal distention is the most common sign, and nonspecific abdominal pain, diarrhea, malnutrition, edema, early satiety, and dyspnea may also appear ,4. WeighTreatment depends on the etiology. It should be as conservative as possible, and it will resolve in 67-75% of cases ,6. DepenThis is a rare case of chylous ascites secondary to retroperitoneal para-aortic lymphadenectomy that resolved with medical treatment. Chylous ascites secondary to postoperative complications can appear early, probably due to rupture of the lymphatic vessels, or late, as occurred in our case, due to adhesions or extrinsic compression of the lymphatic vessels (lymphocele). Treatment consists of a high protein diet with fat restriction and medium-chain triglyceride supplements, reserving surgery for situations refractory to treatment.