Colorectal cancer may yield metastasis to the choroid. Its management may be challenging, since there is no consensus about treatment. We describe a case of a 70-year-old male with colon cancer who complained of worsening visual acuity of his better-seeing eye to 20/40 secondary to a nonpigmented choroidal mass of medium reflectivity under the inferior temporal arcade and neurosensory foveal detachment. Besides systemic chemotherapy, local treatment with verteporfin photodynamic therapy (vPDT) was performed. After one month, visual acuity improved to 20/25 and subretinal fluid faded. In conclusion, vPDT may be a useful adjuvant treatment modality for choroidal metastasis secondary to colorectal cancer. Colorectal cancer (CRC) consists of the development of cancer from the colon or rectum. Various histology types of CRC have been described, whereas adenocarcinoma comprises over 95% of the cases. About 20% of the patients with CRC present with metastases at diagnosis, and the most common sites include the liver, lung, peritoneum, and bones –3.Ocular and periocular metastases in patients with CRC have been described in the medical literature, with the choroid being the main site –8. ChoroThe primary purpose of this paper was to report on a case of presumed choroidal metastasis in a patient with colon carcinoma treated by photodynamic therapy with verteporfin (vPDT). The secondary goal of the paper was to present a review of medical literature about epidemiology, clinical features, and multimodal imaging findings, with special emphasis on the management options of choroidal and retinal metastasis secondary to CRC.A 70-year-old male was referred with a complaint of complete and sudden visual loss in the left eye (LE) immediately following a cardiac surgery . The patient informed previous diagnosis of a spinal lesion following a spinal cord abscess on T9 which led to paraplegy. On ophthalmic examination, best-corrected visual acuity (BCVA) was 20/20 in the right eye (RE) and no light perception in the LE, which showed a relative afferent pupillary defect (RAPD). Intraocular pressure (IOP) was 15 mmHg in both eyes (BE). Multimodal imaging demonstrated acute central retinal artery occlusion in the LE; in the RE, there were discrete soft drusen throughout the macula. A small area of hypofluorescence was seen on ICG angiography near the inferior temporal vascular arcade in the RE but was deemed to be irrelevant . No intrFive months later, the patient returned to the ophthalmology office complaining of worsening of vision in the RE (better-seeing eye). In the meantime, he was diagnosed with colon adenocarcinoma at a metastatic stage (multiple lesions in the liver and lungs recently discovered) and treated with endovenous chemotherapy. The assistant oncologist informed that the chemotherapeutic regimen (bevacizumab+FOLFIRINOX) had led to a partial reduction of the systemic metastasis (estimated around 30%). FOLFIRINOX is a chemotherapy regimen for the treatment of advanced pancreatic cancer made up of the following four drugs: folinic acid (leucovorin), fluorouracil (5-FU), irinotecan, and oxaliplatin. At the second ophthalmic examination, BCVA was 20/40 in the RE and no light perception in the LE; anterior segment was normal in BE; there was a shallow neurosensory foveal detachment seen on SDOCT, along with a choroidal mass of medium reflectivity superior to the inferior temporal arcade in the RE . The cho2 dose of verteporfin and a 689 nm laser  with 50 J/cm2 of laser light delivered over a duration of 83 seconds on the area of the tumor. The spot size was adjusted to as wide as possible, in order to cover the largest diameter of the tumor with a 0.5 mm free margin. Three overlapping spots were necessary to cover the entire lesion.Potential risks and benefits of verteporfin photodynamic therapy (vPDT) were discussed with the patient, and a signed informed consent was obtained. As the RE was the only seeing eye of the patient, it was decided that only the inferior lesion should be treated, fearing collateral damage by extensive vPDT in a single session. Laser settings and treatment guidelines of vPDT were performed according to the guidelines of the Treatment of Age-related Macular Degeneration with Photodynamic Therapy study protocol: standard full-fluence PDT was performed using a 6 mg/mOne month after vPDT, we observed a significant reduction in choroidal tumor thickness and in subretinal fluid. BCVA improved to 20/25 in the RE after successful vPDT. Fluorescein angiography disclosed a hypofluorescent plaque under the tumor region with mottled hyperfluorescent spots . ICG angAdenocarcinomas make up about 95% of CRC. Other less common tumors are lymphomas and sarcomas. The 5-year survival rate for patients with stage I colon cancer is about 90%, while those with a more advanced disease, such as in stage IV CRC, have an estimated survival rate of 10%. CRC may lead to a variety of distance metastases including the lung, liver, peritoneum, brain, and bones , 10, 11.Gastrointestinal metastases are relatively uncommon in the uvea , 29, 30.The incidence of metastasis of CRC to the choroid and retina is not yet clear, even though a survey by Shields determined that 4% of all uveal metastases (43 eyes of 40 patients) are caused by tumors of the gastrointestinal tract in a survey of 2214 tumors in 1111 patients . In 2014Details of the clinical features such as laterality and types of masses of choroidal metastasis can be obtained from case reports. Papers such as those published by Ma et al., Ha et al., Khawaja et al., and Lin et al. showed unilateral single choroidal mass in reports of colorectal adenocarcinoma , 19, 32.Only four cases of retinal metastases occurring in patients with CRC have been published in the medical literature so far to our knowledge , 35–37. Treatment of symptomatic choroidal metastasis depends on the systemic status and staging of the metastatic disease. Options include observation , chemotherapy, immunotherapy, hormone therapy, radiotherapy, and even enucleation for blind and painful eyes harboring metastatic tumors . Local pPhotodynamic therapy is a nonthermal laser modality primarily employed in the treatment of vascular diseases, through light activation of the photosensitizing agent verteporfin. This therapy may also be employed in the treatment of ocular tumors through induction of necrosis and apoptosis, damage to the intratumoral vasculature, and local inflammatory reaction . vPDT seThere have been sporadic reports of vPDT for choroidal metastasis secondary to other sites, such as the breast, with good results –43. In tIn addition to vPDT, other reports discussed intravitreal bevacizumab for local therapy of a choroidal mass. Intravitreal treatment might be a good therapeutic option for patients with a metastatic disease as it preserves the quality of life without reducing clinical effectiveness. Mathis et al. suggested beginning with a single dose followed by a monthly as-needed regimen . It coulPrognosis of patients with choroidal metastasis is usually not favorable. In many patients, metastatic disease may be found elsewhere, associated with a low survival rate. A high index of suspicion must be considered in choroidal masses of unknown systemic malignancies. Systemic control of colon carcinoma may aid in the ocular tumor regression.In summary, we presented a case of a patient with presumed choroidal metastasis secondary to colon adenocarcinoma. Local vPDT therapy was performed with marked reduction of the subretinal mass and vision improvement. Choroidal metastasis secondary to CRC may be usually unilateral, with a single mass, and associated with advanced systemic spread of the disease.


Fibroma or leiomyoma is the most common benign tumor of the female reproductive system, which is usually found in the uterus, but may also occur in other places, such as the ovary, the broad ligament, and in rare cases in the abdominal wall. The formation of the abdominal wall leiomyoma may result from the implantation of myometrium tissue following surgical removal of the uterine leiomyoma, but sometimes these masses occur in a person who has no history of myomectomy.This case was a patient who became a candidate for laparoscopy due to abnormal uterine bleeding and pain in the right upper quadrant of the abdomen and ovarian mass. The patient underwent laparotomy due to the inability of surgeons to insert the veress needle because of the presence of mass in the abdominal wall. The pathologic report of the abdominal mass was leiomyoma. This article has been approved by the Ethics Committee of the University (6562276).The formation of myoma on the abdominal wall is rare but given the fact that leiomyoma can be created at each part of the body with smooth muscles, including the anterior abdominal wall, this diagnosis should be considered for the differential diagnosis of abdominal masses. Fibroma or leiomyoma is the most common benign tumor of the female reproductive system, with 20% of women suffering from the problem . The mosSeveral theories have been presented to explain the cause of myoma formation in the abdominal wall. Generally, these myomas are divided into two primary and parasitic groups. Theories such as smooth muscle cell transformation and secondary metaplastic changes of non-muscle cells seem logical for the development of the primary myoma. In contrast, for parasitic myoma, the best explanation is the existence of a series of events that attach the uterine myomas to the anterior abdominal wall, and then the source of its blood supply is developed and its connection with the womb is separated .Treatment of abdominal wall myoma is the complete removal of the mass and in case of full resection of the mass, the likelihood of recurrence is rare .3L1ab2 woman with a history of infertility, complaining from irregular uterine bleeding and she was diagnosed with a pelvic mass in MRI. She got married 7 years ago.The case was a 25-year-old MGAll of her pregnancies were by induction and ovulation and the first and second pregnancies were aborted spontaneously between 6 and 8 weeks. The third pregnancy, 3 years ago, was terminated by cesarean section and resulted in the birth of a healthy baby.mm in the anterolateral and right border of the hip with the extension to the hypogastric region was reported suggesting tumoral lesions in the right ovary or endometrium  in the suprapubic region  female was reported. She was first admitted to the general surgery clinic with a complaint of vague abdominal pain. Abdominal ultrasound and computed tomography (CT) revealed the mass, measuring 10x9x7Pathology detected the mass as leiomyoma .In our patient, failure to enter the abdomen for laparoscopy and laparotomy led to the discovery of the abdominal mass.In radiology images, there was also a mass in the posterior surface of the rectus muscle.Perhaps preoperative abdominal examination and accuracy in radiological images could help determine the proper surgical procedure and prevent confusion of the surgeon.The treatment of the abdominal wall myoma is the complete removal of the mass, and in case of complete and successful resection, the probability of recurrence is rare . A complMeticulous examination of the mass’ parasitic blood supply is crucial to safe resection and good outcomes for patients .The formation of myoma is rare in the abdominal wall, but given the fact that the leiomyoma can be created at each part of the body that has smooth muscles, such as the anterior abdominal wall, it should be included in the differential diagnosis list of the abdominal wall masses. The treatment of the abdominal wall myoma is the complete removal of the mass, and in case of complete and successful resection, the probability of recurrence is rare.


Epstein-Barr virus-positive (EBV+) primary central nervous system lymphoma (PCNSL) is a clinical entity rarely reported in young immunocompetent patients. Here, we present the case of a 40-year-old female with no history of immunosuppression or immunodeficiency, who presented with a ring-enhancing lesion in the right basal ganglia. The tumor generated significant vasogenic edema and mass effect, causing midline shift, symptoms of increased intracranial pressure, and rapidly progressive neurologic dysfunction. She underwent gross total resection of the tumor through a tubular retractor. Her tumor was of the diffuse large B cell lymphoma (DLBCL) subtype of PCNSL and was positive for EBV. No immunodeficiency or extracranial disease was identified. After adjuvant therapy with high-dose methotrexate, rituximab, and temozolomide, she remains disease-free two years after initial presentation. EBV+ PCNSL, although rare in young immunocompetent adults, poses unique clinical challenges and may require surgical intervention in the acute setting in some cases. Primary CNS lymphoma (PCNSL) is a rare, highly aggressive extranodal subtype of non-Hodgkin’s lymphoma originating in the brain, spinal cord, eyes, or leptomeninges , 2. PCNSPCNSL is classified histologically as diffuse large B-cell lymphoma (DLBCL) in 90-95% of cases, despite arising in the brain, which does not contain conventional lymphoid tissue -3, 6, 7.Epstein-Barr virus (EBV) is a gamma-herpesvirus found in over 90% of the general population. It is associated with multiple malignancies, including non-Hodgkin’s lymphomas and systemic AIDS-related B-cell lymphomas . EBV posHere, we present a rare case of EBV+ PCNSL, classified as DLBCL, in a young immunocompetent patient. We highlight the surgical and medical management, as well as the radiographic and histologic findings of the tumor, which make it a unique presentation in such a young patient.The patient is a 40-year-old, right-handed female with a past medical history of migraines, who presented in the emergency room with a persistent right-sided headache for one week. She characterized the headache as significantly more painful and different in quality from her previous migraines. She also reported gait instability, vomiting, and progressive lethargy since the onset of headache. Neurologic examination revealed lethargy and left-sided facial weakness, but no other focal deficits. The patient had no history of immunodeficiency, immunosuppressive medications, prior chemotherapy treatment, or clinical evidence of HIV infection or AIDS.Magnetic resonance imaging (MRI) revealed a ring-enhancing tumor in the right basal ganglia, measuring approximately 3.9 x 2.9 x 3.6 cm  Figure -1C. TherGiven the patient’s profound lethargy and radiographic signs of subfalcine herniation, we decided to perform an urgent surgical resection of the tumor. Under general anesthesia, we generated a right frontal craniotomy and accessed the tumor via a Viewsite Brain Access System  tube  inserted through a trans-sulcal approach in the right middle frontal sulcus approximately 2 cm anterior to the coronal suture Figure -1H. The Postoperatively, the patient’s mental status and the left facial weakness improved. Systemic steroid therapy was initiated. The EVD was removed on postoperative day seven. MRI on postoperative day one demonstrated gross total resection of the tumor Figure -2C. HIV Additional workup was performed to rule out peripheral involvement. Computed tomography (CT) of the chest and abdomen demonstrated enlarged left axillary and subpectoral lymph nodes. Ultrasound-guided biopsy of the left axillary and cervical lymph nodes revealed benign lymphoid tissue. Bone marrow biopsy did not indicate peripheral disease. There was no ocular involvement. Flow cytometric analysis of cerebrospinal fluid from the EVD revealed paucicellular sample. Collectively, these findings suggested EBV+ PCNSL.She received adjuvant therapy with eight cycles of high-dose methotrexate and rituximab, followed by two cycles of high-dose cytarabine (HiDAC) consolidation. She then received four cycles of maintenance therapy with methotrexate. Because of the side-effects of methotrexate therapy, she then opted for maintenance therapy with temozolomide. She remains free of disease and neurologically intact 25 months after her initial diagnosis Figure .We present the rare case of a young immunocompetent patient who developed acute neurologic deterioration due to a large EBV+ PCNSL in the basal ganglia. Management included urgent surgical resection, and adjuvant therapy, which combined have led to sustained remission for over two years since the initial presentation. Multiple aspects of the case are unusual and merit discussion. First, EBV+ PCNSL in young immunocompetent patients is rare, especially in the United States. Second, the clinical deterioration was unusually rapid, suggesting a rapidly enlarging tumor. We postulate that the EBV positivity may have biologically contributed to rapid tumor cell proliferation, as demonstrated with the dramatically elevated Ki-67 proliferative index (90%) of the surgical specimen. Third, the diffusion restriction was limited, unlike most PCNSL cases, thus broadening the preoperative differential diagnosis to include primary brain tumor (high-grade glioma) and metastasis. Fourth, the rapid neurologic deterioration necessitated urgent surgical resection. This was achieved safely via a minimal access approach to the basal ganglia with a tubular retractor. Such retractors allow for resection of deep-seated tumors that have traditionally been considered inoperable. The surgical approach is, therefore of interest, not only as an essential component of therapy that generated the excellent clinical outcome in this case but also as a novel technique that warrants the attention of cranial surgeons.Immunocompetent patients with PCNSL present most commonly with focal neurologic deficits, mental status changes, and symptoms of increased intracranial pressure (ICP) . Our patIn immunocompetent patients, PCNSLs have a deep, periventricular distribution, either solitary or multifocal , 9, 14. Gene expression profiling studies of immunocompetent PCNSL have demonstrated molecularly heterogeneous tumors. The predominant DLBCL subtype is the non-germinal center, activated B-cell (ABC) phenotype, which is thought to contribute to a worse prognosis when compared to the germinal center phenotype , 7, 15. EBV+ PCNSL may be seen in less than 5% of immunocompetent patients . In factA Turkish cohort of 32 patients found EBV+ PCNSLs in four patients (12.5%) . The autThe standard of care in PCNSL treatment includes high dose methotrexate and rituximab as first-line induction therapy . TraditiEBV+ PCNSL is a distinct clinical entity that is rarely reported in immunocompetent patients, especially in Western countries and in patients under the age of 50. Studies of EBV+ PCNSL in immunocompetent patients do not consistently report clinical, radiographic, and histologic findings. We present a rare case of EBV+ PCNSL in a 40-year-old immunocompetent patient who had a large, rapidly growing tumor in the basal ganglia causing rapid neurologic deterioration. The acute presentation prompted urgent surgical resection of the tumor with a tubular retractor, followed by a standard regimen of methotrexate and rituximab, with a favorable outcome. It is important for neurosurgeons and other clinicians to be aware of the potential for such a unique clinical presentation of EBV+ PCNSL in young immunocompetent patients. It is also important for cranial surgeons to consider tubular retractor approaches to deep-seated brain tumors if needed.


Escherichia coli and Klebsiella pneumoniae emphysematous cystitis in a known diabetic.Emphysematous cystitis is a relatively rare and potentially life-threatening condition characterized by the collection of gas in the bladder wall and lumen due to infection caused by gas-forming organisms. Imaging studies are necessary to detect emphysematous cystitis. The management consists of broad-spectrum antibiotics, strict glycemic control, and bladder drainage. Complications may arise in some cases, requiring surgical treatment. We present a case of extended spectrum beta-lactamase producing  Escherichia coli, Klebsiella pneumoniae, Enterobacter aerogenes, Proteus mirabilis, Streptococcus species, or Clostridium perfringens) [Emphysematous cystitis, also known as cystitis emphysematosa, is a condition in which pockets of gas are formed within the bladder wall and lumen due to infection caused by gas-forming organisms (ringens) -5. It isringens) , 5. The ringens) . Cases aringens) , 3. Otheringens) -3. Alcohringens) , 5. Amonringens) -3. It isringens) -5.A 76 year-old-man with DM controlled on metformin was admitted for a decline in his overall well-being. His friends reported he had become fatigued, forgetful, less involved, missed medications, and had lost some weight. He reported passing foul-smelling dark urine but denied dysuria, frequency, fevers, chills, or rigors. He denied abdominal pain, nausea, vomiting, or a history of recent urinary bladder instrumentation. Escherichia coli and Klebsiella pneumoniae. Blood cultures obtained on admission were negative. CT images of the chest, abdomen, and pelvis performed to rule out malignancy showed diffuse bladder wall thickening with air seen circumferentially within the bladder wall  of the brain showed moderate to severe small vessel ischemic changes but no acute abnormality. Rapid plasma reagin (RPR) was negative, and vitamin B12 and thyroid-stimulating hormone levels were normal. Urinalysis revealed pyuria and urine culture grew > 100,000 CFU/mL Escherichia coli strain was an extended spectrum beta-lactamase producer). A urinary catheter was inserted for effective bladder drainage, and he completed a total of 14 days of antibiotic therapy. After completion of antibiotic therapy, a repeat CT of the abdomen and pelvis showed complete resolution of the bladder wall emphysematous changes.Based on his clinical presentation, microbiologic and radiologic findings, he was diagnosed with emphysematous cystitis, a rare complication of lower urinary tract infection. He was initially treated with empiric intravenous piperacillin/tazobactam then discharged to a nursing facility on ertapenem (Escherichia coli and Klebsiella pneumoniae are often isolated from urine cultures [Escherichia coli was the causative pathogen in 58% of cases, followed by Klebsiella pneumoniae in 21% [ Enterobacter aerogenes, Clostridium perfringens, Clostridium welchii, Proteus mirabilis, Pseudomonas aeruginosa, Group D Streptococcus, Enterococcus faecalis, Staphylococcus aureus, Candida albicans, Candida tropicalis, and Aspergillus fumigatus [The clinical presentation of emphysematous cystitis ranges from being asymptomatic to pneumaturia or irritative voiding symptoms to acute abdomen with severe sepsis , 3. In acultures -3. In thPerforming blood cultures, urinalysis, Gram staining of the urine and urine cultures are essential for detecting the responsible pathogen and helps to select the appropriate antibiotic regimen. The presence of hematuria and pyuria with positive urine cultures is usually revealed in this process. About half of the patients are reported to have bacteremia . SelecteImaging methods, such as plain conventional abdominal radiography and CT, are pivotal for obtaining a definitive diagnosis . Eighty-CT is the most sensitive and specific diagnostic tool . It is cEmphysematous cystitis is a rare complication of urinary tract infection due to gas-forming organisms that is potentially life-threatening. Diagnosis can be made using a plain abdominal radiograph; however, CT is considered to be the imaging modality of choice. Successful management depends on early diagnosis with correction of any predisposing factor, prompt administration of appropriate antibiotics, adequate bladder drainage, and surgical excision of involved tissue when required.


Sarcomatoid carcinoma (SC) is a malignant tumour composed of spindle cells. The incidence of SC is low, especially in the uterus. The imaging features of uterine sarcomatoid carcinoma (USC) are rarely reported. We report a case of USC and discuss the dynamic contrast-enhanced MR (DCE-MR) and PET/CT findings.A 69-year-old woman presented to the Department of Gynaecology with vaginal bleeding. Ultrasound examination discovered a heterogeneous mass in the cervix. Then, MRI examination of the pelvis was performed. On T2-weighted images, the uterus was replaced by an ill defined and diffuse lesion with inhomogeneous intensity. On T1-weighted images, the lesion appeared with signal hypointensity and was heterogeneously enhanced with contrast material. Additionally, enlarged lymph nodes were found in the pelvic cavity. PET/CT demonstrated high uptake in the region of the uterus and pelvic lymph nodes, which was consistent with MRI findings. The radiologists diagnosed the patient with malignant uterine lesions. The patient underwent hysterectomy and bilateral adnexectomy with pelvic lymph node dissection. Then, systemic radiotherapy and chemotherapy were performed. USC with lymph node metastasis was diagnosed with the help of immuno-histochemical analysis. There was no treatment related complication and no evidence of tumour recurrence at the postoperative 6-month follow-up.MRI and PET/CT features are sufficient to indicate the malignant nature of a USC, but they are not pathognomonic. SC is a rare spindle cell carcinoma , 2. It iTo date, 18 cases of sarcomatoid squamous cell carcinoma of the cervix have been described in the English-language literature. However, only two reports have discussed the MRI or PET features of USC. Here, we present a case of pathologically confirmed USC and the accompanying DCE-MRI and PET/CT findings.A 69-year-old woman with a past medical history of hypertension, tuberculosis, and meningioma presented with abnormal vaginal bleeding for 10 days as well as fever. Furthermore, her family history was unremarkable. Physical examination revealed a barrel-shaped uterus. The patient felt mild tenderness upon palpation. Laboratory studies noted an elevated carbohydrate antigen 125 (CA125) level of 201.1 U/ml, while the carcinoembryonic antigen (CEA) and carbohydrate antigen 19–9 (CA19–9) levels were normal.The patient underwent a pelvic Two-dimensional ultrasound that showed an enlarged uterus and a heterogeneous mass in the cervix. Then, MRI examination of the pelvis was performed with a 1.5 Tesla MR scanner . The T2-weighted images showed that the uterus was replaced by an ill defined and diffuse lesion with inhomogeneous intensity. On T1-weighted images, the lesion appeared with hypointensity. The lesion showed invasive growth with enlarged lymph nodes in the pelvic cavity. DCE-MRI demonstrated inhomogeneous enhancement and resulted in a plateaued curve with a prolonged scanning time  stained sections showed that the uterine tumour was composed of spindle cells and nodal metastasis was confirmed. Immunohistochemical analysis supported the diagnosis of USC Fig. . The patSC is an extremely rare malignant tumour of the uterus that has not been listed in the WHO classification as a separate entity. Because of the rarity SC, its differential diagnosis often includes aggressive uterine lesions. As an entity, USC should not be confused with uterine carcinosarcoma. Pathologically, USC is characterized by the presence of spindle cells, showing broad-spectrum epithelial and mesenchymal markers. In contrast to uterine carcinosarcoma, USC does not express malignant heterologous elements, such as chondrosarcoma or osteosarcoma –10.To the best of our knowledge, only two reports have discussed the MRI or PET features of USC in the literature , 12. ShrDistinguishing USC from uterine sarcoma is not possible because these tumours share many imaging characteristics, including heterogeneity, cystic degeneration and necrosis –15. TherUSC is a rare and aggressive tumour, and its imaging features may not be pathognomonic. The recognition of features that are suggestive of a malignant condition is sufficient to assist the surgeon in managing such patients.


Schwannomas are benign tumors affecting the nerve sheath. Their presence in the subperiosteal region is extremely rare. We report a case of a 66-year-old male patient with a 10-year history of unexplained pain of the anterior leg that turned out to be caused by a subperiosteal schwannoma of the mid-tibia. We believe this case report will increase surgeons’ index of suspicion about this condition when dealing with cases of unexplained bony pain, consequently allowing for early diagnosis and better outcomes. Schwannomas, also known as neurilemomas, are benign tumors that arise from the sheath of peripheral nerves ,2. It isA 66-year-old white Mediterranean patient consulted our team due to a painful swelling on the anterior aspect of his distal left tibia. His pain had started about 10 years ago, and two years ago, he had noted some swelling and tenderness at the same location of the pain.During the physical examination, a 4-cm, well-demarcated mass on the medial anterior aspect of his left tibia Figure  was noteAll laboratory findings including blood count, hematocrit, serum electrolytes, liver function tests, and coagulation tests were normal. Anteroposterior and lateral radiographs of the leg were done and showed evidence of a lytic, geographic, subperiosteal lesion on the medial side of the mid-tibia Figure .An MRI was ordered and it showed a juxtacortical lesion that is isointense on T1- and hyperintense on T2-weighted images. The decision was made for a complete surgical excisional biopsy. For this, the patient was taken to the operation room, and a longitudinal incision was done along the lesion. The subcutaneous tissue was dissected and it had a normal appearance. The lesion appeared to be embedded in the cortex  of the anterior aspect of the tibia. It was well-circumscribed and encapsulated without the involvement of surrounding tissues. It was excised entirely as one piece and was sent to the pathology laboratory for histological studies and culture. The wound was then closed. Figure The postoperative period was uneventful, and the patient was discharged home a day after surgery.The laboratory results showed a sterile culture. The hematoxylin and eosin-stained sections revealed a subperiosteal benign schwannoma that was completely excised. The pathology report mentioned the presence of a well-encapsulated lesion formed of spindle cells in addition to thin wavy spindle nuclei and nuclear palisading (Verocay bodies). There was no mitosis or necrosis area. Immunohistochemistry staining showed diffuse expression of S100 proteins.The patient's pain disappeared and he is still free of symptoms at the operation site 13 years after the surgery.Tumors of the peripheral nerve sheath are relatively uncommon neoplasms in the general population . They caOf these subgroups, schwannoma, which is more properly known as neurilemomas, is the most common tumor of peripheral nerves, usually affecting people aged between 20-50 years of age . They arThe intraosseous location of schwannomas is occasional and may affect any bone of the body, especially the mandible, which is classified as the most commonly affected location where schwannomas arise from the mandibular nerve ,13. FawcThe first case of subperiosteal schwannoma was reported by Verma et al. in 2002 when they described two adjacent diaphyseal femoral subperiosteal schwannomas in a 38-year-old man, who had been suffering from thigh weakness and pain  for fourPain was a constant and chief complaint in all reported cases, and most patients had delayed diagnosis. Interestingly, all cases reported in the literature involved patients around 30 years of age. Our case is the first case to be presented at 66 years of age, which is a very unusual age of presentation, especially given that schwannomas in general show up between 20-50 years of age . FurtherImaging is the most important diagnostic tool for the evaluation of patients with suspected schwannomas ; the radDifferential diagnoses of schwannomas include fibroma, neurofibroma, neurosarcoma, ganglion cyst, and lipoma. The gold standard method to make an accurate diagnosis is a surgical biopsy that should be evaluated by a pathologist with expertise in peripheral nerve tumors .GeneticAll cases of subperiosteal schwannomas, including our case, were treated with complete surgical excision and had favorable outcomes. However, data about the recurrence rate is lacking.Although extremely rare, schwannomas or neurilemomas should be considered as a possible differential diagnosis for surface lesions of the bone. As for the clinical aspect and presentation of this disease, the diagnosis should also be considered when a patient has had unexplained localized vague pain and swelling for a prolonged period of time. Surgical excision remains the best-proposed method of treatment by far.


Invasive giant prolactinomas are a rare type of prolactin-secreting tumors. Most lactotroph adenomas, including giant prolactinomas, consist of the sparsely granulated subtype and respond well to medical therapy with dopamine agonists. Proptosis due to intra-orbital tumor extension and ischemic infarction are two rare complications associated with these tumors.We report a case of a 51-year-old woman with a 30-year history of a macroprolactinoma who was lost to follow-up and returned with severe proptosis, a 10-cm invasive sellar mass on imaging, and markedly elevated serum prolactin levels, consistent with invasive giant prolactinoma. She was initially managed with dopamine agonists followed by palliative debulking of the tumor, which microscopically demonstrated a highly proliferative neoplasm predominantly consisting of sparsely granulated lactotroph adenoma with a minor component of the rare and aggressive acidophil stem cell adenoma subtype. Postoperatively, she developed a large left middle cerebral artery infarct and ultimately died.This case is notable in that it demonstrates the aggressive nature of invasive giant prolactinomas when not treated and highlights two rare findings in patients with this tumor: orbital invasion and ischemic infarct. Pituitary adenomas are benign tumors of the anterior pituitary, and prolactin-producing pituitary adenomas, so-called prolactinomas, are the most common type . MicroscTherapeutic goals for prolactinomas include normalization of hormone levels, reduction of tumor size, relief of mass effect, and restoration of gonadal function . First-lWe present a case of a patient with an invasive giant prolactinoma who was lost to follow-up and presented with several unique features.The patient is a 51-year-old woman with a history of a prolactinoma that was diagnosed 30 years prior to her current admission when she presented to her primary care physician with a headache. She was lost to follow-up until five years prior to the current admission when she presented to a hospital with left eye ptosis and peripheral vision loss. Imaging at that time revealed a 3.6 cm × 3.3 cm × 3.2 cm mass in the sella turcica, and she underwent endoscopic endonasal excision of the pituitary adenoma. Postoperative CT scan after the initial operation showed a residual 2.7 cm × 3 cm × 2.6 cm sellar mass invading the left cavernous sinus. She was discharged from this hospitalization with instruction to take a dopamine agonist but was lost to follow-up and was not compliant with her medications for five years. Two months prior to the current admission, her condition was complicated by severe left eye proptosis with complete loss of vision and panhypopituitarism, and at this time she was started on cabergoline.The patient now presented to the emergency department for intermittent episodes of staring associated with unresponsiveness. It was also reported that she had been increasingly lethargic and altered over the past month.On physical exam, the patient was morbidly obese with a body mass index of 45, somnolent, and oriented only to self. She had a right eye temporal visual field defect and severe left eye proptosis with erythema and corneal ulceration associated with complete visual loss Figure . She hadCT scan of the head was done and showed a 10 cm × 7 cm × 6 cm sellar mass invading the left orbit, frontotemporal region, insular lobe, cavernous sinus, paranasal sinuses, and nasopharynx, with associated hemorrhagic necrosis, dilation of the right lateral ventricle, 1 cm of left to right midline shift, and mass effect on the brainstem Figure . Her proFive days into her hospitalization, the patient became increasingly altered. Repeat CT scan of the head showed increasing hemorrhage and vasogenic edema, and worsening left to right midline shift. The patient was upgraded to the intensive care unit and was intubated due to her declining mental status and concern for inability to protect her airway. Medical management was continued, and four days later she underwent a left craniotomy for palliative debulking of the tumor. Neoplastic tissue was removed primarily from the retroorbital area to improve her proptosis, as well as to debulk some of the tumor burden in the frontal lobe.Histopathologic evaluation of the resected tissue with immunohistochemistry (IHC) revealed a synaptophysin-positive neuroendocrine neoplasm, and the majority of the neoplastic cells exhibited prolactin immunopositivity. These findings were suggestive of a SGLA mixed with another lactotroph adenoma subtype compatible with ASCA. Immunostains for other pituitary hormones were negative Figure .Immediately following the surgery, the patient was awake and alert, but she never regained her preoperative ability to follow commands. A postoperative CT scan showed a residual 7.9 cm × 6 cm × 4.4 cm tumor, as well as thin left frontal and parietal subdural and epidural hemorrhage, scattered surgical site pneumocephalus, and 1.4 cm of midline shift, but was otherwise unchanged from prior scans Figure . Two dayWe present a case of a 51-year-old female with a macroprolactinoma who was lost to follow-up and returned many years later with an invasive giant prolactinoma complicated by invasion into the left orbit and a postoperative left MCA stroke. This case had several unique features, including intra-orbital extension with marked proptosis, postoperative ischemic stroke, and an intriguing histopathologic diagnosis. There are numerous reports in the literature of patients with invasive giant prolactinomas responding well to medical therapy, but to our knowledge, ours is one of the few to demonstrate an aggressive natural course in an untreated patient with a giant prolactinoma.One of the major limitations of assessing the clinical behavior of prolactinomas as reported in the medical literature is that many authors do not subclassify these neoplasms. Lumping lactotroph subgroup under one heading nullifies the differences between them, which may offer an explanation for the wide range of reported clinical behavior. It is important to subclassify pituitary adenomas based on their histological features as some subtypes, such as the DGLA and ASCA, are known to exhibit aggressive behavior .In this patient, the majority of the tumor was composed of SGLA, which is the most common prolactinoma subtype and typically shows a good response to medical management . HoweverThe patient’s course also had unique clinical features. Orbital extension of prolactinomas is very rare; based on our review, there are only 14 other cases reported in the literature, with only 4 of them being in females . In one Ischemic stroke is another very rare complication of large pituitary tumors, and to our knowledge, there have only been 34 cases reported in the literature, with 4 occurring in the absence of apoplexy, such as in our case -14. TherIn the cases noted above, the cerebral ischemia was the cause for the patient’s presentation to the hospital; it is noteworthy to address that the patient in our report did not have her stroke until after surgery. There are only 11 reported cases of ischemic infarction occurring after surgical removal of a pituitary mass, 10 of which occurred in the setting of vasospasm and 1 in the setting of thrombosis -18. VasoPrior to surgery, the patient was alert and following commands, but she never regained the ability to follow after surgery. Her immediate postoperative CT scan showed no evidence of cerebral infarction, but both MRI and CT on postoperative day 2 showed a large area of infarct. Based on the imaging and the timing of her change in exam, we propose that her stroke happened either during or soon after surgery. This timing of our patient’s stroke makes it highly unlikely that vasospasm was the cause of her ischemia. The patient’s invasive tumor encased many vascular structures, including the left MCA, and we propose that this, in addition to the increasing cytotoxic edema, produced mass effect on the MCA leading to her infarction.We did not perform cerebral angiography or transcranial Doppler on our patient to further evaluate the cause of her stroke, as neither would have changed our management due to her advanced disease. It is important to note however that either of these can be done to definitively determine the cause of the ischemia; this is significant as treatment options vary based on the underlying cause. In one very small retrospective study done in patients with pituitary adenoma removal, all patients with a postoperative decline in Glasgow Coma Scale (GCS) were found to have either ischemic infarct or hemorrhage, both associated with vasospasm . This hiTo our knowledge, our case is one of the few to demonstrate the potentially aggressive nature of untreated invasive giant prolactinomas. Microscopically, the tumor showed a remarkable histopathology featuring predominantly SGLA subtype mixed with a minor population of prolactin-positive cells compatible with the rare and aggressive ASCA. The microscopic findings suggest that, over the years that the patient was lost to follow-up, the neoplasm may have de-differentiated from a benign lactotroph adenoma subtype to a more aggressive one; to our knowledge, this has not been reported in the literature.This case is also remarkable for the severity and rarity of the sequelae that complicated this patient’s clinical course. Although proptosis is a rare complication of pituitary adenoma, neoplastic orbital invasion should be considered in the differential diagnosis of any patient with proptosis of unknown etiology. Another exceptional complication of invasive giant prolactinomas that can rarely occur after surgery is ischemic stroke, which should be considered in any patient with a postoperative decline in mental status or new focal neurologic deficits after surgery. The aggressive clinical course displayed by this neoplasm highlights the need for coordinated multidisciplinary management of such patients, whereas the microscopic findings highlight the need for histopathological subtyping of pituitary adenomas in order to better characterized their clinical behavior. These multifactorial issues require timely management with a multidisciplinary approach in order to optimize therapeutic outcomes for the patient.


Leiomyosarcoma, primarily a tumor of smooth muscle origin, frequently originates from the uterus, retroperitoneum, and intra-abdominal region. Rarely, the tumor may arise from the conjunctiva, inferior vena cava, or oral cavity. Here we report a case of a 65-year-old male patient who presented with a swelling in the posterior thigh for six months. The swelling was progressively increasing in size for the last two months. Examination of thigh showed a swelling of 20×30 cm in size, which was firm, non-compressible, immobile, and not transilluminating. CT scan showed no metastasis in the liver, lung, or bone. The histopathology report showed poorly differentiated leiomyosarcoma involving the muscles of the posterior compartment of the left thigh. The tumor was resected, and the patient was referred to rehabilitation clinic. Early diagnosis of such cases is essential to improve the outcome in patients as these tumors can metastasize early. Leiomyosarcoma is a malignant tumor of the smooth muscle connective tissue. The National Organization for Rare Disorders (NORD) enlists leiomyosarcoma as a rare malignancy . Soft tiRare cases of leiomyosarcoma arising in the oral cavity, conjunctiva, and inferior vena cava have been reported in the literature -7. An exA 65-year-old male, with no known comorbidities, presented to the outpatient department (OPD) of Civil Hospital Karachi with a swelling on the posterior side of the left upper thigh for six months. The swelling had been progressively increasing in size and interfered with the mobility of the patient. History for anorexia, weight loss, and constipation was positive. The patient was a smoker and had been smoking (one pack/week) for the last 15 years. Family history was negative for any chronic or malignant disease.On general physical examination, the patient was afebrile, pale, and lethargic. There were no palpable lymph nodes, and only solitary swelling was noted on the left thigh. All reflexes were intact, and the patient had a Glasgow Coma Scale (GCS) score of 15/15. Respiratory, gastrointestinal, cardiovascular, and all other systemic examinations were unremarkable.Previous reports showed that two months back, the size of the swelling was 13×7 cm (length×width). On local examination, a well-defined mass measuring approximately 30×20 cm (length×width) was noted on the posteromedial aspect of the left upper thigh. Physical examination revealed that the swelling was warm, erythematous, firm in consistency, and non-compressible with a fluctuant center. The transillumination test was negative for the swelling. Figure 3/µL). The platelet count (388×103/µL) was normal. His renal and liver function tests were unremarkable too. The detailed baseline investigations are summarized in Table Baseline investigations were conducted, which showed a low hemoglobin level (9.2 gm/dL) and raised total leukocyte count 18×108×103/µL.Malignancy was suspected due to the patient’s history of weight loss and the rapidly increasing size of the mass. Imaging studies and necessary investigations were carried out. MRI showed that the mass involved the semitendinosus, semimembranosus, and biceps femoris muscles of the thigh. A biopsy was performed, and histopathology report showed multiple fragments of a neoplastic lesion. Immunohistochemical analysis confirmed poorly differentiated high-grade sarcoma, which was highly suggestive of leiomyosarcoma. The chest x-ray was normal and showed no evidence of pulmonary involvement. CT scan was done to look for metastasis; fortunately, no metastatic lesions were noted in the liver, lungs, and skeletal system. Surgery was planned to remove the mass.The patient underwent compartmental excision of the mass. Perioperative findings showed an encapsulated tumor in the biceps femoris, invading the fascia and skin over the posterior thigh Figure . The finBased on the histopathological findings, a final diagnosis of grade III leiomyosarcoma was made. The grading was done according to the Fédération Nationale des Centres de Lutte Contre Le Cancer (FNCLCC) grading of soft tissue sarcomas . After rLeiomyosarcoma is a very rare malignancy. The development of this tumor outside of its usual cutaneous, uterine, retroperitoneal, and intra-abdominal regions is termed as ‘leiomyosarcoma of somatic soft tissues’ (SSTs). Cases of leiomyosarcoma of SSTs are poorly documented and not well studied due to their extremely low prevalence. Farshid et al., in their study, stated that leiomyosarcoma of SSTs has vascular origin . The smaThe etiology of this type of cancer is unknown, and the risk factors have not been identified yet. The symptoms vary according to the location and stage of cancer, but common symptoms of cancer such as fatigue, fever, weight loss, malaise, nausea, and vomiting, are often seen. Pain in the area is uncommon, but swelling or mass is often noticed as the tumor is usually very fast growing ,4-6,13. A primary diagnosis of the tumor can be made using basic imaging techniques, such as ultrasound, CT scan, and MRI ,6,14. ThThe most common treatment is surgical resection, followed by radiation to eradicate any residual disease. Chemotherapy is used in the case of metastasis or recurrent disease ,5,6. TheLeiomyosarcomas can originate in many unusual locations. Only after biopsy and histology, the final diagnosis of rare malignancies can be made. Very few cases of leiomyosarcoma in thigh muscle have been previously reported; therefore, there are no guidelines related to the treatment protocols following surgery. Because of the increasing size and aggressive nature of the tumor, the need for rehabilitation and physical therapy of extremities should also be evaluated. The definitive treatment for leiomyosarcoma is surgery with wide margins removal. The need for chemotherapy and radiation, as for other leiomyosarcomas, needs to be evaluated in tumors arising in the limbs through trials. We conclude that clinicians should keep leiomyosarcoma as a differential when patients present with a rapidly growing mass in lower limbs. Early diagnosis and definitive treatment can improve the outcome of the patient and reduce the chances of metastasis, thus increasing survival.


ΤΜ laser . Sporadic cases have also been reported in the literature as side effects of pelvic radiation therapy. We present a 65-year-old male patient who underwent PVP as an elective procedure for the treatment of severe lower urinary tract symptoms. The primary management after the diagnosis of the fistula was conservative but as this did not result in an expected improvement, the patient underwent radical prostatectomy as a last resort. PSF formation is the result of the communication between the anterior capsule of the prostate and the bladder neck via pubic symphysis and the surrounding tissues. This condition often leads to either urinoma formation or osteitis pubis. In the majority of cases, treatment options are complex surgical reconstruction using flaps or grafts, radical prostatectomy or urinary diversion as an ultimate solution. The rarity of the complication and the accompanied atypical signs and symptoms warrant a low threshold for suspicion so as to diagnose the event early and provide the appropriate treatment.Prostatosymphyseal fistula (PSF) is a very rare complication described after transurethral surgery of the prostate including photoselective vaporization of the prostate (PVP) with GreenLight TM laser  has become an important tool of the modern endourology for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Prostatosymphyseal fistula (PSF) formation is a rare complication and has been anticipated practically for any form of transurethral prostate surgery for BPH that expends energy to the prostatic tissue. PSFs occur when the anatomic integrity of the lower urinary tract system is compromised, allowing urine leakage into the surrounding tissues and thus causing a wide spectrum of signs and symptoms from pelvic pain to recurrent urinary tract infections. A literature search found less than 10 reported cases which were treated predominantly with surgery [Photoselective vaporization of the prostate (PVP) or GreenLight surgery .TM laser . The total operation time was 51 minutes, total lasering time was 32 minutes and 229 kJ of energy was delivered. The operative procedure was uncomplicated, and continuous bladder irrigation was stopped after three hours. The patient failed a trial without catheter the next day and following an uneventful recatheterization, he was discharged. We present a 65-year-old white male who had been referred by his general practitioner for surgery because of worsening LUTS refractory to treatment with an alpha-blocker. Preoperatively, urine dipstick was clear, the prostate was measured by transrectal ultrasound at 55cc, International Prostate Symptom Score (IPSS) score was 20 and digital rectal examination showed a smooth, benign-feeling gland. Treatment was performed using the 180 W XPS GreenLight9/L and elevated C-reactive protein.A week after his discharge, he presented to the acute and emergency department with a left thigh pain transmitted to his left groin on exercise and mild LUTS. The district nurse removed his catheter the previous day as per local guidelines management and since then he had difficulties in walking despite adequate analgesic medication. On physical examination, his left proximal thigh was tender to palpation, oedematous and slightly erythymatous. He developed fever on the day of his readmission, and empirical antibiotic treatment with intravenous amoxicillin and clavulanic acid was commenced on the basis of previous sensitivity and local microbiology guidelines. Urinalysis in the emergency department demonstrated microscopic haematuria, leucocytes and nitrites, and urine culture revealed >108 cfu/L of ß-haemolytic Streptococcus group B susceptible to amoxycillin, trimethoprim and nitrofurantoin. His blood results demonstrated marked leucocytosis at 18x10On the day of admission, he was subjected to an X-ray of his left thigh, which did not show any abnormality, and subsequently to an ultrasound (U/S) scan of the region which demonstrated a 14 x 4 cm collection within the left adductor muscle (Figure On further MRI investigation the next day, a left-sided intramuscular collection was confirmed with a maximally 6.5-cm transverse dimension and a 2.3-cm depth fluid collection noted centred upon the left adductor magnus muscle in the proximal thigh with marked surrounding oedema also involving the adductor brevis muscle. There was also further oedema within the medial aspect of the left pubic tubercle consistent with osteitis pubis (Figure Eventually, the suspected anterior prostate capsule perforation was confirmed. Initial thoughts about decompressing the adductor collection via an U/S-guided drainage procedure were abandoned since the patient became apyrexial, his symptoms and blood results improved markedly and the collection started to decrease in size on further follow-up U/S scans. He remained inpatient for four days being discharged with a two-way 16Fr catheter and oral antibiotic cover for two months as per urine culture.Two months after the operation, a repeat MRI of the pelvis showed only partial resolution of the urinoma Figure  so we deThe 180-W laser is more powerful than the preceding 80 W and 120 W lasers raising concerns regarding safety; however, the depth of tissue effect remains 1-2 mm suggesting this is a function of wavelength rather than power. PSFs are rare, and what makes them difficult to recognize is that patients often present with non-urological symptoms leading to a delay in diagnosis. The high index of suspicion on behalf of the surgeon is crucial for the initial diagnosis of this uncommon complication.The aetiological background is hypothesized to be a capsular tear of the anterior prostatic tissue after prior transurethral resection of the prostate, PVP or radiotherapy. Few cases are reported in the literature after prostate cancer treatment, bladder tumor resection, transrectal biopsy of prostate or salvage cryotherapy . SubsequOur case highlights the challenge of PSF as rare clinical complication which is both difficult to diagnose and treat. Minimal use of high-power laser application in the anterior prostate tissue and high visibility of the appropriate surgical anatomical planes during the procedure are recommended. Regardless of initial conservative therapy, almost all patients will ultimately become recipients of a major invasive procedure.


An 8-year-old intact male German shorthaired pointer was presented for a left pelvic limb lameness. Examination revealed a plantigrade stance with flexed digits in the left pelvic limb, and swelling of the left common calcanean tendon distally. Magnetic resonance imaging revealed a partial rupture of the left common calcanean tendon, involving rupture to the tendons of the biceps femoris, gracilis, and semitendinosus muscles. Surgical repair was performed using a modified 3-loop pulley suture. Postoperatively, the tarsus was immobilized with external coaptation. Destabilization of the external coaptation occurred over 9 weeks followed by physical rehabilitation and complete return to function at 10 months post-operative. This case report illustrates the utility of MRI as a diagnostic tool for evaluation of tendon pathology. MRI provided exceptional detail of the tendons that comprise the common calcaneal tendon and the anatomical relationships to surrounding structures which facilitated appropriate surgical correction. The common calcanean tendon is composed of the tendons of the superficial digital flexor, gastrocnemius, and the common tendons of the biceps femoris, semitendinosus, and gracilis , 2. AlthAn 8-year-old, 33.6 kg (74-lb) intact male German shorthaired pointer dog was evaluated at Red Bank Veterinary Hospital in Tinton Falls, New Jersey for a 6-week history of a left pelvic limb lameness. The lameness occurred acutely after the dog had been running and the owners heard an audible “pop” sound. The dog was used for hunting, although no known trauma had been witnessed at the time of the onset of the lameness. Initially, the dog was treated by the primary veterinarian with oral minocycline hydrochloridePhysical examination was normal with the exception of the left pelvic limb. The dog had a grade 2/5 left pelvic limb weight bearing lamenessBased on the physical and neurologic examination findings, the anatomic diagnosis was attributed to a lesion involving the left common calcanean tendon (CCT). The observation of flexed digits while standing suggested that the superficial digital flexor muscle and its tendon remained intact. Differential diagnoses for these signs and history included disruption of either one or more of the components of the CCT, the muscles that contribute to the CCT, or the attachment of the tendon to the calcaneus. Other differentials included a degenerative CCT tear, calcanean tendonitis, or calcaneal fracture.A complete blood count, serum biochemical profile and 3-view thoracic radiographs were normal. Radiographs of the tarsus were not acquired as the index of suspicion for a calcaneal fracture was low given the soft tissue swelling was primarily located around the left CCT proximal to the calcaneal tuberosity, and combined with the lack of crepitus and inability to palpate subluxation. Under general anesthesia, magnetic resonance imaging (MRI) of the pelvic limbs from the mid-tibia to the mid-metatarsal bones was performed using a 1.5-Tesla unitOn MRI, ~3-cm proximal to the tuber calcanei, the normal hypointense tendon contributions from the biceps femoris, semitendinosus, and gracilis muscles, also termed as the accessory ischial muscles, abruptly ended . From th5 was used to create a reinforcing locking loop suture in the thin region of the distal portion of the gastrocnemius tendon which was anchored using the hole in the tuber calcanei. Using a non-absorbable suture5, simple interrupted mattress sutures were placed in the gastrocnemius tendon at the site of its fold. The fascia along the lateral edge of the superficial digital flexor tendon was closed with horizontal mattress sutures using a resorbable sutureThe dog underwent surgical reattachment of the common tendons of the accessory ischial muscles to the calcaneus. At the level of the tuber calcanei, an ~7 cm skin incision was made over the lateral aspect of the tarsus. A lateral incision was made in the fascial sheath containing the common calcanean tendons. There was a complete disruption of the tendons of the accessory ischial muscles from the tuber calcanei with the distal 2-cm of the tendons having been replaced with fibrous tissue . The gasper os [PO] q 8–12 hr], and deracoxibq 24 hr) for 7 days and instructions for restricted activity for 3 months. In an effort to gradually allow weight bearing forces to be applied to the tendon, destabilization of the external coaptation occurred over the course of 9-weeks following surgery. Objective evaluation of the load applied to the CCT was not performed. Destabilization was subjectively felt accomplished by the use of the bivalved cast for 6-weeks, followed by a lateral splint for 2-weeks, and then a soft padded wrap for 1-week. Bandage changes were performed every 2-weeks. At each bandage change, confirmation of the integrity of the surgical attachment of the tendons was evidenced by the inability to flex the tarsus while the stifle was held in extension. Following the 9-weeks of external coaptation, a nylon Thera-pawPostoperatively, a bivalved cast was applied to the lateral aspect of the left pelvic limb to help protect the repair. The cast extended from just distal to the stifle to the level of the digits and was applied with the tarsus in extension. One day post-operative, the dog was discharged on tramadolNine weeks post-operatively, the dog was started on a physical rehabilitation therapy program. For an 8-month period , the dog received treatments which included passive range of motion, underwater treadmill walking, massage, low level laser therapy, and thermotherapy. By 9 months post-operatively, there was absence of lameness based on examination by a diplomate of the American College of Veterinary Sports Medicine and Rehabilitation. Ten months post-operatively, the dog had recovered well-enough to resume his previous hunting activity.Imaging studies used in the diagnosis of CCT rupture include radiographs, ultrasound, and MRI. This case highlights the utility of MRI in several ways. MRI provides the best soft tissue contrast compared with all imaging modalities and therefore is anticipated to be sensitive for identifying pathologic processes involving tendinous structures. In addition, high resolution, multiplanar images can be acquired to facilitate the assessment of both soft tissue and bone pathology . In the Another advantage of MRI over other imaging modalities such as ultrasonography is that images can be acquired which enable broad visualization of surrounding structures in one single image. This allows assessment of the anatomical relationships between the tendons and surrounding structures such as bone, ligaments, and muscle. Additionally, gradient echo sequences could be used to evaluate for hemorrhage in acute CCT injuries, and proton density weighted (PDW) images with fat saturation also are useful in evaluation of bony structures such as the ridges of the talus, and for identification of ligaments . FinallyUltrasonography has a high diagnostic accuracy for tendinopathies . In veteRecommended MRI sequences for evaluating the tarsal region should include T1W pre- and post-contrast, T1W with fat saturation, T2W, T2W with fat saturation, STIR (short tau inversion recovery), GRE (gradient echo), FLAIR (fluid attenuated inversion recovery), and PDW , 16. ComAs in the present case, information gained through MRI should better serve to guide treatment recommendations and surgical repair over data provided by other imaging modalities. In acute cases of CCT injury, it is recommended to suture each component of the CCT individually to reestablish tendon integrity . In the To the authors' knowledge, this is the first case report describing MRI findings of a partial rupture of the left CCT in a dog. Although MRI may not be feasible in every veterinary patient, use of MRI to evaluate CCT rupture and other musculoskeletal diseases should be recommended to clients and considered as a valuable diagnostic tool. Further research regarding the benefits of MRI for evaluating CCT rupture and tendon pathology should be pursued to improve diagnosis and treatment of affected patients.The original contributions presented in the study are included in the article/Written informed consent was obtained from the owners for the participation of their animals in this study.ML contributed to writing the manuscript, interpreting and describing the imaging findings, and literature review. EG was the main clinician during case presentation and performed the neurologic consultation. EG and MK contributed to writing and editing the manuscript and interpreting and describing the imaging findings. 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.


Intraductal papillary mucinous neoplasms are rare papillary pancreatic neoplasms arising from major pancreatic ducts, characterized by duct dilation and mucin secretion. They comprise approximately 1% of all exocrine neoplasms and are classified according to their anatomical sites into main duct-type, branch duct-type, and mixed-type intraductal papillary mucinous neoplasms. Histological examination plays a crucial role in distinguishing and classifying intraductal papillary mucinous neoplasms into gastric, intestinal, pancreatobiliary, and oncocytic subtypes.We present the case of a 70-year-old Syrian woman who was admitted to our hospital due to an intermittent epigastric pain accompanied by diarrhea and weight loss with a recent diagnosis of diabetes mellitus. Following clinical, laboratory, and radiological examination, distal pancreatectomy involving the body and the tail of the pancreas was performed. Interestingly, histological examination of the resected specimens revealed the diagnosis of a mixed-type intraductal papillary mucinous neoplasm with a unique combination of gastric and pancreatobiliary subtypes.To the best of our knowledge, the combination of multiple histological subtypes of intraductal papillary mucinous neoplasms has been recorded in a few studies with reference to the challenging histological detection. Herein, we report a rare case with a significant histological combination, highlighting the difficulties in differential diagnosis due to the absence of ancillary techniques, with a brief review on diagnostic methods, histological characteristics and surgical recommendations. Also,A 70-year-old Syrian woman presented to the gastroenterology department of our hospital in March 2019 due to an intermittent localized epigastric pain for 10 days accompanied by diarrhea, nausea, and weight loss with no fever. Her blood pressure and electrocardiogram results were normal during physical examination., Six days previously, our patient had noticed that her urine was a dark color.Her medical and surgical history mentioned a recent diagnosis of type 2 diabetes mellitus during a routine check-up examination only 25 days prior to the initial presentation, in addition to a history of a partial thyroidectomy 20 years ago and hip replacement surgery 7 years ago. Her family history included a diagnosis of type 2 diabetes mellitus in her father and brother, while her psychosocial history was unremarkable. Additional files and details of our patient’s surgical history and previous medical investigations before presentation to our institution were not available.3/UL, a lymphocyte count of 47%, a neutrophil count of 50%, hemoglobin value of 13.2 g/dl, total bilirubin of 0.8 mg/dl, direct bilirubin of 0.3 mg/dl, amylase of 42 U/L, glucose value of 237 mg/dl, and C-reactive protein (CRP) value of 120. In addition, her thyroid-stimulating hormone (TSH) value was determined to be 8.22 u IU/m (reference range 0.38–4.31 u IU/ml), with normal values of free thyroxine (FT4) and free triiodothyronine (FT3).On initial presentation to our hospital, a blood test revealed a white blood cell (WBC) count of 5 × 10An abdominal ultrasound revealed a cystic dilation in the main pancreatic duct across the body of the pancreas, and involved an irregular-shaped mass Fig. . EndoscoNevertheless, based on detailed examination of the radiological and morphological features with multiple pathological and radiological consultations, the diagnosis was confirmed as a low-grade mixed-type IPMN with a mixed histological combination of gastric and pancreatobiliary subtypes. The rest of the pancreatic tissue was diagnosed as chronic pancreatitis. Although the admitted specimens included pieces of tissue labeled as proximal margins according to the surgical report, margins status could not be assessed by the pathologist due to the fragmentation of the specimens. Nevertheless, there was no evidence of high-grade dysplasia or malignancy. A whole-body computed tomography (CT) scan revealed no suspected lesions in her other organs. After the surgery, blood tests revealed lymphopenia, anisocytosis, high levels of CRP and serum glucose. However, our patient’s test results, except for glucose and TSH, went back to normal 5 days later. No adjuvant therapy was recommended, and our patient was put on levothyroxine (Eltroxin) (due to the high level of TSH), and insulin (Mixtard). According to the monthly blood test results, her TSH levels went back to normal 5 months later, while a moderate elevation in glucose value is still being reported (ranging between 203 and 245 mg/dl up to the time of reporting this case).Furthermore, ultrasonographic monitoring every 6 months was recommended. From the surgical procedure until her last visit in March 2020, our patient has been in a stable condition. A timeline of our patient’s case can be seen in Fig. IPMNs comprise approximately 21–41% of pancreatic cystic neoplasms and 1–3% of all pancreatic exocrine neoplasms. Although the exact incidence is still unknown due to the absence of symptoms in most cases [Many risk factors have been shown to increase the incidence of these neoplasms including diabetes mellitus, as in our case, chronic pancreatitis, family history of pancreatic ductal adenocarcinoma, and mutations in GNAS and KRAS genes. Interestingly, smoking is not reported as a risk factor although it can induce malignancy in IPMNs .According to their anatomical sites, IPMNs are classified into main duct-type (MD-IPMN), which has a higher risk of malignancy, branch duct-type (BD-IPMN), which is associated with multifocal cystic lesions, and mixed-type IPMN, which is a combination of both types . As our While IPMNs might be accompanied by extra-pancreatic malignant tumors involving the breast, lungs, prostate, colon, and rectum –5, CT scAbdominal CT scan has been historically considered the most common radiological method used in diagnosing IPMN. However, ERCP is considered more reliable for early diagnosis and demonstrating detailed features of the ductal system , 7. In oStudies reveal that both CT and magnetic resonance imaging have equal accuracy in staging malignancy of pancreatic ductal neoplasms , 8, MagnFurthermore, EUS is highly preferable as an imaging method for pancreatic cystic neoplasms as it can distinguish IPMNs anatomical types, and demonstrate features of suspected malignancy, in addition to the ability to perform a guided fine-needle aspiration for further evaluation .Histologically, a considerable heterogeneity is noticed in the epithelium by identifying four histological subtypes of the precursor component: Gastric subtype, which is characterized by thick short papillae lined by columnar cells with eosinophilic cytoplasm, basally located nuclei, and strong positivity for MUC5AC. This subtype represents the most common subtype and is usually associated with the BD-type in contrast to our case. Other histological subtypes include the intestinal subtype, which is usually associated with the MD-type and resembles intestinal villous neoplasms with columnar cells, pseudostratified hyperchromatic nuclei and strong positivity for MUC2; pancreatobiliary subtype, which is a rare subtype characterized by complex papillae lined by cuboidal cells with amphophilic cytoplasm, hyperchromatic nuclei, marked atypia, and strong positivity for MUC1; and oncocytic subtype, which presents with branching papillae lined by oncocytic cells with intracellular lumina and focal positivity for MUC1 –12. InteNevertheless, our case showed a rare combination of gastric and pancreatobiliary subtypes in a mixed-type IPMN that was diagnosed based on assessing morphological features with hematoxylin and eosin (H&E) stainings only due to economic restrictions, as the aforementioned IHC stainings were not available.Despite the above, at the current time, it is not likely that histological subtypes have an influence on decided clinical management in non-invasive neoplasms like in our case, while they have a significant prognostic implication in invasive carcinoma , 11.Differential diagnosis includes many lesions, most commonly are MCNs, serous cystadenoma, pseudocysts, and chronic pancreatitis. Many factors play a crucial role in establishing the diagnosis including the age of the patient, radiological findings, clinical presentation, anatomical location, and morphological features .MCNs are spherical cysts with peripheral calcifications, an ovarian-type stroma, and variable-thickened septations. They are more common in young women, and they usually arise in the body and the tail of the pancreas without connecting to the ductal system.Serous cystadenomas tend to affect older women and they are usually located in the head of the pancreas accompanied by multiple microcysts with a honeycomb-like pattern, central calcification, a thin peripheral wall, and a non-mucinous clear fluid. Also, the absence of septations, mural nodules and the lack of an epithelial lining, as well as the presence of necrotic hemorrhagic debris increases the possibility of pseudocysts , 16. RegGenetically, next-generation sequencing revealed that the presence of IPMNs correlates with multiple genetic mutations including GNAS mutations, which are considered the most common and specific alteration in this neoplasm. Also, an activation in G-protein signaling seems to be associated with the progression of IPMNs, while the expression of phosphorylated substrates of protein kinase A contributes to the pathological grade of this neoplasm .Regarding surgical recommendations, researchers have different points of view toward IPMN enucleation because, on one hand, it can preserve the pancreatic function for a long time as most of the parenchyma is preserved. On the other side, cysts may be ruptured during the procedure, which leads to peritoneal seeding. Furthermore, postoperative complications like pancreatic fistula are commonly noticed. Thus, regional pancreatectomy as a curative procedure is the main challenge, and researchers have discussed frozen section analysis as an important component of the surgery , 19. ThuInternational guidelines for IPMNs treatment include pancreaticoduodenectomy, distal pancreatectomy, or total pancreatectomy with lymph node segmentation and malignancy-free margins , 20.Overall, invasive IPMNs were found to have the best response to pancreaticoduodenectomy, while non-invasive IPMNs of the body and the tail respond to distal pancreatectomy, and finally, patients with diffused IPMNs or IPMNs that extend through the body and tail undergo total pancreatectomy , 20. As One study revealed that invasive IPMNs have recurrence rates of almost 67–91% with a 5-year survival rate of 40–60%, while non-invasive IPMNs are found to have almost no recurrence with a survival rate up to approximately 100% , 19, 20.In conclusion, our case demonstrated a rare histological combination that represented a hard diagnostic challenge due to the difficulties in differential diagnosis and the lack of proper immunohistochemical and molecular techniques. However, with clinical correlation, accurate observation of radiological and morphological findings, as well as reliable surgical management, we were able to confirm the diagnosis.


Gastro-Gastric Fistula is a rare but potentially serious complication of Roux-en-Y Gastric Bypass. Orogastric tube stapling is an adverse bariatric surgery iatrogenic complication that surgeons should be aware of and that has rarely been described.A 51-year-old patient, operated in our University Hospital Center of a Gastric Bypass 3 years ago, presented on consultation with anemia and weight regain (BMI 36). An upper Gastrointestinal (GI) endoscopy showed a Gastro-Gastric Fistula and visualized the tip of a Faucher tube fixed in the blind pouch and an erosive ulceration on the gastrojejunal anastomosis. Multiple biopsies showed a low-grade dysplasia in the remnant stomach. A subtotal gastrectomy was performed with refashioning of the gastrojejunal anastomosis.Anemia and weight regain, with or without the association of marginal ulcers are the most common signs of Gastro-Gastric Fistula after Gastric Bypass (1–6%). Surgical treatment remains the standard of care and should be tailored to the size and location of the fistula and the status of the gastrojejunal anastomosis. Orogastric tube perioperative complications are rare occurrences during bariatric surgery and not reported at a later stage. They can be associated with significant morbidity. Prevention strategies must be taken and standardized to prevent such events.The surgical option remains the standard of treatment and can be performed safely in Gastro-Gastric Fistula Type II. Orogastric tube accidental complications should be identified preferably perioperatively and measures of prevention should be implied to avoid such events. Bariatric surgery is considered the front line of morbid obesity treatment, with Gastric Bypass gaining popularity and still being considered as the gold standard. Gastro-Gastric Fistula is a known rare complication after Gastric Bypass surgery, opening an abnormal communication between the excluded gastric remnant and the neo gastric pouch. It can lead to weight regain, marginal ulcers and epigastric pain. The incidence varies from 1 to 6% .Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remains a technically demanding surgery and orogastric tube stapling can occur during the performance of the gastrojejunal anastomosis. It is a rare yet dreadful complication in bariatric surgery.Malignancy in the gastric remnant is very rare following gastric bypass surgeries. However, endoscopic evaluation and follow up remain very difficult due to the isolated nature of the pouch indicating that a dysplasia should not be ignored.2A 51-year-old patient, with a history of an efficient RYGB performed 3 years ago, presented with dizziness, light headedness and weight regain. Lab tests showed anemia with Hemoglobin 8.8 g/dl, iron deficiency, and controlled diabetes by HbA1c 6.4% (11.4% prior to LRYGB).An upper GI endoscopy was performed showing a large Gastro-Gastric Fistula between the upper Capella pouch and the gastric remnant. An erosive ulceration was also found on the gastrojejunal anastomosis. Multiples biopsies were taken, showing metaplastic intestinal cells with a low-grade dysplasia, in the gastric remnant. Finally, the tip of a Faucher tube was found fixed in the blind pouch distally and could not be retrieved endoscopically . RetrospFollowing both diagnoses, the patient underwent a laparoscopic subtotal gastrectomy with refashioning of the gastrojejunal anastomosis. The gastric remnant was resected completely, including the Faucher Tube of 20 cm, along the greater curvature .Fig. 2FaThe two days follow-up course was uneventful. Gastrotraphin® swallow on day 1 post-op, was normal. Anatomic pathology results showed inflammatory reactivity surrounding the Gastric Fistula site, in the absence of any residual signs of dysplasia or malignancy. The patient was seen at 6 months post-op without anemia, in good health, and with a 15 kg weight-loss.3Gastro-Gastric Fistula is a rare but known complication of RYGB, resulting from a communication between the Capella pouch and the excluded stomach . The incType I: More than 1 cm above the gastrojejunal anastomosisType II: Less than 1 cm above the gastrojejunal anastomosisIn the case of type II or the presence of intractable marginal ulcers, the anastomosis should be resected and recreated ,5,6,10.In type I, conservative medical treatment consists of high PPI doses and should be started for symptomatic patients without weight regain. Small fistulas might close spontaneously on medical treatment alone . EventuaIn type II, surgical treatment remains the standard of care for large fistulas and those that fail conservative or endoscopic treatment. Multiple surgical options can be performed depending on the anatomical findings and the surgeon’s preference. A simple fistulectomy could be eventually performed. However, due to the fear of marginal ulceration and increased risk of recurrence, a more radical remnant gastrectomy is recommended, with 87–100% symptom resolution ,13.Orogastric tube stapling is a seldomly reported complication of bariatric surgery, with an incidence of 0.5–1.2%, more often detected perioperatively with an immediate repair. These occurrences might be increased in motorized staplers due to less tactile perception.However, very late stage, years after surgery as in our case, complications have rarely been reported in the literature and hence should be emphasized as they may lead to severe complications if unrecognized .Early perioperative recognition and repair of these complications is very important to reduce morbidity, and prevention strategies should be implemented to avoid them. Active communication with anesthetists is imperative to ensure the mobility of the orogastric tube during stapling and complete removal by checking the tip integrity of the Faucher tube. There are many intraoperative cues a surgeon should be aware of to avoid these complications: failure of a stapler to fire correctly, deformity of the stapler jaws, the need to use excessive force to close a stapler and finally control of the integrity of the Faucher tube, when removed .Malignancy post RYGB is a rare occurrence with only around 30 cases reported in the literature . DetectiIn our case report, the final biopsies didn’t find residual dysplasia on the Gastrojejunal site. A protective and selectively subtotal gastrectomy was performed anyway to eliminate both fistula recurrence and increased dysplasia.4The Remnant Gastrectomy, associated with pouch refashioning, remains the standard treatment and can be performed safely in Gastro-Gastric Fistula, type II. Orogastric tube accidental complications should be preferably identified perioperatively. Strict measures of prevention protocols and control should be implied to avoid such events. Finally, the surgeon should keep a high awareness for dysplasia and malignancies prior to bariatric surgery in the excluded stomach, which should be treated aggressively due to the difficulty of reaching these lesions endoscopically.All authors declare having received no funding for the present case report.The study is exempt from ethnical approval in our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The study conception of the case report, the supervision and finalisation were executed by the corresponding author and senior surgeon Pr Elie Chelala.The first author, Simon Rizk PGY4 general surgery, wrote the draft paper in coordination for the review of the literature with Nidal Assaker PGY4 and Wissam El Hajj Moussa PGY5.Elias Makhoul, Senior gastroenterologist, performed the gastroscopy and contributed in the decision making, management and supervision of the work.This is not a study of a series that needs a research registration, and therefore a case report doesn’t need it.Pr Elie Chelala is the coordinator and corresponding author.Not commissioned, externally peer-reviewed.All authors declare having no conflict of interest in the current case report.