This report describes two cases with stepwise management of chronic ocular burn sequelae with concurrent total limbal stem cell deficiency (LSCD) and advanced symblepharon. Both were mono-ocular patients with the other eye being phthisical. In both cases, a sequential approach was planned, and at the first stage, the symblepharon was released to stabilize the ocular surface and form the fornices. This was followed by a type 1 keratoprosthesis (KPro) after four months of symblepharon release in the first case, and after nine months in the second case. In the first case, after symblepharon release, the resultant bare sclera was addressed with an oral mucous membrane graft (MMG). Over two years of follow-up, there was no evidence of recurrence of the symblepharon. No further surgical interventions were required. In the second case, after symblepharon release, the resultant bare sclera was addressed with a cryopreserved amniotic membrane (AM). Over eight years of follow-up, six episodes of recurrence of the symblepharon were noted over the optic of the KPro, necessitating trimming of the conjunctiva from over the optic. Thus, with these two cases, we would like to emphasize that addressing adnexal pathologies such as a symblepharon with an oral MMG before implanting a KPro, may help prevent further recurrences of symblephara and the need for multiple surgical interventions. The oral mucosa is a better alternative to the conjunctiva as compared to the AM in a mono-ocular patient where conjunctiva cannot be harvested from the contralateral eye. Various chronic sequelae ensue from ocular chemical burns of which limbal stem cell deficiency (LSCD) is perhaps one of the most visually debilitating. In a study that described the etiologies of LSCD, ocular chemical burns were the most common cause for both unilateral and bilateral LSCD . The manCase 1A 26-year-old male presented with a history of fall of lime in both eyes 12 years prior to presentation. He had undergone a penetrating keratoplasty and a KPro in the left eye. A retinal detachment was observed one month following the KPro implantation and the eye subsequently became phthisical. At presentation, he had a visual acuity of perception of light with an accurate projection of rays in the right eye. There was no perception of light in the left eye. In the right eye, the lid margins were normal, and the ocular surface was wet with a Schirmer’s value of 9 mm after five minutes. A superior symblepharon was observed extending 4 mm onto the corneal surface. Total LSCD with central leucomatous scar measuring 6 mm x 8 mm was present with retained lime foreign bodies . The edges of the donor area were sutured with four interrupted 6-0 polyglactin sutures for faster healing. The graft was trimmed to reduce the submucosal adipose tissue and the minor salivary glands and sutured onto the superior bare sclera with interrupted 7-0 polyglactin suture and fibrin glue . The superior de-epithelised corneal surface from where the symblepharon was released was covered with cryopreserved AM. A bandage contact lens (BCL) was placed upon completion of the procedure.Postoperatively, the MMG was in situ and the ocular movements were full. The patient was started on topical antibiotics , corticosteroids  and lubricants . An anesthetic lip gel  application before meals was advised along with chlorhexidine mouth wash after meals. The healing of the donor area was complete without any complications at two weeks. The topical steroids were gradually tapered over six weeks. At four months following MMG surgery, there was no recurrence of symblepharon, and a stable ocular surface was noted , or an oral MMG. Solomon et al. reported the outcomes of AM transplantation (AMT) after symblepharon lysis to form the conjunctival fornices, specific to eyes with ocular chemical burns . In theiConjunctival autografts in conjunction with AMT have been used to address symblepharon with excellent success rates ,11,12. AThe outcomes of oral MMG for symblepharon secondary to ocular chemical burns have been encouraging. In a study by Martinez-Osorio et al., six eyes with ocular chemical burns underwent symblepharon release with labial mucosal grafts and none of the eyes had a recurrence with a follow-up period of 36 to 44 months . In eyesPrior to KPro implantation, it is essential to address the symblepharon appropriately as a recurrence can encroach onto the optic of the KPro and substantially affect the visual function. Patients requiring a KPro usually have bilateral visual dysfunction and hence, the resultant visual morbidity significantly affects the quality of life in such individuals. Also, if the symblepharon is not addressed prior to performing a KPro, fitting the eyes with a large diameter contact lens post-KPro may not be possible, which leaves the cornea exposed and at the risk of desiccation. Furthermore, the multiple surgeries performed may cause repeated disruptions of the tear film and increased surface inflammation.The current case emphasizes the need for addressing symblephara pre-emptively in eyes that require a KPro. A meticulous preoperative examination will help detect the eyes that will require symblepharon release prior to surgical interventions for visual rehabilitation. In mono-ocular patients where a conjunctival autograft cannot be harvested, oral MMG sutured to the bare sclera after symblepharon release can lead to a successful long-term anatomical outcome without recurrences and further interventions.


Cholecystocolonic fistula (CCF) and hemorrhagic cholecystitis are rare complications of gallstones that have a wide range of non-specific symptoms and clinical severity. We present a case of a 74-year-old woman on warfarin who presented to the emergency department with a 10-day history of abdominal pain, vomiting, and watery diarrhea. Her abdomen was distended with generalized tenderness and palpable mass in the right lower quadrant. Laboratory tests revealed leukocytosis and an elevated international normalized ratio (INR). After admission and imaging, exploratory laparotomy showed hemorrhagic cholecystitis with CCF in the cecum. There was no pus or stool contamination. A cholecystectomy followed by right hemicolectomy with primary ileocolic anastomosis was performed. The postoperative course was uneventful, and the patient was discharged in stable condition.The presence of hemorrhagic cholecystitis in conjunction with CCF could lead to significant consequences such as hemorrhagic and septic shock in older patients with comorbidities. It is crucial to identify and intervene early before clinical deterioration. The prevalence of gallstones among adults in developed countries is 10-15%. Many risk factors were reported in the literature to be associated with gallstone disease. Risk factors include but are not limited to family history, genetic predisposition, ethnic background, female sex, patient age, obesity, rapid weight loss, metabolic syndrome, medications, and lifestyle changes . Most gaCholecystoenteric fistulas are a rare consequence of gallstone disease. According to a current case series involving more than 10,000 patients who underwent cholecystectomy, cholecystocolonic fistulas (CCFs) were found in 0.06-0.14% of cases . CCF is From a pathological perspective, CCF secondary to gallstones can be explained by two theories. The first theory is that acute calculus cholecystitis leads to inflammation and adhesion of the gallbladder wall to the serosal surface of the adjacent structures, resulting in ischemia that eventually becomes gangrenous. Subsequently, the gallbladder contents penetrate the gangrenous wall due to the increased pressure on the gallbladder ,6. The oHere, we report the case of an elderly female patient with multiple medical comorbidities presenting with abdominal pain, diarrhea, and a high INR. These are two uncommon pathologies, hemorrhagic cholecystitis and CCF in the cecum. A 74-year-old woman with a history of mitral valve replacement (MVR) 13 years prior with chronic treatment of 6 mg warfarin presented to the emergency department with a 10-day history of right upper quadrant abdominal pain, persistent vomiting, and watery diarrhea.On physical examination, the patient was afebrile and vitally stable. The patient was tachycardic, initially reaching 120 bpm, and then improved to 80-90 bpm with analgesia. The abdomen was distended with generalized tenderness, mainly on the right side with a negative Murphy’s sign. A mass in the right lower quadrant was palpated. Her work-up revealed a raised white blood cell count of 13,700 cells/μL, hemoglobin level of 9.8 g/dL, and an INR of 16.00.The patient was admitted, and nothing by mouth (NPO) was maintained with intravenous fluid and analgesia. Cardiology was consulted because of the high INR. A computed tomography (CT) scan with intravenous contrast of the abdomen and pelvis revealed a heterogeneously enhancing mass in the right lower quadrant indivisible from the small and large bowel, with the cystic duct tethered toward the mass Figure .Additionally, there were regional peritoneal deposits, lymphadenopathy, and a small volume of hemoperitoneum, which could be related to the described mass.As malignancy was suspected, the surgical oncology team advised a chest CT and colonoscopy for proper staging, which showed cardiomegaly and a small volume of right-sided pleural effusion with no evidence of intrathoracic metastases. The gastroenterology team considered colonoscopy unnecessary at this stage. Abdominal magnetic resonance imaging (MRI) showed a large hemorrhagic lesion on the right side of the abdomen surrounding a thickened gallbladder abutting the right side of the colon.Exploratory laparotomy was performed, due to the lack of improvement, through an upper midline incision. The decision to proceed to exploratory laparotomy was due to the patient fragility as she could not tolerate a long laparoscopic procedure and moreover, there was a possibility of colon or gallbladder malignancy. The gallbladder was separated from the liver, inferiorly migrated and adhered to the cecum Figures , 3.The cystic duct stump was auto avulsed from the gallbladder and controlled using a silk stitch. The colon was dissected from the gallbladder and a fistula opening was identified Figure .The gallbladder was inflamed, with a thickened wall and blood clots within the lumen Figure .We elected to do oncological resection as there was a possibility of hidden colon malignancy. Cholecystectomy followed by right hemicolectomy was performed with primary side-to-side ileocolic anastomosis.During the postoperative course, the patient was transferred to the intensive care unit (ICU) for two days and then transferred to the surgical ward. The patient was discharged in a stable condition. One month later, she visited the outpatient clinic with no complaints and a well-tolerated diet.The surgical pathology report revealed the right colon to have focal ulceration, fistula tract formation, granulation tissue, submucosal edema, congestion, and serosal surface exudates. These findings were observed mainly in the cecum and pericecal regions, and no evidence of malignancy was found. The gallbladder showed acute hemorrhagic necrotizing cholecystitis with a large blood clot occluding and distending the gallbladder lumen. A fistulous tract with granulation tissue and fibrosis was also identified.Both CCF and hemorrhagic cholecystitis are rare gallstone complications that can lead to considerable symptoms and have a major impact on patient health -10. EarlHemorrhagic cholecystitis clinically manifests with right upper quadrant pain, positive Murphy’s sign, impaired liver function, and leukocytosis ,15. HaemImaging techniques play a crucial role in the early diagnosis of hemorrhagic cholecystitis. Ultrasonographic findings can include focal wall thickening, intraluminal membranes, non-shadowing, and non-mobile intraluminal echogenic material ,18. CT sThe preoperative diagnosis of CCF is rare, accounting for only 7.9% of all CCF patients, compared to 43% of the series reporting cholecystoenteric fistulas in general ,19,20. MAvailable abdominal radiography, abdominal ultrasonography, barium studies, biliary scintigraphy, and endoscopic retrograde cholangiopancreatography (ERCP) techniques have been used in cases of CCF ,6,22. InFor cholecystoenteric fistulas, surgical intervention is the treatment of choice; however, controversy exists between laparoscopic and open surgical approaches. Chowbey et al. reported that a large number of fistula cases approached laparoscopically had a conversion rate of 6.3% . MoreoveHemorrhagic cholecystitis and CCF require a high clinical suspicion. Early recognition and intervention are the cornerstones of management for avoiding life-threatening consequences. Careful review and consideration are required in patients presenting with right upper quadrant pain, positive Murphy’s sign, impaired liver function, and leukocytosis that use chronic anticoagulants or antiplatelet medications.


Endometrioid Stromal Sarcomas are an infrequent group of mesenchymal tumors that we must take into account in the differential diagnosis despite representing only 0.2% of tumors of the female genital tract, as they can go unnoticed until advanced stages.Fifty-fourth year-old woman referred from the Urology department due to incidental finding of adnexal mass in MRI during examination after renoureteral colic, in the case of a 50 mm solid cystic mass in LE. MT were within the normal range, and the CT scan observed this mass in contact with the left ureter. The surgery was completed with hysterectomy and contralateral adnexectomy without incident and chemotherapy treatment was not added. The pathological result was ovarian tissue with low-grade endometrial sarcoma. Currently, after two years of follow-up, the patient remains stable without any recurrence of disease.Endometrioid stromal sarcomas are rare tumors that originate in the endometrial stroma, the ovarian location being rare. Management lies in surgical treatment, and adjuvant therapy is sometimes necessary in advanced stages. Endometrioid Stromal Sarcomas (ESS) are rare mesenchymal tumours that can occur in women across a wide range of age, from puberty to menopause, taking place around a median age of 50 years, and that represents only 0.2% of all female genital tract tumors and 15–26% of primary uterine sarcomas .An extrauterine location is extremely rare with ovaries being the most common location, although another type of locations has been reported involving the intestinal wall, peritoneum, pelvis and vagina , 5–7. ThThe main treatment for this type of tumour is surgery, although adjuvant treatment, chemotherapy and radiotherapy, may be of benefit in advanced stages , 4. TherA 54-year-old woman with a personal medical history of hypertension only who is receiving hydrochlorothiazide therapy. No other pathologies, no drug allergies and no previous surgeries. Regarding her obstetric and gynaecological history, she has had two deliveries and one spontaneous miscarriage, as well as established menopause one year and half ago. The last gynaecological examination with transvaginal ultrasound was performed 3 months earlier and was reported to be normal.The patient was referred to the gynecological outpatients department from the urology unit due to an incidental finding of adnexal mass on MRI during a medical examination performed after a renal-ureteral colic.The MRI report included the following: solid-cystic mass in the left ovary with a 50 mm size, anterior cystic component and a heterogeneous solid pole on the posterior wall visualised on the contrast-enhanced ultrasound, having irregular contours and diffusion restriction Fig. .Fig. 1MRThe abdomen was soft, depressible and painless to palpation with no palpable masses present. The vagina and external genitalia were normal in appearance, and the cervix was macroscopically normal. Bimanual examination revealed a mobile cyst formation involving the left adnexa, but it was hard and tender palpation, and with regular contours.An ultrasound scan showed an anteverted uterus measuring 59 × 33 mm with a 5-mm-thickened endometrium at the expense of a formation with hyper reflectivity compatible with an endometrial polyp. The right adnex was normal in appearance. In the left ovary, it was observed a multiloculated (5 loculi) solid-cystic mass measuring 50 × 46 mm, with anechoic contents and regular contours, thin septa, no papillae, with crescent sign and a vascular score of 1 compatible with a borderline lesion Fig. . No freeAfter diagnosis, tumor markers and an abdominopelvic CT scan were requested. Tumor markers (TM) were in the normal range  and the CT scan was reported as showing a heterogeneous solid-cystic image measuring 55 × 59x64 mm located in the left parauterine region of potential left adnexal origin that seems to be in contact with the left ureter Fig. .Fig. 3AbThe case was discussed in a committee comprising specialists in gynecology and gynecology oncology, and it was decided along with the patient to perform an exploratory laparotomy.A midline infra-umbilical laparotomy was performed. During surgery it was observed the above-mentioned solid-cystic mass measuring 60 mm in the left ovary, with smooth surface, firmly attached to the peritoneum of the ovarian fossa and loosely to the colon. No infiltration or compromise of the ureter or vascular structures was observed. The rest of the examination of the abdominopelvic cavity was normal. An intraoperative biopsy was performed and no malignant features were found, so the surgery was completed with total hysterectomy and contralateral adnexectomy with no incidents.The postoperative course was favourable and the patient was discharged after four days without complications.Peritoneal lavage cytology was examined in the pathological report and results were negative. There was present a moderate chronic cervicitis, an inactive endometrium and an endometrial polyp inside the uterus. The right adnex was normal and there was a fragment of ovarian tissue with low-grade endometrial sarcoma in the left ovary.The pathological report revealed nests of cells with uniform oval and round shape in fragments of the left ovary, with very scant cytoplasm, no cytologic atypia and a low mitotic index accompanied by abundant small vessels Fig. a.Fig. 4HAt immunohistochemistry, tumor cells were positive for CD 10, desmin and for estrogen and progesterone receptors . They were negative for smooth muscle actin (SMA) and alfa-inhibin. Proliferative index < 5% Fig. b.The case was presented to the tumor committee of our hospital  and it was agreed to follow up by gynaecology without the need for adjuvant treatments. After two years of follow-up care in the oncology outpatients department, the patient is asymptomatic and is having routine checkups with normal TM and six-monthly CT scans that show no findings.Endometrioid stromal sarcomas are an infrequent group of tumors that arise in the endometrial stroma and primarily affect the uterus. These show differentiation in the proliferative stage, which is similar to that of the endometrial stroma but without evidence of a uterine origin, being the ovary the most frequent location . In our The latest WHO classification from 2014 divided ESS into 4 subgroups based on clinical and pathological characteristics: endometrial stromal nodule (ESN), low-grade endometrial stromal sarcoma (LG-ESS), high-grade endometrial stromal sarcoma (HG-ESS) and undifferentiated uterine sarcoma. The most frequent group is the low-grade ESS with a 5-year survival rate of 90% in the early stages, although it presents a high recurrence rate [Therefore, its diagnosis includes different techniques such as the use of imaging tests (contrast-enhanced T2-weighted MRI) or the positive expression of tumor markers, such as CD-10, vimentin or estrogen/progesterone receptors by immunohistochemistry , 7. HoweThe basic treatment for the initial disease includes hysterectomy and bilateral salpingo-oophorectomy , 4, 7. RThis tumor can lead to local recurrence or even distant metastasis a few years later after the initial diagnosis. It has been estimated that they usually recur in about 50% of cases , 10. TheAfter reviewing the literature, we have found a total of 91 cases, of which 41 have been treated with surgery only and 41 with a treatment-associated surgery , whereas only 9 cases were treated with radiotherapy.Ovarian adenosarcomas have a similar prognosis to the homonymous uterine sarcoma and have a tumour recurrence in 50% of patients, which occurs almost always within the first 5 years after surgery , 2, 10. The appearance of this type of ovarian tumor may be related to the previous presence of endometriosis. Although the pathogenesis is not clear, there seems to be a risk of malignization of these endometriotic foci. Nevertheless, the presence of endometriosis is considered a favorable factor since these patients have a higher DFS than patients without endometriosis.In cases of extrauterine tumor without endometriosis (as in the case of our patient) the origin may arise from pluripotent mesothelial and mesenchymal mesenchymal cells of the pelvic cavity.Most patients at stage I have at least one relapse. High recurrence rates are associated with patients aged under 53 years with stage I disease, a high-grade tumour rupture and sarcomatous overgrowth. The time from diagnosis to the first recurrence has been estimated to be 0.4 to 6.6 years . Distant metastatic lesions, if any, are usually preceded by intra-abdominal recurrences. A recurrence can occur as a low-grade or high-grade adenosarcoma or as a sarcoma of variable grade , 13.In our case, the patient was presented to an Oncology Committee and, given that it was a low-grade tumor confined to the ovary, it was decided not to prescribe adjuvant therapy but to follow her closely. Currently, after two years of follow-up, the patient remains asymptomatic and stable with no evidence of recurrence.As shown above, there are several strategies used in the management of this disease entity, partly justified by its rarity and the absence of specific protocols laying down solid standards for the disease management. Although no significant differences were found in terms of results, this challenge is one of the main objectives of future research at ESS.


Teaching Point: Unilateral choreiform movements combined with contralateral hyperdense lentiform and/or caudate nucleus on computed tomography is suggestive for non-ketotic hyperglycemia, warranting further metabolic workup. Figure 1). Noticeable cerebral atrophy, old lacunar supratentorial infarctions, and periventricular leukoencephalopathy hadn’t changed significantly compared to a prior examination one year earlier.An 88-year-old male with dementia was sent to the emergency department for bilateral choreiform movements and worsening confusion. Brain computed tomography (CT) was performed, showing a hyperdense lentiform nucleus, more prominent on the right side than on the left side. A hyperdense right-sided caudate nucleus with 52 Hounsfield units (HU) versus 42 HU (Hemoglobin A1c (HbA1c) and blood glucose level were measured. The glycemia was normal, but high HbA1c of 13.8% or 127 mmol/mol  confirmed the diagnosis of new onset diabetes mellitus. During the work-up for the diabetes, abdominal CT demonstrated a mass in the body of the pancreas, believed to be the cause of the diabetes mellitus. Considering the patient’s mental state, no further investigation was performed.Hemichorea consists of unilateral, continuous, nonrhythmic, rapid, involuntary dance-like movements . When reCT findings are usually unilateral hyperdense striatum on the contralateral side of the choreiform movements, but can be bilateral .The most important magnetic resonance imaging (MRI) findings are unilateral high signal in the affected caudate and/or lentiform nucleus on T1-weighted images, increased paramagnetic susceptibility and mild to moderate diffusion restriction [If found incidentally, these findings warrant further investigation of blood glucose levels, serum osmolality and urinary ketone levels. High blood glucose levels and elevated serum osmolality are usually found, whereas urinary ketone levels are normal . Treatme


Paratubal cysts are adnexal masses located in the broad ligament; whenever the size of the cyst is >20 cm, it is considered a giant cyst and can present with complications including ovarian torsion and perforation. Diagnosis can be made clinically with the help of radiological investigations, although the gold standard diagnostic tool is diagnostic laparoscopy. Managing this condition relies mainly on surgical intervention (open or laparoscopic). Giant paratubal cysts carry challenges in their surgical excision as they carry a higher risk of spillage. We present a case of giant paratubal cyst in a 26-year-old Bahraini female who presented with abdominal distension and pain for 3 years. Paratubal cysts are adnexal masses that originate from paramesonephric, mesonephric, or mesothelial origins ; they coA 26-year-old woman who has no known case of any chronic medical illnesses presented to the general surgery clinic with the complaint of progressive abdominal distension for 3 years. Additionally, the patient noticed abdominal distension with on and off vague generalized abdominal pain. The patient did not seek prior medical advice for her abdominal distension. There were no other associated complaints and no history of trauma.The patient is single and nulliparous with no history of sexual intercourse, no history of hormonal supplementation, and no past surgical history. Upon abdominal examination, distension involving the lower abdomen was present and reached the epigastric area. There was no tenderness or skin changes that could be appreciated . Rectal The patient was investigated initially with laboratory tests, abdominal and pelvic ultrasonography, and pelvic magnetic resonance imaging (MRI). Blood tests were all within normal range , in addition to negative serum tumor markers . The abdominal and pelvic ultrasonography  showed aMRI of the pelvis  showed aThe decision to start with laparotomy instead of diagnostic laparoscopy was made due to the large size of the mass and the uncertainty of the pathology of the tumor ; the patient underwent elective exploratory laparotomy with excision of the mass; intraoperatively, the mass was found to be left paratubal  and measuring 40 × 20 cm with 7 liters of clear content, with crossing blood vessels over the cyst .The patient was discharged second day postoperatively in a stable condition and with no complaints; she was followed up in the outpatient general surgery clinic regularly until full healing of the wound; the patient had no complaints during her visits.In view of the patient's history, physical examination, and radiological investigations, the differential diagnoses were mesenteric cyst and ovarian cyst. However, the histopathology sections revealed wall of cyst lined by a single layer of cuboidal cells with focal area showing ciliated cells. No papillae or atypia was seen. One of the sections revealed part of the fallopian tube; thus, the final diagnosis was benign paratubal cyst.Postoperatively, the patient was discharged home on the 3rd day in a stable condition; follow-ups in the clinic revealed resolution of the symptoms.5, and only a few cases of giant paratubal cysts (>20 cm) have been described [Paratubal cysts (PTCs) are fluid-filled masses that occur in the mesosalpinx within the broad ligament . Overallescribed . The larescribed . In our PTCs originate from the paramesonephric (Mullerian) embryological remnants in up to 76% of the cases, whereas the remaining types are mesothelial or rarely mesonephric (Wolffian) in origin . Cysts tMost of the PTCs are small and asymptomatic and rarely require treatment . The larPhysical examination might be unremarkable, but as the PTCs grow in size, abdominal and adnexal tenderness can be elicited on pelvic examination, in addition to palpation of the cyst. In case of complicated PTCs , examination may reveal peritoneal signs . LaboratPTCs can be detected preoperatively with radiological investigations, with ultrasonography and magnetic resonance imaging (MRI) being more useful than CT scan . PTCs arThe treatment approach for symptomatic PTCs is surgical excision via laparotomy or laparoscopic approach; in case of symptomatic PTCs, excision has not been recommended by some authors . LaparotWhenever the size of the cyst allows laparoscopic excision, it is preferred as it has the advantages of smaller incisions, shorter hospital stay, and faster patient's recovery . AbsolutParatubal cysts are masses that originate in the broad ligament and are common in the 3rd and 4th decades. Giant PTCs (more than 20 cm) are rare and difficult to diagnose and differentiate from other abdominal and pelvic pathologies. Complications of this diagnosis can be torsion, hemorrhage, and perforation. Prompt diagnosis is required and can be aided with imaging studies that include ultrasonography and MRI. Surgical excision is the mainstay of management of PTCs and can be performed with laparotomy or laparoscopy if feasible.


Pancreatic cancer (PC) occurs when changes (mutations) in the pancreas cells lead them to multiply out of control. A mass of tissue can result. Sometimes, this mass is benign (not cancerous). In PC, however, the mass is malignant (cancerous). A 79-year-old male presents to the emergency department with complaints of yellow discoloration of the eyes and body as well as itching all over the body. On general examination, his vitals were normal. Laboratory investigations showed raised levels of bilirubin and hepatic enzymes. The CT abdomen study revealed abnormal enhancing soft tissue density in the pancreatic head region obstructing the pancreatic duct and common bile duct leading to its proximal gross with upstream dilatation. The lesion described lesion in the pancreatic head region is of a malignant neoplastic etiology and needed to be evaluated with endoscopic retrograde cholangiopancreatography (ERCP), biopsy, and histopathology correlation. Associated pancreatic parenchymal atrophy was also seen along with gross dilatation of the extrahepatic and intrahepatic biliary system. There were no associated enlarged draining lymph nodes and minimal free fluid was seen in the peritoneal cavity. Following the deployment of a stent in the common bile duct, the patient was discharged. The patient prognosis was good and the patient was scheduled for routine blood work after four weeks to assess bilirubin levels and hepatic enzymes. Obstructive jaundice is the most prevalent sign of pancreatic head malignancy. Surgical resection is the gold standard treatment option for individuals with a resectable tumor and no radiologic signs of spread. Preoperative biliary drainage due to significantly elevated bilirubin was developed to enhance the postoperative result since it is believed that surgery in patients with jaundice increases the risk of postoperative complications . PancreaPeople with a long family history of PC or who are genetically predisposed to it are more likely to acquire the disease over several years. Clinicians should pick patients most likely to benefit from pancreas monitoring, talk to them about its advantages and disadvantages, and treat patients with lesions found by surveillance as best they can .The fact that PC is rarely identified at an early stage is one of the reasons influencing the patient's poor prognosis. However, it was challenging to detect PC since several variables, including gender, age, main pancreatic dilatation, tumor marker, and the blood amylase level at admission, were not substantially linked to the disease. Only the discovery of a pancreatic mass allowed for the early identification of PC, even though 41.7% of those affected by PC had their mass recognized at the first sign of acute pancreatitis. PC can cause upstream PD dilation and post-obstructive pancreatitis. A key indicator of PC is the main pancreatic dilatation .A 79-year-old male presented to the emergency department with a complaint of yellowish discoloration of skin and eyes, yellow discoloration of urine and stools for 15 days, and pruritus for two months. The patient had noticed a gradual decrease in appetite for one month. The patient had no episodes of abdominal pain, nausea, vomiting, fever, cold, or cough in the past two months and no history of alcohol and tobacco. He had a history of diabetes mellitus type II and hypertension for three years and was taking medication for it. A year prior, the patient had transitional cell carcinoma of the bladder and had undergone nephroureterectomy for the resection of carcinoma. Biopsy was performed in which the section from the resected specimen of bladder tumor showed histopathological features of transitional cell carcinoma  and section from deep muscle biopsy showed remarkable fibromuscular tissue and focal collection of chronic non specific inflammatory infiltrate on histopathology. Malignant epithelial cells were seen in histopathology suggestive of infiltration.On general examination and laboratory investigations, the patient’s vitals were normal but his skin and eyes were yellowish with the presence of lesions on the hands and chest Figures -3. ElevaOn performing a CT scan of the abdomen and pelvis, an abnormal enhancing soft tissue density lesion in the head of the pancreas was observed, measuring approximately 25 × 22 mm in maximum cross-sectional dimension. The lesion obstructed the common bile duct and the pancreatic duct, leading to its dilatation. There was a gross dilatation of the pancreatic duct with significant atrophy of the pancreatic parenchyma surrounding the dilated duct Figure .The pancreatic duct measures 13 mm in maximum diameter in the head region. The lesion is in close proximity with the posterior aspect of the superior mesenteric vein with the maintained plane of separation in between or just abutting the posterior aspect of the superior mesenteric vein. Its plane of separation with the superior mesenteric artery is also very well maintained. On the right side, it is in close proximity to the distal part of the second part of the duodenum and the proximal part of the third part of the duodenum with no obvious signs of infiltration. Posteriorly, its plane of separation with the inferior vena cava is well maintained. The patient's prognosis was good after endoscopic retrograde cholangiopancreatography (ERCP) and reduce clinical manifestation Figure .Obstructive jaundice is a prevailing condition all over the world. Its common cause includes neoplasms of the pancreas, gallbladder, biliary system, or the ampulla of Vater, choledocholithiasis, and chronic pancreatitis . Due to ERCP is often used to assess the patient with obstructive jaundice. ERCP is a more precise measure to detect lesions which are difficult to detect in CT or transcutaneous sonography . ERCP isThe main pancreatic duct (MPD) can also be examined with ERCP to check whether the tumor is obstructing it. During initial hospitalization, ERCP is not performed due to the high-risk factor of post-ERCP pancreatitis . The onlIn conclusion, ERCP is an appropriate and precise technique for diagnosing the extrahepatic biliary tree obstruction. Our results suggest that the common cause of obstructive jaundice was the development of a soft tissue density lesion in the head of the pancreas, which led to PC diagnosis. The degree of precision in this technique is quite comparable to other techniques like CT, ultrasonography, etc., to gauge the frequency of serious complications. We believe that the surgical care of obstructive jaundice would be improved by using ERCP to identify the condition's etiology.


The diagnostic workup of male infertility commonly includes scrotal ultrasound as an adjunct to physical examination. Testicular volume and morphology are readily evaluated; signs of testicular dysgeneses, such as heterogeneous echotexture and microcalcifications, and non-palpable focal testicular lesions can be identified. Additional sonographic findings include signs of spermatic obstruction, such as dilatation of the rete testis, enlarged epididymis, and absent vas deferens. In men with varicocele, the presence of venous reflux during Valsalva maneuver is assessed using Doppler .The widespread use of ultrasound, combined with improved resolution of modern transducers, has led to increased detection of focal non-palpable testicular lesions. Their prevalence is higher by 20% in men with azoospermia compared with the general population , 2. DespTypical sonographic features in KS men include small-volume testes with a coarse or nodular echotexture . In a siLeydig and Sertoli cell tumors are the main solid lesions to be differentiated from germ cell tumors, both belonging to the family of sex cord-stromal tumors of the testis. LCT is the most frequent sex cord tumor, accounting for up to 3% of testicular tumors, and is benign in over 90% of cases. Small lesions typically have a slow, indolent course. Leydig cell hyperplasia is a benign condition that overlaps with LCT; it is commonly detected in cryptorchid testes and in KS. Unlike in LCT, Leydig cells are arranged in a more diffuse micronodular pattern within the testicular interstitium. Well-preserved or atrophic tubules can be observed among the hyperplastic nodules, a feature that is absent in LCT .Leydig cell tumors are typically round, sharply defined hypoechoic lesions with homogeneous echotexture. They cannot be reliably differentiated from germ cell tumors purely based on morphological sonographic features. They have a characteristic Doppler appearance, consisting of moderate hypervascularity relative to the adjacent parenchyma .The combined use of morphological ultrasound, color Doppler, contrast-enhanced ultrasound (CEUS), and real-time elastography, referred to as multiparametric ultrasound, has been explored in recent years to characterize non-palpable focal testicular lesions with promising results. Increased stiffness has been found on strain elastography in both malignant and benign neoplastic lesions, including LCT, whereas non-neoplastic lesions tend to be soft . On CEUSOptimum management of non-palpable focal testicular lesions is a matter of debate in the urological community. A lack of clinical and imaging parameters to distinguish benign from malignant lesions has led to overtreatment by means of radical orchidectomy. A systematic review by Giannarini et al.  reportedIndeterminate lesions of the testis are common sonographic findings in infertile men, including those affected by KS. Published data reflecting the experience of a few specialized centers show that most non-palpable lesions correspond to benign LCT; these lesions can be safely followed up or biopsied at the time of microsurgical sperm retrieval. Multiparametric ultrasound shows potential for improved lesion characterization and may assist in their management in future. Unnecessary surgery or prolonged imaging follow-up could be avoided in the presence of lesions with sonographic features favoring benignity; prompt organ sparing surgery could be directed to lesions with malignant features.AP drafted the manuscript. DP edited the manuscript to its submitted form. 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.


In this study, we present an extremely rare case of thoracic spinal glomangioma located at the thoracic T7–8 level in the foraminal region, mimicking a schwannoma tumor, in a 65-year-old female patient who was admitted to our clinic with a 6-month history of back pain and weakness in legs. Benign tumors that grow gradually over a long period of time cause the body to allow for intruders. Various soft tissue, bony and neural modifications occur as a result of compressive effects of the tumor . ForaminA 65-year-old female patient was admitted to our clinic with the complaints of back pain and progressive weakness in her legs for the last 6 months. An ethics approval and consent to participate were not applicable since the present study is a report about the experiences and observations of medical practices associated with a single individual. On physical examination, the patient had paresthesia and hyperreflexia in both legs.There was no bladder dysfunction or loss of motor strength, while there was bilateral loss of vibratory sense below T8 and moderate loss of pinprick. Bilateral knee clonus and the Babinski sign were negative. Thoracic magnetic resonance imaging (MRI) showed a mass lesion mimicking a meningioma or schwannoma at the foraminal level of the right T7–T8 vertebrae. The tumor was hypointense on T1-weighted images and hyperintense on T2-weighted images in both contrast and noncontrast-enhanced images . The patImmunohistochemical examination indicated the following features in neoplastic cells: CD34 (+), CD31 (+), SMA (+), P53 (−), EMA (−), PanCK (−), Progesterone (−), S100 (−), PAS (−), CEA (−), GFAP (−), Synaptophysin (−) and Chromagranin (−). Additionally, Ki-67 proliferation index was determined as <1% . Based oGlomus tumor is mostly seen in hands, particularly in the nail beds . The ratet al., only 13 cases were reported [In a review by Zheng reported . In MRI reported . Most aureported . In the In patients presenting with a mass compressing the medulla spinalis, glomus tumor should be suspected even if the lesion mimics a spinal meningioma or schwannoma.


Primary intraosseous meningiomas (PIOMs) are a rare subset of meningiomas, comprising fewer than 1% of all such tumors. Furthermore, PIOMs presenting as osteogenic lesions that invade both the dura and subcutaneous tissue are extremely rare. Unlike intracranial meningiomas, diagnosing and treating PIOMs are challenges due to their insidious clinical behavior and a lack of clear radiological diagnostic criteria. We report the case of a 60-year-old female with headache and a slightly outward protrusion of the parietal region of the skull. CT showed an osteogenic lesion in the right parietal bone. MR imaging indicated mild to moderate homogeneous enhancement with an intense dural reaction. The suggested clinical diagnosis was lymphoma, so we performed a skull biopsy, which revealed an intraosseous benign meningioma. A precise resection strategy was planned with a neuronavigation system accompanied by a one-step customized titanium mesh cranioplasty. The lesion was completely removed, and pathological analysis confirmed a meningothelial meningioma (WHO Grade I) of intraosseous layer origin invading the dura mater and subcutaneous tissue. This case highlights the need for an initial biopsy when the lesion is difficult to diagnose on imaging. Complete resection should be attempted to minimize the risk of recurrence. Primary epidural meningiomas (PEMs), once defined as entities that develop in the extradural compartments, account for less than 2% of all meningiomas . PrimaryA 60-year-old woman was admitted to our neurosurgery department for headache and a 6-month history of a skull mass in the right parietal region. No trauma had previously occurred in that region. Neurological examination and laboratory data showed no significant abnormalities. Thin-cut skull computed tomography (CT) showed a large parietal osteogenic calvarial lesion measuring 7.1 × 5.8 × 2.2 cm . The lesConsidering the possibility of lymphoma according to the radiologist’s assessment, we performed a skull biopsy in the most prominent area of the lesion. An arc incision was adopted in case of possible subsequent surgery. The result confirmed an intraosseous ectopic meningioma.As there were no neurological deficits, 2 weeks after the biopsy, precise resection of the lesion and a cranioplasty were performed. Before the operation, the approximate extent of the resection was determined by the neuronavigation system . The infPostoperative CT showed total resection of the tumorous calvaria lesion with complete restoration of the symmetry of the skull . MicroscMost PEMs are considered to be rare tumors involving bone and subcutaneous tissue, of which approximately two-thirds are PIOMs. The incidence of these latter meningiomas peaks at 60 years of age, with a significant female predominance 85%) (% (5). ThThe presence of certain tumors invading the dura during surgery raises the question of whether they should be classified as PEMs. Bassiouni et al.  reportedTo date, several hypotheses have been proposed regarding the origin of PIOMs. They may be derived from the abnormal differentiation and migration of mesenchymal stem cells . AdditioIn one study, the imaging characteristics of PIOMs included hyperostosis in 56% of the meningiomas, osteolysis in 33%, and mixed features in 11% . These fWide surgical excision is the primary treatment of choice for PIOMs . The litWe encountered a rare case of osteoblastic intraosseous meningioma that originated from the cranial diploic layer and invaded the dura mater and subcutaneous tissue. PIOMs may appear to be highly aggressive even if the histology is benign. To prevent recurrence and deterioration, surgery should be performed to achieve complete resection of the lesion. The clinical features and surgical techniques described in this report may provide a good reference for the diagnosis and treatment of similar diseases in the future.


Lipomas of the of the head and neck region are rare, more so in the retropharyngeal space. Lipomas in this region can produce symptoms that demand surgical excision. This paper describes a case of lipomatous hamartoma of the retropharynx, which to the best of our knowledge has not yet been reported in English literature.A 53-year-old gentleman presented to the ENT department with snoring, voice change and stridor. Examination revealed a smooth bulge in the posterior wall of the oropharynx causing near complete obstruction of the airway. A contrast enhanced computed tomogram revealed a non-enhancing hypodense lesion in the retropharyngeal space extending from C1-C4 level, which was suggestive of a lipoma. The tumour was surgically excised trans-orally. A limited review of literature is also presented.Trans-oral approach is preferred to external approach for surgical removal of benign retropharyngeal tumours that cause obstructive symptoms, as our case. This approach is safe, effective, and associated with lesser post-operative morbidity. Lipomas are benign encapsulated tumours consisting of lobulated, slow growing mature adipocytes with minimal connective tissue stroma . HamartoThe retropharyngeal space is bounded on either side by the major neck vessels and lower cranial nerves making it a difficult region to gain access through the external approach. The trans-oral approach possesses the inherent advantage of avoiding the important neurovascular structures and lower post-operative morbidity . HoweverA 53-year-old gentleman with no co-morbidities presented to the outpatient department with complaints of noisy breathing for 20 days. He also gave history of progressive snoring and change in voice from 6 months. Examination revealed a smooth mass in the oropharynx extending inferiorly from the level of the base of tongue and superiorly beyond the level of the soft palate causing near complete obstruction of the oropharyngeal airway. A contrast enhanced computed tomogram (CECT) of the neck was done which was suggestive of a well-defined, non-enhancing fat density lesion in the retropharyngeal space measuring 8.2 cm craniocaudally, 4 cm antero-posteriorly and 6.2 cm transversely causing marked narrowing of the airway. The lesion is seen to compress the left carotid artery and displacing it laterally . It was As the patient was in stridor he was immediately shifted to the operation theatre where he underwent a tracheostomy under local anaesthesia. Tracheostomy secured the airway and relieved the respiratory distress. A trans-oral core biopsy of the lesion was done in the same sitting which was reported as a lipoma and the patient was planned for trans oral excision under general anaesthesia. Patient was placed in the Rose position. Exposure of the lipoma was achieved using a Boyle Davis mouth gag. The soft palate was retracted to expose the superior limit of the tumour. A vertical incision was made over the posterior pharyngeal wall and the constrictor muscles exposing the lipoma. Dissection was carried out from above downwards with traction over the tumour, releasing its attachments by blunt dissection. The tumour was found anterior to the prevertebral muscles within the confines of the retropharyngeal space. The tumour was delivered per-orally as a whole . Gross examination revealed a partly encapsulated tumour measuring 8x6x3.5cm with yellow fatty areas on cut section. Histopathological examination revealed a lipomatous hamartoma, which showed lobules of mature adipose tissue with skeletal muscle bundles, few nerves and fibrocollagenous tissue . Post-opClinical presentation of benign retropharyngeal tumours depends on its location and size, it varies from a vague globus sensation, dysphagia, snoring with or without obstructive sleep apnoea syndrome or stridor with respiratory distress  or can bThe pre-operative histological diagnosis was lipoma and the definitive treatment for a retropharyngeal lipoma is surgical excision ,4. In thThe retropharyngeal space is in close proximity to major neurovascular structures on either side making the external approach to this space fraught with potential serious complications ,6. The tA significant lateral extension would warrant an external transcervical approach. Transoral excision of retropharyngeal lesions with parapharyngeal extension can be attempted, but visualisation of the lateral component of the tumour is compromised and dissection is done blindly with the finger . In our review of literature, all the patients that underwent an external surgical approach had parapharyngeal extension and two cases with parapharyngeal extension were removed trans-orally. The largest dimension among the lipomas removed trans-orally and externally in our review were 12 cm and 11.7 cm respectively. The nasopharyngeal part of the lipoma in this case was visualised after retracting the soft palate anteriorly. The soft palate can also be split in midline to gain access to this part of the tumour . Owing tLipoma in the retropharyngeal space is very rare and to the best of our knowledge, this is the first case reporting of lipomatous hamartoma of the retropharynx. Complete surgical excision is curative. This case report shows that the trans oral route for surgical excision of benign retropharyngeal tumours such as a lipomatous hamartoma is a safe, feasible, and an effective option. The external approach provides better access but is associated with higher -operative morbidity.


At our institution, radiation oncologists routinely treat early-stage oral cancer with low-dose-rate brachytherapy (LDR-BRT) using Au-198 grains. In this report, we show a unique case of a patient with a gold grain located within the submandibular gland, found incidentally during follow-up after LDR-BRT for floor of mouth cancer. One month after the implant, he showed sialadenitis-like symptoms, but the pain resolved two months later. All the grains were detected around the anterior sublingual area by computed tomography (CT) four months after the implant. Unexpectedly, 11 months after the implant, CT revealed that a grain was located in an intraglandular site of the submandibular gland. This finding clearly demonstrates that the grain entered Wharton’s duct and retrogradely migrated to the submandibular gland through the duct. As a mechanism of the calculus formation within Wharton’s duct, retrograde migration of foreign bodies to the inside of the duct has been proposed. Our incidental finding after LDR-BRT highlights the need for monitoring post-LDR-BRT using Au-198 grains for the treatment of floor of mouth cancer and sheds additional light on retrograde theory within Wharton’s duct. Brachytherapy (BRT) is performed for early-stage oral cancer as a definitive radiotherapy. In addition to being equivalent to the local control achieved by surgery, it retains oral function, resulting in a high quality of life with minimal side effects -4. This A 63-year-old Japanese man noticed a mass on the left side of the floor of his mouth in November 2020. Past medical history was unremarkable. The patient visited the oral surgeon at our hospital and was diagnosed by biopsy with squamous cell carcinoma (SCC). He was referred to our department for brachytherapy in December 2020. Clinical examination revealed a 1.2 × 0.7 cm exophytic mass in the left anterior floor of the mouth Figure . On palp18F-FDG PET/CT) revealed uptake in the left floor of the mouth (SUVmax=5.6) , and contrast-enhanced magnetic resonance imaging (MRI) could not detect the tumor. Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography  Figure . No evid) Figure , and dra) Figure . The patAfter S-1 (tegafur/gimeracil/oteracil) oral chemotherapy , in February 2021, eight Au-198 grains were implanted into the left side of the floor of the mouth under local anesthesia, and the patient was hospitalized in isolation for four days. The number of grains was determined as follows. The treatment target area was set as a circle of 2 cm in diameter Figure , and theAfter the LDR-BRT, we followed the patient in an outpatient setting. In March 2021, while apparent mucositis due to acute toxicity had almost resolved, he had recurrent pain in the left distal floor of his mouth after drinking water, and it resolved after 20 minutes. Saliva from the orifice exhibited good flow, but the sublingual fold was hard on palpation. In May 2021, while the pain had disappeared, salivary outflow from the left sublingual caruncle was not clear. In June 2021, four months after the implantation, CT showed no evidence of recurrence in the floor of the mouth and no cervical lymph node metastasis. Implanted gold grains were detected in the left floor of the mouth Figure . The patIn January 2022, after a careful follow-up, CT showed a sialolith-like structure in the left submandibular gland Figure . During Five months later, MRI showed saliva throughout Wharton’s duct, but the apparent flow was still unclear near the left sublingual caruncle. In addition, the left submandibular gland showed high signal intensity in the T2-weighted fat-suppressed MRI, suggesting the existence of inflammation Figure .Except for the short-term pain after drinking water approximately one month after the implant, he had unclear salivary outflow from the left sublingual caruncle and no other significant subjective symptoms. Moreover, he exhibited no radiographic or clinical evidence of cancer recurrence. During our follow-up, he received radiation therapy for primary lung cancer and surgery for gastric cancer, and neither of them recurred.-14 MBq when it moved to the submandibular gland. Therefore, the direct effect of radioactivity from the Au-198 grain on the submandibular gland can be considered negligible. Fortunately, the patient currently shows no significant subjective symptoms, but we need to carefully follow up to see if submandibular adenitis or duct obstruction worsens in the future.The Au-198 grain consists of an Au pellet and a sheath of Pt coated on platinum plating Figure . In addiGold grains were not detected in the left submandibular gland before BRT Figure  or four There are some reports that foreign bodies including a fish bone , shrimp Our case may be the first report of a foreign body traveling in a retrograde fashion almost the full length of Wharton’s duct presumably from the site near the orifice to the center of the submandibular gland. Based on this rare experience, it may be recommended to carefully check the running direction of Wharton’s duct or insert a bougie into Wharton’s duct during the implant to avoid direct implant to the duct. This case report calls attention to using LDR-BRT with Au-198 grains, and also, unexpectedly, the existence of a potential function of Wharton’s duct, which has the ability to generate forces and pressures sufficient to produce retrograde flow toward the submandibular gland. Our new clinical findings may shed additional light on the retrograde theory.


Liposarcomas of the spermatic cord are extremely rare, with less than 200 cases in the literature. We present a case of sclerosing mixed with myxoid liposarcoma of the left spermatic cord in a 55-year-old male patient, mimicking an inguinal hernia on pre-operative ultrasound. The patient underwent orchidectomy and is currently on follow-up surveillance with no signs of recurrence. Less than 200 cases of paratesticular liposarcomas have been reported so far in the literature -3. Most A 55-year-old male patient with a history of irritable bowel syndrome and generalized anxiety disorder was referred to the Urology clinic by his treating physician after he had noticed a “lump” in the area above his left testicle. On clinical examination, the “lump” was easily felt as a hard and painless nodule, highly suspicious of malignancy. USG revealed a normal left testicle Figure  and a soCT of the chest and abdomen did not detect any signs of metastatic disease. Following discussion with the patient, who was informed about the high possibility of the tumor to be malignant and consented to the proposed treatment, a left orchidectomy, along with excision of the left spermatic cord up to the level of the internal inguinal ring, was carried out through an inguinal incision Figure .A scrotal drain was inserted and left for 18 hours, and the patient was discharged the next day with no complications. Histology revealed a mixed variety of well-differentiated sclerosing liposarcoma , with myxoid liposarcoma (grade II - FNCLCC system) of the spermatic cord, with negative surgical margins. An oncology consultation was requested, and after a thorough discussion with the patient, it was decided not to undergo any adjuvant treatment and continue with active surveillance. The patient was followed up with regular clinic visits, and CT scans every three months, with no sign of local recurrence or metastatic disease at the 12th postoperative month.Clinical diagnosis of the tumors of the spermatic cord can be difficult. These tumors usually present as unilateral, hard, slow-growing masses of the inguinal canal or the scrotum, varying sizes between 1.5 and 30 cm ,10. ClinOn ultrasound, liposarcomas appear as hyperechoic and heterogeneous solid formations. There are no pathognomonic sonographic features to differentiate benign from malignant lesions, and additional imaging, usually with CT, is often required ,12. NoneRadical orchidectomy with en-block resection of the tumor, as in our case, is the treatment of choice . Wide loBecause of the high propensity of local recurrence after surgery , radiothLiposarcomas of the spermatic cord are rare and can be easily misdiagnosed for hernias or another groin pathology. Diagnosis is usually established following radical orchidectomy, which is the standard form of treatment; nonetheless, recurrences are common. The role of both radiotherapy and chemotherapy remains to be determined. Patients with liposarcomas of the spermatic cord require meticulous medical attention and close follow-up for the prevention of tumor relapse.


Renal leiomyosarcoma is a rare, aggressive tumor of the smooth muscles of the kidney. In our case, the tumor has special characteristics that made it highly challenging, as it involved major vessels and other adjacent vital structures. The rarity of the tumor type itself and the special challenging features we faced intraoperatively encouraged us to report the case including the management plan for R0 resection. Our patient is a forty-two years old previously healthy female, with vague nonspecific presenting complains, ended up with a major highly advanced surgery necessitating the need for vascular reconstruction of IVC. The surgery was performed by a multidisciplinary team of highly specialized surgeons in related fields. The surgery went well, and the outcome was promising. The patient was followed up for about four months later, with uneventful course. Renal leiomyosarcoma (LMS) is a rare and aggressive mesenchymal tumor that usually arises from the smooth muscle cells of the intrarenal blood vessels or the renal pelvis . Renal sLeiomyosarcoma has high tendency of local recurrence; hence, complete surgical excision is recommended . The typA margin-free resection may be curative, but the resection must involve the tumor en bloc with the affected segment of vena cava and locally involved organs. IVC resection often requires vascular reconstruction, which can be done with prosthetic graft .Literature review showed that reconstruction of IVC and RV is usually not necessary after the resection of IVC in retroperitoneal mass excision , but in n = 1). Surgical reconstruction of IVC was achieved in each case (100%). The favorable outcome of this case series demonstrates that IVC-associated tumor lesions can be approached if there is an appropriate expertise of the surgical team, a sufficient perioperative management, and an adequate financial background with a reasonable survival rate. The variable prognosis of the various tumor lesions depends on tumor entity, stage, resection status, and individual risk factors [A review of a case series reported 12 patients with 6 primary IVC-tumors (leiomyosarcoma) and 6 secondary IVC-tumors . The RO resection rate was 83%. The perioperative morbidity was 33%, whereas the hospital mortality was 8.3%  or invasion of IVC from adjacent leiomyosarcoma of other organ. Reconstruction of the IVC is not always necessary but is often required to facilitate venous drainage of the kidney for the tumors at the pararenal area of the IVC, or—as in our case—when one or both kidneys is at risk . So whenHistologically, leiomyosarcoma of kidney has to be differentiated from sarcomatoid renal cell carcinoma, leiomyoma, and angiomyolipoma. Immunohistochemically, the tumor cells showed diffuse and strong positivity for smooth muscle actin (SMA), desmin, and vimentin .Primary renal extraskeletal Ewing sarcoma is an another rare renal mesenchymal neoplasm, often metastatic at diagnosis, and with a poor outcome .It is worthy to mention that other rarer renal mesenchymal tumors that can occur in adults include angiosarcoma (less than 5% of angiosarcomas arises in the genitourinary tract), rhabdomyosarcoma, osteosarcoma , synovial sarcoma, Ewing sarcoma, angiomyolipoma, epithelioid angiomyolipoma, leiomyoma, hemangioma, lymphangioma, hemangioblastoma, juxtaglomerular cell tumor, and schwannoma.A 42-years-old female patient started to complain from intermittent attacks of dull aching RUQ and epigastric abdominal pain. Physical examination revealed mild RUQ tenderness, without palpable mass. Abdominal ultrasound revealed a heterogeneous lesion at upper pole of right kidney. A computerized tomography (CT) was performed and showed heterogeneous lesion at the upper pole of the right kidney that measures 7.5 × 7 cm, invading adjacent liver parenchyma without clear cleavage Figures –3.Abdominal MRI was done next and showed a heterogeneously enhanced soft tissue mass in the upper pole of the right kidney measuring 6.8∗9.5 cm with the involvement mainly of segment VII of the liver and a small part of segment VIII of the liver. The mass abutting IVC and severely narrowing it appearing slit-like. However, the lower segment of IVC wall looks involved by the mass.Ultrasound guided tru-cut biopsy was performed and showed histopathologic evidence of leiomyosarcoma with many mitotic figures.The case was discussed with oncologists, surgeons, radiologists, and pathologists in MDT meeting, and the decision was to go for surgery intending to achieve R0 resection of the tumor.Although evidence showed that renal artery embolization before radical nephrectomy for renal masses seems to be a useful tool in surgical management of a large mass and advanced disease, as it induces preoperative infarction and facilitates surgical intervention , this waSurgery was performed through Makuuchi incision. Intraoperatively, a large solid retroperitoneal mass was found, engulfing and invading IVC to the level of the left renal vein and extending upwards to the hepatic veins and compressing the right liver lobe (segment VII).Right nephrectomy, IVC segment resection , and complete excision of the tumor were performed.As there was no previous radiological evidence nor intraoperative grossly detectable prominent collateral venous drainage to IVC, IVC graft implantation was necessary.Reconstruction of the vena cava was performed by the implantation of a 22 mm Dacron graft, anastomosed obliquely to the IVC at the level of the left renal vein. Intraoperative blood loss was about 3 liters, surgery lasted for about seven hours, and there were no intraoperative complications .Postoperatively, the patient was kept for 48 hours in ICU for close observation then transferred to the general ward. In the following hours, she developed intra-abdominal bleeding with hematoma formation and bloody drain output, managed conservatively with blood products transfusion. She was discharged two weeks later in good general condition.A week after discharge, she complained of abdominal pain and distention, imaging revealed an accumulation of intraperitoneal fluid, and an ultrasound-guided drain was inserted, draining old blood with successful resolving of her symptoms.Histopathology report of the specimen showed a 9 cm leiomyosarcoma predominately involving the kidney  and pushes into the renal sinus and ipsilateral adrenal gland, with a negative ureteric margin. Separate vascular wall pieces with chronic inflammation and focal mural thrombosis were negative for tumor. The tumor seems to be limited by a thin fibrous capsule superiorly. By immunohistochemistry, the tumor cells are positive for SMA and desmin.A CT scan follow up at two months showed only postoperative changes, with no evidence of metastatic disease or local recurrence. Patient was followed up closely for four months after surgery, and her condition showed an uneventful course. She was sent to an oncological center and started on a radiotherapy course.Invasive leiomyosarcoma of the kidney represent a technical challenge. Careful preoperative investigation and an experienced dedicated team consisting of vascular, urologic, and—in our case—hepatobiliary surgeons are usually needed for a safe and successful R0 resection despite extensive tumor involvement.


Escherichia coli, Klebsiella, and Enterococcus species. Streptococcus gallolyticus subsp. pasteurianus, previously known as Streptococcus bovis biotype II/2, rarely causes endocarditis, meningitis, and septicemia, mainly in children. Biliary tract infections by Streptococcus gallolyticus subsp. pasteurianus are extremely rare. There have been no reports of cases in Japan. Here, we describe the first case in Japan of acute calculous cholecystitis caused by Streptococcus gallolyticus subsp. pasteurianus infection. A 63-year-old man was admitted to our hospital with epigastric pain and vomiting. He had moderate tenderness and a full sensation in the epigastrium. Abdominal imaging revealed multiple stones in the gallbladder. After admission, he had a high fever that did not improve with antibiotics. Percutaneous transhepatic gallbladder drainage was performed. The patient underwent open cholecystectomy. During surgery, several small stones in the gallbladder and an abscess were observed at the gallbladder base. Streptococcus gallolyticus subsp. pasteurianus was detected by bacterial culture of the bile juice. The gallstones were bilirubin calcium stones. The endoscopic study showed three adenomas in the colon, but the histopathological examination demonstrated no malignant cells. Although infection by this bacterium may not be rare, this is the first reported case in Japan of acute calculous cholecystitis caused by Streptococcus gallolyticus subsp. pasteurianus infection.Acute cholecystitis is an infectious disease of the gallbladder caused mainly by  Streptococcus gallolyticus subsp. pasteurianus (SGSP) belongs to the group D Streptococcus, formerly known as Streptococcus bovis type II/2 [S. bovis was originally classified into type I (mannitol-fermentation-positive), type II/1 (mannitol-fermentation-negative and β-glucuronidase-negative), and type II/2 (mannitol-fermentation-negative and β-glucuronidase-positive) [S. bovis-group bacteria based on genetic differences [S. bovis. Organisms from the S. bovis group have been associated with endocarditis, meningitis, sepsis, and colorectal cancers [ype II/2 . Based o cancers ,4,5,6. H cancers . ReportsA 63-year-old male with a history of herpes zoster at the age of 24 and acute gastroenteritis after the ingestion of raw egg at the age of 61 was admitted to our hospital for upper abdominal pain and vomiting. The day before admission, two hours after eating a pork cutlet for dinner, he felt a burning pain in the epigastrium. Less than 24 h after the start of his symptoms, the patient consulted our institution. He continued having epigastric pain and started vomiting after admission. Physical examination revealed marked tenderness in the epigastrium and right upper quadrant but no rebound tenderness. His vital signs were within the normal range except for a body temperature of 37.3 °C. The blood analysis showed a slight elevation of leukocytes, neutrophils, C-reactive protein, triglycerides, low-density lipoprotein cholesterol, and liver enzymes . No anemAbdominal ultrasonography and computed tomography (CT) findings showed a moderately fatty liver and multiple stones in an enlarged gallbladder with suspicion of stone impaction in the gallbladder neck A,B. HoweAfter admission, the patient received antibiotic therapy, including 1 g of ceftriaxone sodium hydrate (CTRX) twice daily. Percutaneous transhepatic gallbladder drainage (PTGBD) was performed on the same night. Sixty milliliters of turbid concentrated bile was aspirated from the PTGBD tube. The PTGBD is recommended by the Tokyo Guidelines 2018 in cases with complications or comorbidities . CholecyOn the 11th day of hospitalization, the patient underwent an open cholecystectomy through a right subcostal incision. More than 30 dark brown stones 2–3 mm in diameter were found in the gallbladder, and the gallbladder base had partially melted due to necrotizing cholecystitis, forming an abscess, which was coated with a large mesh A. In addS. bovis group are commonly associated with colorectal cancer [The histological specimens from the cholecystectomy showed erosions, fibrosis, and a moderate inflammatory cell infiltration with neutrophils, but no malignant findings B. Infrarl cancer . A colonAfter removing the drain on the 12th postoperative day, the patient was discharged on the 17th postoperative day.S.bovis II/2) infection in a 63-year-old male. Microorganisms of the S. bovis group are commensal intestinal bacteria that can infect humans and animals, including birds [S. bovis from cows to people [S. bovis group members are increasingly isolated as predominant species from fermented products in Europe, Asia, and Africa [In this report, we described a case of acute calculous cholecystitis caused by an SGSP  [S. bovis group, including SGSP, can live in bile. Lee et al. evaluated 37 cases of S. bovis bacteremia and found that 14 (38%) had biliary tract disease, indicating that biliary tract infection was the main source of bacteremia by S. bovis [S. bovis, 9 cases (23.7%) of biotype II  had a hepatobiliary source of infection [S. bovis and S. salivarius and found that S. bovis-biotype-II-associated bacteremia had a hepatobiliary origin in 50% of the patients [S. infantarius (biotype II/1), 20 (39%) cases of SGSP (biotype II/2), and 2 (4%) cases of S. gallolyticus subsp. gallolyticus (biotype I). They concluded that biotype II bacteria of the S. bovis group are predominant in biliary tract infection.Microorganisms that degrade gallic acid have been isolated from koalas’ intestines and named olyticus . This bas (SGSP) . The lats (SGSP) . TherefoS. bovis . Ruoff enfection . Similarpatients . In 2013Escherichia coli (25.0%), Enterococcus spp. (13.4%). Klebsiella spp. (11.1%), Pseudomonas spp. (11.1%), and coagulase-negative Staphylococcus (9.7%) [Acute cholecystitis is a complication of cholelithiasis in more than 90% of patients . Gallstos (9.7%) . Most ofs (9.7%) ,22. In tS. bovis group of bacteria has long been associated with colorectal cancer, although not all genospecies are closely related to this malignant complication. The meta-analysis reported by Boleij et al. reported four subspecies of S. gallolyticus and demonstrated a strong association of S. bovis biotype I  with the development of colorectal adenoma/cancer [The a/cancer . The assa/cancer . We perfAlthough infection by this bacterium may not be rare, this is the first reported case of acute calculous cholecystitis caused by SGSP infection in Japan. In addition, careful clinical follow-up is recommended due to a potential association between SGSP and the development of colorectal cancer.


Mesenteric cysts are uncommon benign abdominal tumors that may extend from the root of the mesenteric layers of the gastrointestinal tract into the retroperitoneum or the peritoneal cavity; they are usually asymptomatic and often represent an occasional finding. Definitive diagnosis is confirmed by the surgical intraoperative view and by histopathological examination. Surgical excision of the cyst is the treatment of choice. We present a case of a female patient who presented with back pain and a palpable abdominal mass. Due to large size of the mass and its contiguity with midline, patient underwent an hybrid combined surgical technique, with a first open phase followed by a laparoscopic excision. Complete surgical removal of the cyst was successfully performed without bowel resection, intraoperative spillage of cystic content and without morbidity. Histopathology confirmed diagnosis of simple mesenteric cyst. We strongly recommend a combined approach whenever a large intraperitoneal benign cystic lesion has been diagnosed.  Mesenteric cysts are very uncommon and literature usually deals with single case report or little consecutive series. An incidence of 1/140.000 in surgical departments and 1/20.000 in pediatric departments has been reported . MesenteA 52-year-old female was visited at our outpatient service on November 2021 for increasing back pain  and the presence of a huge palpable mass occupying the entire right abdomen; she complained of a decade history of recurrent abdominal pain and repeated ultrasound (US), revealing an increasing abdominal cystic-like bulk with fluid content (18 × 8.5 cm. at last US). Neither previous abdominal surgery nor significant familiarity was referred; canalization and food intake were described as regular. At physical examination, a large mass occupying right abdomen could be easily detected; basic laboratory panel and tumoral markers were within range, while body mass index and KPS were, respectively, 21.2 and 90%. Angio-computed tomography (CT) scan revealed a ‘Gross oval-shaped mass with clear fluid content (10–15 HU) and regular margins, measuring 15 × 10 cm. in maximum axial diameter and cranio-caudal extension of ~20 cm, surrounded by a thin hyperdense wall in the absence of intralesional enhancement on delayed phase’ . SeveralClinical and radiological finding of a gross endoperitoneal cystic lesion is uncommon: differential diagnosis with pancreatic pseudocyst and cystic tumors, peritoneal hydatid cyst, pelvic malignancies and aortic aneurysm is mandatory . US reprNone declared.None.


Cutaneous spread of solid malignancies is rare. We present the case of a 61-year-old woman with a history of endometrial adenocarcinoma, presenting two years after a total abdominal hysterectomy with bilateral salpingo-oophorectomy with a mass on her mons pubis. The mass was found to be an adenocarcinoma favoring a gynecological origin. With the exception of breast cancer, the cutaneous spread of solid malignancies is very rare. The general incidence of an internal malignancy spreading cutaneously has been reported anywhere from 0.7% to 10% . We are A 61-year-old woman with a known history of well-differentiated FIGO grade 1 endometrioid adenocarcinoma presented to the clinic with complaints of a lesion on her mons pubis. She stated that there had been swelling that came and went for a few months, but the current 13-cm lesion had been constant for a month. She had been treated by her primary care provider with oral amoxicillin-clavulanate 125 mg twice a day for a week prior to referral to general surgery. Two years prior to her presentation, she had an open total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH with BSO). A lymphadenectomy was not performed at that time due to her large body habitus, with a BMI of 39. Following her TAH with BSO, she received 25 treatments of adjuvant pelvic radiotherapy utilizing a four-field box technique to the pelvis and regional lymph nodes. The vaginal cuff received high-dose radiation to decrease the likelihood of recurrence.The new lesion was 13 cm in diameter, raised, reddish-purple, and indurated, with scant purulent drainage  was placed in the deep portions of the wound and brought out through the anterior abdominal fat. The fat and skin were reapproximated with 0 and 3-0 Vicryl sutures  respectively. The final pathology of the lesion was concordant with the core biopsy, and all margins were negative. Given the R0 status and routine surveillance, an oncology consultation did not recommend any additional therapy.After lung, breast, and colorectal cancer, endometrial carcinoma is the fourth most common cancer in women. It is also the most common gynecological cancer . Sohaib Morcellation, a minimally invasive technique that involves cutting the uterus into smaller pieces and removing it, has been widely stopped in the United States due to the risk of malignant seeding . Scant sRarely, similar cases to this have been reported. The Indian Journal of Dermatology reported a case of a 50-year-old woman with fungating lesions on her vulva due to spread from her cervix . El M’raDue to the early diagnosis, high clinical suspicion, and surgical resection of this patient's malignancy, the patient continues to do well and has shown no evidence of disease recurrence or complications on follow-up.Soft tissue masses can oftentimes present with vague symptoms and can be misleading on examination. A thorough history with a focus on oncologic aspects is invaluable to suspicious appearing lesions. This case highlights that metastatic deposits in soft tissue can occur during open abdominal oncologic procedures and should remain in the differential diagnosis despite statistical rarity.


Abdominal compartment syndrome is a rare emergency condition characterized by the development of organ dysfunction due to increased intra-abdominal pressure. Gynecologic conditions are an uncommon etiology of abdominal compartment syndrome. We report a case of a 35-year-old woman who presented with severe abdominal pain and vomiting. The patient had a history of long-standing gastroesophageal reflux disease. On physical examination, the abdomen was distended and tense, suggestive of acute abdomen. Computed tomography revealed a large abdominopelvic cystic lesion, arising from the ovary, causing a significant pressure effect on the abdominal viscera. The patient’s condition deteriorated and had an altered level of consciousness with hemodynamic instability. She was intubated and received inotropic support. Subsequently, a life-saving emergency surgical decompression was performed. The ovarian cyst was evacuated and yielded 10 liters of fluid. Histopathological examination confirmed the diagnosis of ovarian cystadenoma. The patient remained in the intensive care unit postoperatively and was discharged in a good condition after 14 days of hospitalization. The case emphasizes the importance of considering abdominal compartment syndrome in patients with a clinical picture of acute abdomen. Failure to recognize this condition can lead to multiorgan failure and death. Abdominal compartment syndrome refers to a new onset of single or multiple organ dysfunctions due to increased intra-abdominal pressure . It is cWe present the case of a 35-year-old woman who came to our emergency department with a complaint of severe abdominal pain and vomiting. The pain was sharp in nature and was rated 8 out of 10 in severity. It was diffuse but more severe in the lower part of the abdomen. She reported having this pain for the last two weeks, but it worsened progressively over the last two days. It was non-radiating, and she could not identify any aggravating or relieving factors. There was no change in bowel habits. The patient also complained of decreased appetite and generalized fatigue. The past medical history was remarkable for gastroesophageal reflux disease for which she was using daily omeprazole 40 mg. She did not undergo any previous surgeries. The family history was unremarkable.3, a normal platelet count, a creatinine level of 2.1 mg/dL, and normal liver enzymes.On physical examination, the patient appeared drowsy and had no signs of respiratory distress. The vital signs revealed tachycardia (110 beats per minute), tachypnea (22 breaths per minute), and hypotension (98/60 mmHg) with normal temperature and oxygen saturation. Abdominal examination revealed a distended and tense abdomen with generalized guarding and absent bowel sounds. Laboratory investigations revealed a hemoglobin level of 12.5 g/dL, a leukocyte count of 10,500 cells/mmDespite the resuscitation with intravenous fluid therapy, the patient developed a progressive worsening of her symptoms and had an altered level of consciousness. The patient was intubated with mechanical ventilation (maximum settings) and received inotropes to maintain blood pressure. The patient had decreased urine output. The clinical impression of the surgery team was suggestive of a perforated viscus. Subsequently, a computed tomography scan was performed to confirm the diagnosis and identify the possible site of perforation Figures -2. UnexpThe patient underwent an emergency laparotomy under general anesthesia. During exploration, a markedly large cyst was noted arising from the ovary. A total of 10 liters were evacuated from the cyst. The fluid was dark in color suggestive of prior hemorrhage. Bilateral salpingo-oophorectomy was performed. The patient tolerated the operation. The incisions were closed. The patient did not need to have another abdominal surgery. Cytological examination of the fluid revealed no evidence of malignancy. Histopathological examination confirmed the diagnosis of ovarian serous cystadenoma Figure . PostopeWe present a rare case of abdominal compartment syndrome due to a massively large ovarian cyst, presenting with acute abdominal pain. The prompt decompressive laparotomy resulted in the survival of the patient who was in critical condition with hemodynamic instability.Gynecologic conditions are considered an unusual etiology for the abdominal compartment syndrome with a limited number of reports in the literature ,5. For eThe definitive diagnosis of abdominal compartment syndrome requires measurement of intra-abdominal pressure. This pressure can be obtained indirectly by catheters in the stomach, bladder, or inferior vena cava. In the present case, we used an intravesical catheter, as per recommendations of guidelines . ManagemAbdominal compartment syndrome is associated with significant morbidity and mortality. A prospective study involving 33 patients with confirmed abdominal compartment syndrome who underwent surgical decompression revealed a mortality rate of 36% at 28 days and 55% at one year. The study revealed that patients with advanced age and those who required mechanical ventilation were at higher risk of mortality [The diagnosis of an ovarian cyst was readily made by computed tomography scan in the present case. This allowed for rapid life-saving emergency laparotomy. The differential diagnosis for intra-abdominal cystic lesions is limited. Such lesions include mesenteric, peritoneal, or gastrointestinal tract cysts . These cWe reported a case of giant ovarian cystadenoma resulting in abdominal compartment syndrome. The clinical symptoms and physical examination findings were inaccurate in predicting intra-abdominal compartment syndrome. The case highlights the importance of considering abdominal compartment syndrome in patients with a clinical picture of acute abdomen. Failure to recognize abdominal compartment syndrome can result in multisystem organ failure. Prompt surgical decompression is essential to reduce associated morbidity and mortality.


Literature regarding primary osteosarcoma of the uterus is confined to only a small number of case reportsCase: A 57-year-old female with a history of uterine fibroids presented to the emergency department with abdominal pain. Imaging was notable for an enlarged uterus with a 15 cm calcified fibroid extending along the posterior uterus. The patient underwent a laparotomy for total hysterectomy and bilateral salpingo-oophorectomy. Pathological evaluation of the specimen yielded mesenchymal proliferation with osteoid formation and tumor cells with densely eosinophilic cytoplasm resembling osteoblasts with a final diagnosis of primary uterine osteosarcoma. Multidisciplinary tumor board recommended against adjuvant treatment, given the lack of evidence for improved outcomes for early-stage uterine sarcomas. The patient was followed up with surveillance visits every-three months, entailing physical examination and computed tomography(CT) scans. Unfortunately, she had locoregional oligometastatic recurrence of her disease at 1-year follow up.Primary uterine osteosarcoma is an extremely rare and aggressive neoplasm with limited understanding regarding optimal treatment options. This ra. . Uterine. .In the published literature composed of small number of case reports, the mean age of diagnosis of primary uterine osteosarcoma was 64 years of age (range 41 to 82) . Table 12A 57-year-old female with a history of uterine fibroids presented to the emergency department with abdominal pain. Her past medical history was unremarkable. The patient reported intense infraumbilical abdominal pain, abdominal distention, urinary frequency, and incomplete bladder emptying. Her physical exam was notable for large uterus measuring approximately 18 weeks with fullness palpated in the posterior cul-de-sac. Upon admission, she was found to have acute kidney injury with creatinine of 2.04 mg/dL . Other laboratory findings including serum electrolytes and hepatic functions were within normal limits. CT of the abdomen and pelvis noted a 15 cm heterogeneous pelvic mass with peripheral coarse calcification, inseparable from the posterior uterine wall and bilateral mild hydroureteronephrosis secondary to mass effect on the distal ureters. A pelvic magnetic resonance imaging (MRI) was notable for an enlarged uterus measuring approximately 19 × 12 × 14 cm with a complex proteinaceous and calcified lesion measuring 15 × 10 × 12 cm extending between the posterior uterine fundus to the lower uterine segment . No maliFinal pathological evaluation of the hysterectomy specimen yielded a weight of 701 g and intermediate-grade primary uterine osteosarcoma, measuring 7 × 4 cm arising in a leiomyoma with degenerative changes. The specimen was noted to have dusty red brown, edematous tissue. Microscopically, low magnification showed mesenchymal proliferation with osteoid formation, with tumor cells having densely eosinophilic cytoplasm resembling osteoblasts. There was significant cytological atypia and the associated leiomyoma consisted of proliferated smooth muscle cells without cytological atypia. There was a moderately pleomorphic sarcomatous component, forming thin trabeculae of bone . A post-3Extraskeletal osteosarcoma, also known as soft tissue osteosarcoma, is a rare malignant neoplasm that produces osteoid, bone, or chondroid material but lacks bone or periosteum involvement. It is an extremely aggressive tumor with a poor prognosis. The exact etiology of ESOS is still unknown but several associated prognostic factors have been proposed, such as the history of trauma, local radiation therapy, and changes in soft tissue lesions and malignant fibrous tissue disease . This caIn summary, we present a 57-year-old female with a rare diagnosis of primary uterine osteosarcoma. Most notably in this case was the rapid and aggressive locoregional recurrence, approximately 1 year after initial diagnosis. This case adds to the growing but still sparce literature surrounding this rare tumor. There are limited data regarding systemic treatment options. Therefore, until more effective systemic treatment options are developed, surgical resection remains the primary treatment in the up-front and recurrence settings.Written informed consent and IRB review 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.Merima Ruhotina: Conceptualization, Writing – original draft. Joanna Kukla: Investigation, Writing – original draft. Annemieke Wilcox: Investigation, Writing – review & editing. Colleen Murphy: Investigation. Gulden Menderes: Conceptualization, Writing – review & editing, Supervision.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Germ cell tumors (GCT) are rare, frequently diagnosed in men aged 20–34 years old, and have a 95% 5-year relative survival rate. Metastasis from GCT has predictable spread to retroperitoneal lymph nodes. However, in cases of scrotal violation or tumor spillage, lymphatic drainage can be altered. Beyond the retroperitoneum, the most reported extra-nodal sites of metastases include the liver, lung, brain, and bone. Here we report a case of an unusual site of metastasis to the corpora cavernosa, as well as the complex reconstruction required to preserve sexual function. In August of 2020, he reported a lesion at the right penile base, which was presumed to be a recurrent GCT lesion. The patient was treated with carboplatin and etoposide in Guyana. The mass recurred in the same location, and was treated with bleomycin, etoposide, and cisplatin in 2021. However, due to severe nausea and vomiting, he was only able to tolerate two cycles.The patient presented later in 2021 to an outside emergency department in the United States with urinary retention and was found to have a 5.7 cm palpable mass at the base of the penis and an elevated alpha fetoprotein (AFP) of 59.4 ng/mL, wherein his care was transferred to our hospital. Biopsy-proven recurrence of non-seminomatous germ cell tumor (NSGCT) in the penis was treated with four cycles of paclitaxel, ifosfamide, and cisplatin therapy with adequate response in serum tumor markers (STMs) (AFP 871.9 → 5.8 ng/mL). One month following chemotherapy, the mass had regressed slightly in size (5.2 × 4.6 cm), but the AFP began to rise. At this time, the patient denied associated fever/chills with the mass but did endorse intermittent pain in the right groin area and difficulty voiding. The physical exam was significant for a hard, immobile, non-tender penile mass approximately 5 cm in diameter and a right inguinal scar with no palpable inguinal lymphadenopathy. The patient underwent an autologous stem cell transplant with an improvement of AFP (88.5 → 4 ng/mL). Restaging magnetic resonance imaging (MRI) demonstrated a predominantly cystic penile base lesion measuring 4.6× 4.8 cm containing multiple internal septations and no evidence of pelvic metastatic disease or lymphadenopathy . The patThe excision of the mass left a significant defect in the right corpora cavernosa, which was reconstructed with bovine pericardium allograft sewn to the proximal and distal cut edges . The fin3This case underscores an uncommon metastatic soft tissue lesion in a patient with NSGCT that was resistant to second-line chemotherapy and stem cell transplant requiring excision. Removing the mass resulted in a significant excision of the corpora cavernosa, which required complex reconstruction with IPP placement.There have been very few reports of GCT metastases to the soft tissues, namely of the upper arms, psoas muscle, and thighs, with variable nodal involvement and management.The high resectability of a penile mass was confounded by its complex invasion of the corpora and required coordinated surgical planning and operative collaboration between urologic oncology and reconstructive urology. The integration of both teams achieved adequate communication with the patient regarding oncologic outcomes and sexual function expectations, ensuring proper patient selection for graft incorporation and implantable devices given his immunocompromised status. Clearly, the oncologic benefit of a sufficient margin necessitated substitution of the corpora defect with pericardium allograft, which has been previously described in corporal reconstruction.Consistent, interval evaluation for the early detection of recurrence and metastasis is pivotal in patients with testicular cancer, and patient compliance should be considered during shared decision-making of treatment plans. Here we highlight the unique case of a residual penile mass lesion in a patient with NSGCT and the benefits of collaboration between urologic oncologists and reconstructive urologists.4Interval evaluation for evidence of recurrence and metastasis in patients with testicular cancer should include the soft tissue and may require a multidisciplinary treatment team.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors have no conflicts of interest to declare.


After total resection of nodes, the pathology report confirmed that all specimens were involved by the tumor. As part of an institutional study evaluating somatostatin receptor avidity of melanoma by 99mTc-HYNIC-TOC scan, she also underwent a whole-body octreotide scan, which surprisingly showed intense tracer uptake in the right cervical region, confining in SPECT/CT images to a mass at the C2 spinal level, adjacent to the right carotid bifurcation. Neck surgery with gamma probe after injection of another dose of 99mTc-HYNIC-TOC was performed successfully, and the pathology report was consistent with a carotid body tumor. To best our knowledge, our case is the first one in the literature, which reports an incidental paraganglioma with 99mTc-HYNIC-TOC scan which resected via radio-guided surgery, again with 99mTc-HYNIC-TOC tracer.A 53-year-old woman with a plantar malignant melanoma lesion was referred to our tertiary clinic for sentinel lymph node mapping. Lymphoscintigraphy with  They ca99mTc-HYNIC-TOC scan would be an appropriate alternative (99mTc-HYNIC-TOC scan.pathologic study) . Best reernative . We pres99mTc-Phytate detected sentinel lymph nodes in popliteal and inguinal regions. After resection of all nodes, a pathologic study confirmed the tumoral involvement of all nodes . Then, we performed a  Anterior and posterior whole-body images were obtained with GE healthcare Discovery NM/CT 670 DR dual-headed gamma cameras. The protocol included a 30 to 40minute acquisition (10 cm/min bed reposition) on a 1024×256 matrix with the Low Energy-High Resolution collimators and application of 140 keV peaks with a 15% window, four hours after tracer injection. Whole-body views revealed physiologic biodistribution of radiotracer throughout the body and a focus of intense tracer accumulation in the right side of the neck. Further localization showed a mass in the C2 level on the SPECT/CT images. The lesion was located close to the right common artery bifurcation .99mTc-HYNIC -TOC accumulation. These findings raised suspicion for a metastatic lymph node or a synchronous octreotide-avid neck tumor like a paraganglioma. The SPECT acquisition protocol includes a 30-minute stop and shot acquisition on a 64×64 matrix with the same collimators and peaks as mentioned previously. A Butterworth filter with that an order of 7.0 and a cutoff of 0.30 with attenuation and scatter correction were also used. A low dose CT scan was also performed simultaneously for attenuation correction and better localization of the mentioned lesion ( SPECT/CT scan from the neck four hours after tracer injection revealed a 1.5 cm round hypodense lesion with soft tissue density. It was located adjacent to the right common carotid artery bifurcation and showed intense d lesion .99mTc-HYNIC-TOC, two hours before the surgery. During the  Since lymphatic metastasis to the neck is considered distant metastasis in plantar melanoma, the inguinal and popliteal complete dissections were postponed, and we decided to examine neck mass pathology first. The patient received 10 mCi of intravenous .surgery, we used a gamma probe to precisely localize and remove the mass . Patholo99mTc-HYNIC -TOC scan. The importance of finding simultaneous melanoma and paraganglioma in a relatively middle- aged person raises suspicion for syndromic diseases; Wadt et al. proposed that mutations in BRCA1-associated protein-1 may make the patient susceptible to melanoma, para-ganglioma, and breast cancer. Diagnosis of these patterns, which are usually familial, is vital for We present an incidental paraganglioma in a patient suffering from melanoma who underwent an experimental 177Lu-DOTA-TATE, are developing methods that are used widely in the treatment of some somatostatin-expressing tumors, namely metastatic neuroendocrine tumors. Still, it warrants further investigation to be applied for metastatic octreotide-avid melanomas.future follow-ups of such patients . Additio99mTc-HYNIC-TOC scan, which was also resected via radio-guided surgery after injection of this tracer. The 99mTc-HYNIC-TOC scan could be a promising agent for detecting such lesions and associated metastases and radio-guided strategies to decrease surgical interventions and related morbidities. In conclusion, our case is the first to describe an incidental finding of a paraganglioma by