Hypertrophic olivary degeneration (HOD) is a rare type of neuronal degeneration seen after interruption of the dentato-rubro-olivary tract also known as the Guillain-Mollaret triangle (GMT). It is associated with hypertrophic changes of the inferior olive. Commonly reported in adults, this lesion presents with ataxia and oculopalatal myoclonus. Up to date, few cases have been published in the literature that refer to pediatric cases. This diagnosis is particularly important in the setting of brainstem tumor surgery as it should not be confused for tumor recurrence or metastasis, in turn avoiding unwarranted surgical intervention. We present the case of a 15-year-old male who underwent resection of a left superior cerebellar peduncle (SCP) pilocytic astrocytoma. On follow-up, magnetic resonance imaging (MRI) demonstrated evidence of mild residual tumor as well as progressive engorgement of the inferior olivary nucleus (ION). The patient was clinically asymptomatic and has since been observed expectantly without any issues. We were able to pinpoint the most probable location of injury in our patient’s GMT. HOD remains a somewhat obscure entity. Its presentation may be early and not accompanied by significant neurologic findings, in contrast to what has been previously reported. Particularly in neoplastic cases, it may represent a diagnostic challenge and could be easily confused for tumor recurrence. A multidisciplinary approach for this entity, as with other pathologies, is of particular importance. Its proper recognition will result in the best outcomes for the patient. The Guillain-Mollaret triangle (GMT), also known as the dentato-rubro-olivary tract, is a synaptic circuit between the ipsilateral red nucleus (RN), the ipsilateral inferior olivary nucleus (ION), and the contralateral dentate nucleus (DN) . As partWe present the case of a 15-year-old male who presented with a left SCP pilocytic astrocytoma and underwent resection. On subsequent post-operative imaging, he presented with findings consistent with HOD, but he did not have all of the associated clinical findings.A 15-year-old male without a previous history of systemic illness was evaluated for progressive headaches and discoordination. Physical examination showed left-sided dysmetria, left-sided fast-phase nystagmus, and ataxia. Brain MRI revealed the presence of a left cerebellar peduncle contrast-enhancing lesion with an associated cyst, highly suggestive of a pilocytic astrocytoma Figure . He undePrior to tumor resection, no ION hypertrophy was observed Figure . On subsHOD is an unusual type of neuronal degeneration in that it results in neuronal hypertrophy, as opposed to atrophy, which is the most common type of neuronal degeneration seen in other synaptic circuits ,11,12. MWe believe the injury to the GMT that caused HOD in our patient was related to the disruption of the CTT during tumor resection Figure . RetrospFamiliarity with HOD and the ability to recognize HOD on MR imaging is important, particularly when the surgeon is performing brainstem surgery, given that disruption of the GMT at different areas can result in HOD. The surgeon should not confuse HOD for tumor, as a misdiagnosis may result in unwarranted surgery A multidisciplinary approach, including a conversation with neuroradiology colleagues may provide some additional insight whenever the diagnosis is unclear. If the patient is asymptomatic, observation could be a reasonable option given the behavior of the treated pathology.HOD may occur early after brainstem surgery and may not be accompanied by significant neurologic findings. In neoplastic cases, HOD may represent a diagnostic challenge since it could be easily confused for tumor recurrence. A multidisciplinary should result in the best outcomes for the patient.


Retinal artery occlusion (RAO) occurs in the elderly population above the age of 60 years due to carotid atherosclerosis as a consequence of long-standing hypertension, diabetes mellitus, smoking, and hyperlipidemia. It can also develop due to paradoxical emboli from patent foramen ovale (PFO), which can happen in a relatively younger population. Early diagnosis mandates prompt management; otherwise, it may lead to vision loss. We present a rare case of branch RAO (BRAO) in a healthy young gentleman with concurrent PFO and large atrial septal aneurysm, which has not been reported much in the literature.Our patient presented with sudden left-sided blurriness of vision, which was diagnosed as BRAO on ophthalmoscope examination. Multidisciplinary teams were involved in reaching the underlying etiology of such a presentation in a young, healthy person. Urgent head CT with cerebral angiography and head MRI was unremarkable for any acute insult. The autoimmune screen and thrombophilia workup were unremarkable. After thorough investigations, a small PFO with a large atrial septal aneurysm was found to be correlating with his clinical picture.We aim to highlight the importance of timely diagnosis and further management in such clinical scenarios, where permanent vision loss can compromise someone’s quality of life. Patent foramen ovale (PFO) is a physiological opening present in fetal life between left and right atria and is pathological when it persists in adult life. It is present in 20-30% of the population and is found generally in 27% of the patients who have previously undergone routine autopsy . HoweverCentral retinal artery occlusion (CRAO) is uncommon in young, healthy patients; however, if presents, it is mostly attributed to underlying PFO in 40% of the cases, leading to cryptogenic stroke in patients younger than 45-55 years of age ,4. It ocWe report the case of a patient who developed an acute episode of left eye vision dimness with blurring and was diagnosed as a case of BRAO due to PFO and atrial aneurysm.A 31-year-old young man without any prior medical condition presented acutely with left-sided decreased and blurred vision from two days. His symptoms started while he was watching a football match on TV. The patient described his visual disturbance similar to the appearance of a static TV with black and white dots. It was painless and occurred in the absence of trauma. There was no associated headache, nausea, vomiting, or any other neurological deficit. He was conscious oriented and was anxious about this episode. There was no history of previous such attacks. Further history of the systemic review was unremarkable.Urgent ophthalmologist review and examination of both eyes revealed left macular edema, engorged vessels, bulging optic disc, and papillophlebitis consistent with occlusion of the superior-nasal branch of the retinal artery or BRAO.The neurologist was consulted, and an urgent CT scan Figure  and MRI Upper and lower extremities venous Doppler ultrasound studies ruled out deep venous thrombosis. Echocardiography revealed a large atrial septal aneurysm (ASA) and a small PFO with shunting, accentuated on the Valsalva maneuver, as shown in Figure Based on thorough investigations, it was concluded that BRAO has resulted from cardioembolic phenomena due to concurrent PFO and ASA. The cardiologist service was consulted, and the patient was commenced on aspirin. His vision started to improve during his hospital stay, and there were no further complications. He was discharged with outpatient follow-ups with an interventional cardiologist for possible corrective surgery of PFO. He was followed for one year. During his follow-up, he traveled abroad for a second opinion and was started on warfarin for a short duration. After he arrived back, he was seen by the cardiologist and ophthalmologists in the outpatient department. There was no indication to keep the patient on warfarin; therefore, it was stopped and aspirin was continued. He was having a large ASA and did not fit the criteria of corrective surgery for PFO. Aspirin was prescribed for lifelong with regular follow-up with the cardiologist as an outpatient, and the patient remained stable.CRAO is rare in patients younger than 25 years, but if present, it is mostly attributed to underlying systemic diseases such as coagulopathies, collagen vascular diseases, or autoimmune diseases. In the elderly, the underlying etiology is mostly atheromatous plaque in the carotid arteries or valvular heart disease. Cardioembolic phenomena can occur in both young and elderly populations ,2,4. PFOUpon the literature review, Nakagawa et al. presented a case of bilateral CRAO in a patient with PFO and deep venous thrombosis . ClifforHere we share our experience of cardioembolic phenomena associated with ASA and PFO in a healthy young man leading to BRAO. Our patient’s history was remarkable for engagement in swimming on that day. He later relaxed to watch a football match on TV and had acute onset of blurring of vision. He was diagnosed as a case of BRAO on an ophthalmoscope examination. An exertional activity might be the reason for his clinical presentation causing paradoxical embolism and BRAO. PFO is usually asymptomatic; it should be considered among the possible causes of BRAO/CRAO . Only a We aim to highlight the association and management of BRAO in a healthy young man due to concurrent PFO and ASA, which is not much reported in the literature. We have to exclude other possible differential diagnoses as well before considering PFO as a cause. Echocardiography, specifically trans-esophageal, is the modality of choice to diagnose. Early diagnosis and close follow-up are warranted along with the involvement of different departments such as neurology, cardiology, and ophthalmology to prevent a grave complication of loss of vision.


Liver abscesses have a low incidence and can be caused by multiple etiologies. We present an interesting case of a 74-year-old woman who presented with abdominal pain and leukocytosis. Imaging revealed a foreign body in the antrum of the stomach extending to an area of hypodensity in the liver. She was taken for an exploratory laparotomy and was found to have a gastric perforation due to a sewing needle. The needle had embedded in the liver causing the formation of an abscess. The patient was successfully treated with surgical management and a course of antibiotics. Liver abscesses have a relatively low incidence, estimated at 2.3/100,000 per year, and can be caused by multiple etiologies including complications of surgery (such as those of the biliary tract and liver), penetrating trauma, foreign bodies, parasites, and more [A 74-year-old Caucasian woman with hypertension, hyperlipidemia, diabetes mellitus type 2, diverticulosis, and a prior appendectomy presented to the ED with several weeks of moderate to severe, intermittent, RUQ and epigastric abdominal pain. She described the pain as a "stabbing" sensation, non-radiating, and acutely worsening in severity and frequency over the past week. Her physical examination was significant for epigastric and RUQ tenderness on palpation without rigidity, rebound, or guarding. She denied fever, chills, myalgias, nausea, and vomiting. Her temperature was 97.8°F and she remained afebrile throughout her hospital stay. Her initial laboratory data is depicted in Table The patient was started on broad-spectrum empiric antibiotics and was taken for urgent surgery. She underwent an exploratory laparotomy, removal of the foreign body, which was found to be a sewing needle, surgical drainage of the abscess, and repair of the gastric perforation. Streptococcus viridans was later isolated in the fluid cultures obtained during surgical drainage. Post-operatively, her abdominal pain had significantly improved and her leukocytosis resolved. She tolerated the procedure well, clinically improved, and was discharged home with a 14-day course of antibiotics.Pyogenic liver abscesses are a relatively uncommon condition with a significant mortality rate of 2%-12% . SeedingThe clinical presentation of pyogenic liver abscesses is non-specific; hence, a high index of suspicion is necessary for prompt diagnosis . In a 10CT or ultrasound is the preferred imaging modalities to diagnose hepatic abscesses. Usually, they appear as non-enhancing, hypodense lesions with an enhancing ring on CT and as hypo- or hyperechoic lesions with internal debris on ultrasound . Treatment involves abscess drainage, foreign body extraction (if present), and targeted antibiotic therapy. With the evolution and advances in interventional radiology, the preferred method of drainage is via the percutaneous route. Criteria for percutaneous drainage include abscess size >5 cm, persistent fevers despite 48-72 hours of appropriate medical therapy, or concerning clinical or imaging features that may suggest impending perforation . Other oTo conclude, clinicians must have a high index of suspicion to diagnose and treat hepatic abscesses effectively. RUQ pain, fever, leukocytosis with or without abnormal liver enzymes should alert clinicians to the possibility of a liver abscess. Abdominal ultrasound or CT imaging is the preferred modalities for diagnosis. Percutaneous drainage, in conjunction with targeted antibiotic therapy, is the mainstay of treatment. Although outcomes have improved over the years, delayed diagnosis or treatment can be detrimental to the patient as this condition is known to have high mortality rates if inadequately treated.


Bicycle accidents are a significant cause of traumatic morbidity in the paediatric population. The handlebar injuries are usually isolated and remain a major source of bicycle related morbidity. We present a case of severe liver laceration with left hepatic duct transection caused by handlebar trauma in a 13-year-old boy.An otherwise healthy 13-year-old Caucasian male patient was rushed to the hospital following a blunt abdominal trauma from a bicycle handlebar. An ultrasound revealed extensive free intraperitoneal fluid with accompanying features of hemodynamic instability. Operative findings included massive haemoperitoneum, a deep laceration almost separating left and right liver lobes, and a near-complete interruption of the left hepatic duct. Interestingly, the vascular anatomy of the left liver lobe was preserved. After haemostasis was established a duct-to-duct anastomosis of the ruptured left hepatic duct was performed. A T-tube biliary drainage was inserted, and intraoperative cholangiography showed no extraluminal spillage of contrast. During the recovery phase, cholangiography was performed several times revealing leakage from left hepatic duct. The leakage was managed conservatively and finally stopped.Management of blunt hepatic injuries has remarkably changed from mandatory operation to mostly nonoperative interventions with selective operative management. Hemodynamic instability remains the main reason for exploratory laparotomy. Near-isolated laceration of main hepatic ducts is an extremely rare finding, and immediate reconstruction is the best option if an experienced surgeon is available.Due to limited evidence, we recommend consultation with an experienced HPB surgeon on a case-by-case basis for every paediatric biliary injury. BesidesIn the present report, we describe the clinical presentation, management and outcome of HBI causing severe liver laceration with haemorrhage and left hepatic duct injury in a young boy. The case report is reported in line with the SCARE criteria .2A 13-year-old Caucasian male patient presented to our surgical emergency department with complaints of severe diffuse abdominal pain and distension. The patient was brought to the hospital by helicopter about 2 h after sustaining a direct blow to the upper right quadrant of his abdomen from a bicycle handlebar. At the scene of the accident, all resuscitation measures were given in line with the recommendations of ATLS.The patient was conscious and well-oriented. During the helicopter transportation, he was noted to be pale with blood pressure around 90/60 mmHg, a heart rate of 110–120 beats/min and haemoglobin 85 g/L. Despite a slightly higher blood pressure (115/80 mmHg) following fluid resuscitation upon admission, he remained pale and tachycardic (120 beats/min). Abdominal examination was remarkable for significant distension and diffuse tenderness, but no visible external injuries on the abdominal wall.Chest x-ray showed no signs for rib injury, pneumothorax or any other expected pathology. FAST scan was performed, showing diffuse echogenic free fluid intraperitoneally with the most probable cause being hemoperitoneum. There were some radiologic signs of contusion of the upper part of left liver lobe, but no signs of splenic injury. Due to the extensive intraperitoneal free fluid seen on FAST and the persisting features of haemodynamic instability , a decision for immediate exploratory laparotomy and omitting abdominal CT was made. Performing CT imaging would have postponed the operation and might have influenced the outcome.An emergency upper median laparotomy was performed under general anaesthesia to determine the exact nature of the abdominal injury. Due to the hematoperitoneum, our operative procedure was in conformity with damage control surgery and tamponade of all four abdominal quadrants was performed.During the exploration, a deep laceration almost separating left and right liver lobes was found with evident bleeding from the laceration . Firstly, with the intention to stop the bleeding, the Pringle manoeuvre was performed, and venous bleeding was stopped with several sutures. Thereafter, a meticulous examination of the laceration was done, and an injury of the left hepatic duct was observed. The left hepatic duct was interrupted almost completely, with less than 10% of the circumference preserved. However, the portal and arterial vessels for the left lobe were mainly preserved. A duct-to-duct anastomosis of the injured left hepatic duct was performed with 6.0 PDS intermittent sutures. Subsequently, cholecystectomy, insertion of biliary T-tube and intraoperative cholangiography were performed . Intraop12, leukocytes 10.4 × 109 and CRP below 5 mg/L. Sedation and vasoactive support were discontinued within the first postoperative day.After operation he was admitted to the paediatric ICU under analgosedation and endotracheal intubation. Immediate post-op laboratory data were as follows: AST 7.02 μkat/L, ALT 7.81 μkat/L, total bilirubin 22 μmol/L, direct bilirubin 10 μmol/L, haemoglobin 107 g/L, erythrocytes 3.76 × 10On the second postoperative day, an US scan was performed, showing minimal free fluid in the peritoneal cavity under the liver. The bile ducts diameters were within normal range.On the fifth postoperative day, an US scan was repeated, revealing biliary ducts of normal diameter; however, there was an intrahepatic fluid collection described at the point of liver laceration measuring approximately 6 × 2 × 3 cm in size. Exact determination of whether the fluid was hematoma, biliary fluid or other was impossible on US, so we decided to perform cholangiography imaging through the T-tube to exclude biliary leakage. The cholangiography revealed evident leakage from the left hepatic duct, with the size and location of the extravasated contrast corresponding to the previously described fluid collection on US. Furthermore, a small leakage of contrast was seen in the right biliary tree with small collection of contrast with diameter around 5 mm. The common hepatic duct and common bile duct were otherwise intact and draining of contrast media to the duodenum was observed . A decisOn the eighteenth postoperative day and 13 days after the first cholangiography, a follow-up cholangiography was performed, which showed no signs of leakage from both the left and right biliary trees .Fig. 3ThIn response to the cessation of leakage, we decided to commence intermittent closure of the T-tube. A series of follow-up abdominal US scans were performed, and the size of the intrahepatic collection was initially noted to be increasing, with the largest diameter being 8.6 × 7.1 × 7.6 cm (approximately 300 mL) on the twenty-first postoperative day - 3 days after initiation of the intermittent T-tube closing. Afterwards, the intrahepatic fluid collection began to decrease in size and finally stabilized.The last US follow-up during hospital stay was performed on the 38th postoperative day and showed a collection measuring 10.6 × 7.4 × 5.9 cm (220–250 ml), indicating that the size of the collection did not change and there were no signs of biliary obstruction. The patient was asymptomatic and feeling well, and we noted a decline of the previously elevated liver enzymes (ALT and ALT) . Consequ3The first follow-up in the outpatient clinic was on the 46th postoperative day. The patient was still asymptomatic and feeling well. A check abdominal US scan showed no significant dynamics of the intrahepatic fluid collection , and no signs of biliary obstruction. We therefore, decided to remove the T-tube. Due to the normal laboratory results and absence of subjective complaints from the patient, we did not deem it necessary to perform percutaneous drainage of the collection.Almost one year after the operation, the size of the collection is decreasing, measuring 9.7 × 8.1 × 2.7 cm (approximately 80 mL) and the patient remains asymptomatic.4The bicycle handlebar injury is somewhat unique regarding its location and the need for intervention, compared to other bicycle injuries . An analBest practice guidelines recommend that the vast majority of blunt liver trauma in children should be managed conservatively ,11. NeveIn the present report, we describe a case of HBI causing severe liver laceration with haemorrhage and left hepatic duct injury.Treatment of liver injuries in children can represent an arduous challenge to the paediatric surgeon. Control of haemorrhage is critical but can be difficult to achieve. Several measures to achieve surgical haemostasis have been described in the literature .Management of injury to the intrahepatic biliary tract should follow the control of associated haemorrhage . In adulTraditionally, laparotomy and hepaticojejunostomy has been the gold standard for treatment of biliary injuries ,20. Neve5Due to limited evidence, we recommend consultation with an experienced HPB surgeon on a case-by-case basis for every paediatric biliary injury.The authors declare no conflict of interests with regard to this case report.There is no relevant external funding in respect of this case report.Our institution does not require ethical approval for publishing a case report. Written informed consent was obtained from the parents of the young patient for publication of this case report and accompanying images.Written informed consent was obtained from the patient’s parents for publication of this article and any accompanying images.Grosek J participated in the operation and drafted the manuscript; Čebron Ž collected the data and was involved in editing the manuscript; Janež J participated in the operation and was involved in editing the manuscript; Tomažič A operated the patient and contributed to critical revision. All authors issued final approval for the version to be submitted.NA.Jan Grosek, MD, PhD.Not commissioned, externally peer-reviewed.


Adrenal lymphangioma is a very rare benign lesion worldwide and remains challenging for early diagnosis, especially when the patient has some complicated clinical disease. This is an unusual case of a 68-year-old man who was admitted to our hospital with a history of pancreatic tumor. Computed tomography (CT) images and subsequent magnetic resonance imaging (MRI) revealed a mass located in the left adrenal gland, presenting a similar enhancement pattern of the pancreatic tumor, and according to the imaging features, the patient was suspected to have an adrenal metastatic tumor originating from the pancreatic tumor. The patient underwent a surgical resection of the pancreatic tumor and the left adrenal gland. The pathologic diagnosis proved to be lymphangioma deriving from the left adrenal gland. This is the first report presenting an atypical adrenal lymphangioma mimicking a metastatic tumor of pancreatic origin, which might be suggestive in the diagnosis of adrenal lesions and the subsequent clinical treatment, especially when patient has a particular medical history. As we know, imaging examination is helpful for accurate preoperative diagnosis; however, the diagnosis of malignant tumor solely based on imaging procedures should be made cautiously by radiologists. Adrenal lymphangioma is a very rare benign lesion generally deriving from the lymphatic endothelial cells . Most lyA 68-year-old gentleman was referred to our hospital with a medical history of pancreatic tumor associated with a left adrenal mass for more than 4 months. Before hospital admission, this patient underwent an MRI scan and an ultrasound-guided biopsy in another hospital. The MRI finding indicated a pancreatic tumor and a left adrenal mass, which was considered to be of a pancreatic origin. The pancreatic biopsy revealed a small number of adenocarcinoma cells. The patient was referred to our hospital for further treatment. Before this hospitalization, he had two cycles of chemotherapy in our hospital to treat the pancreatic tumor and the adrenal mass. At the same time, several CT scans were performed, and the CT findings also supported the left adrenal mass as a metastatic tumor.^9/L (100–300 × 10^9/L) and a slightly elevated white blood cell count level of 10.14 × 10^9/L (3.5–9.5 × 10^9/L). Liver function test revealed a slightly decreased total bilirubin level of 4.6 umol/L (5.0–28.0 umol/L) and a decreased albumin level of 37.9 g/L (40–55 g/L), along with a decreased uric acid level of 152 umol/L (240–490 umol/L). Plasma pancreatic enzyme revealed a significantly elevated lipase level of 4,699 IU/L (13–60 IU/L) and an elevated amylase level of 341 IU/L (35–135 IU/L); plasma epinephrine and norepinephrine were both within the normal range, and plasma aldosterone and renin activity were not tested. To evaluate the pancreatic tumor and the left adrenal mass, an abdominal CT scan was performed, which showed a slightly low-density  and ill-defined mass in the body of the pancreas  level of 59.8 U/ml (<22 U/ml) and an elevated carbohydrate serum antigen 125 (CA125) level of 90.2 U/ml (<35 U/ml). Additional blood laboratory tests revealed an increased platelet count level of 538 × 10Both CT and MRI features supported the malignant suspicion of the adrenal lesion. The surgical resection of the left adrenal gland followed by histological examination was elected for the final diagnosis. Hence, the upper midline laparotomy was performed, the body and tail of pancreas together with the left adrenal gland and spleen were removed, and the tumor of the adrenal was measured at 4 × 3.5 cm during surgery. The postoperative course was uneventful and the patient was discharged on the 25th postoperative day. The patient was followed up by CT scan 3 months after discharge and was asymptomatic, no recurrence sign of pancreatic and adrenal lesions was found.The pathologic diagnosis of pancreatic specimens confirmed pancreatic ductal adenocarcinoma. The specimen from the adrenal gland showed a solid mass with an irregular appearance, measuring 3 × 2 × 0.4 cm, and the definitive diagnosis confirmed a lymphangioma originating from the left adrenal gland Figure 3This is a rare case of lymphangioma originating from the left adrenal gland, with a specific medical background of pancreatic cancer. Till now, this is the first case report presenting such lesion accompanying this type of medical history, and this adrenal lesion was primarily considered as a metastatic pancreatic tumor, with the malignant indicative imaging features on CT and MRI. Fortunately, the patient underwent a successful pancreatectomy and adrenalectomy, and the follow-up CT scan revealed no signs of recurrence.Although these entities of lymphangiomas are commonly thought of as benign lesions mostly located in the neck, axilla, and mediastinum , 3, the Most adrenal lymphangiomas are asymptomatic lesions without specific medical backgrounds. They are usually found incidentally and patients may present with some nonspecific clinical manifestations such as abdominal and back pain, because of the tumor size or the position of the lesion , 7. In tImaging modalities are valuable diagnostic assets for lymphangiomas and may sometimes help characterize these lesions , 9. AlthDifferential diagnosis of the adrenal lymphangiomas reported in this literature mainly refers to metastatic tumors, primary adrenal tumors, angiosarcomas, multi-cystic mesotheliomas, or adrenal cysts . PhaeochFew studies reported adrenal lymphangiomas with clinical manifestation, and most lesions were found incidentally during a physical examination . In our Histopathology, along with immunohistochemistry, makes the final diagnosis and is regarded as the reference standard . In the In the previous series cases of adrenal lymphangiomas, no relevant case with a specific history of pancreatic cancer has been reported. In this case, it was challenging to correctly diagnose a benign lesion of adrenal and may mislead the radiologists given the medical history of pancreatic tumor, along with these atypical imaging findings. In other words, although there are no specific radiological signs yet, we should be aware that adrenal lymphangiomas tend to be cystic-like lesions on images generally , 10, 16,In conclusion, this is the first case report presenting an adrenal lymphangioma with a medical background of pancreatic cancer. On the one hand, we hope this type of lesions can be reminded and suggestive in the clinical differential diagnosis; on the other hand, because pathognomonic presentations of adrenal lymphangioma in imaging tools are still lacking, a preoperative diagnosis of malignant tumor should be made cautiously based on imaging modalities, and more relevant evidence and case reports are needed to help us further investigate this disease.The original contributions presented in the study are included in the article/supplementary material; further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the West China Hospital of Sichuan University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.DC, SW, and XL acquired the data. BT, DC, and ML analyzed and interpreted the data. SW and XL conductued the radiological analysis of MRI and CT images, and prepared the manuscript. YH and BS revised the manuscript. 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.


Adrenocortical cancer is a rare tumor with high malignant potential, often resulting in recurrence and poor survival even after complete excision. Thus, adjuvant therapy needs to be considered despite its unestablished effectiveness.We report a 70‐year‐old man presented with a huge adrenal mass extending into the right liver lobe. He underwent right adrenalectomy concurrent with right nephrectomy and right hemihepatectomy for curative intent. He was given a very low‐dose mitotane (0.5 g/day) adjuvant therapy to be alive without any signs of recurrence for 90 months after surgery without unwanted toxicity.A long‐term and very low dose of adjuvant mitotane could be an option for a patient with complete surgical resection in an expectation to prevent microscopic residual disease from recurrence. ACCadrenocortical cancerCTcomputed tomographyENSATEuropean Network for the Study of Adrenal TumorsMRImagnetic resonance imagingPETpositron emission tomographyRFSrecurrence‐free survivalTDMtherapeutic drug monitoringACC is a rare tumor with high malignant potential and a poor prognosis even after successful surgery. A long‐term and very low dose (i.e. 0.5 g/day) of adjuvant mitotane could be an option for a patient with complete surgical resection to prevent microscopic residual disease from recurrence without toxicity.ACC is a rare tumor with high malignant potential. The patient of ACC often experience recurrence and difficulty to achieve long‐term survival even after successful surgery. Thus, adjuvant therapy needs to be considered for patients without macroscopic residual tumor after surgery but who may potentially have the likelihood of recurrence. Here, we report a case of long‐term survivor of local advanced ACC treated with a very low‐dose mitotane after complete excision.A 70‐year‐old man presented with right back pain and appetite loss to our hospital. Abdominal CT revealed a huge adrenal mass with a maximum diameter of 15 cm which extended to the right liver lobe Fig. . The tumACC is a rare tumor with high malignant potential. The patient of an advanced stage of ACC often experience recurrence and difficulty to achieve long‐term survival even after complete excision.et al.,Thus, even in nonmetastatic disease, adjuvant treatment is recommended due to high recurrence rate.As the effective therapeutic range of mitotane is narrow because of its toxicity,In conclusion, ACC is a rare tumor with high malignant potential and a grim prognosis often resulting in recurrence and poor survival even after successful surgery. A long‐term and very low dose of adjuvant mitotane (i.e. 0.5 g/day) could be an option for a patient with high risk of recurrence despite complete surgical resection, when plasma concentration monitoring is unavailable, in an expectation to prevent microscopic residual disease from recurrence without unwanted toxicity.The authors declare no conflict of interest.


We report the rare case of a 2.5 cm in size mass diagnostic for residual thymus associated with venous vascular malformation  in a 58 years old man. Diagnosis was obtained only after surgical removal that was complicated by a sudden massive bleeding  requiring emergency conversion to median sternotomy. Difficulty in preoperative diagnosis, rarity of histologic pattern, and surgical challenges make this case very interesting for surgeons, pathologists and radiologist. Our message, dealing with mediastinal masses, is: (a) differential diagnosis between the more frequent solid antero-superior mediastinal tumors and vascular malformation should be always considered (b) preoperative angiography should always be performed in case of uncertain diagnosis (c) coil embolization should always be considered to reduce potentially fatal bleeding (d) histologic differentiation with other thymic neoplasms must be always considered. Mediastinum is a space where several vascular or solid pathologic masses can arise. Vascular ones are rare and, according to first classification by Mulliken and Glowacki , have beA 58 years-old man presented at our emergency room with fever, cough and left thoracic pain. His past medical history was unremarkable. Blood test showed WBC and C-reactive protein elevation. He had started antibiotics therapy and, given the persistence of symptoms, CT scan was performed showing lower left pneumonia. Incidentally, a 2.5 cm mass was found in the upper anterior mediastinum, with positive contrast enhancement and a 5 mm vessel arising from left brachio-cephalic vein , 2. BecaIntra-operative emergency required significant blood transfusions and precautionary transfer in intensive care for 24 h. The patient eventually made a complete recovery. We only recorded transitory dysphonia as in case of laryngeal nerve paralysis. At specimen analysis, the cut surface seemed to have some fresh blood and the soft tissue was taupe with multifocal thrombosis in various stages of organization up to phlebolithes. Histopathologically, it was diagnosed a residual thymic tissue surrounded by lipomatous hyperplasia with venous malformation consisting essentially of a large number of dilated vessels with a single layer of endothelial cells with no signs of atypia or mitosis. Most of the channels contained red blood cells in the cavity. Margins were free. Definitive histology was a 7 cm fatty specimen enclosing a 2.5 cm in size mass diagnostic for residual thymus associated with venous vascular malformation .We experienced a similar case 10 years ago . A 29-yeIn our opinion, there are two challenges when dealing with vascular mediastinal mass. The first one is diagnostic and the second strictly related to surgical technique. Traditional non invasive imaging could help in differential diagnosis distinguishing vascular malformations from other masses as hemangioma, angiosarcoma, or even lymphatic malformations such as cystic hygromas or lymphangiomas  and diffMoving to the second point, surgery for mediastinal vascular malformation may be particularly challenging due to adhesions on surrounding vital structures such as great vessels and major airways. Moreover, even tumor manipulation or traction could lead to its rupture with dramatic bleeding. That is why, surgery can be very demanding in some instances and preoperative embolization may be extremely useful to reduce blood flow within vascular component, decreasing technical challenges and lowering intraoperative bleeding risk .Although contrast enhanced CT examination plays a crucial role in the non-invasive diagnosis of mediastinal masses, their differential diagnosis is often based on pathological examination rather than on diagnostic imaging. Thymic cavernous hemangiomas belongs to the family of vascular malformations and, as such, typical CT-features such as multiple venous lakes, calcified phlebolithes, complex multiple venous channels, distant feeding veins and delayed enhancement are helpful to achieve a correct diagnosis . ParticuDespite the diagnostic role of conventional digital subtraction angiography (DSA) has been reduced by the advent of new generation CT scans and MRI scans, it still plays a crucial role in the preoperative evaluation of such vascular malformations as it allows to map the arterial feeders, the draining veins and understand the hemodynamic characteristics. The therapeutic approach is chosen according to size, depth, and extent. As such, DSA can also be used as part of the therapeutic strategy of thymic vascular malformations, as vessel embolization allows to occlude arterial feeders and/or draining veins in order to facilitate surgery or to avoid it . The selAccording to the ISSVA  classification  vascularSpecifically, venous malformations are deviations in the development of the venous system caused by failures in different stages of embryogenesis. They are usually sporadic, but sometimes familiar. In familiar forms and in more than 50% of sporadic cases the malformation is linked to the activating mutation of the TEK gene; more rarely they are related to PIK3CA mutation , 16. TheFrom literature review mediastinal venous malformations are uncommon. Although their origin in the mediastinum is variable, a small number showed thymic origin. Nowadays, only 10 cases of thymic so called “cavernous hemangioma” have been reported in English literature .Histologically they must be mainly differentiated by thymic cystic lymphangioma, characterized by dilated lymphatic spaces consisting of endothelial cells comparable to cells lining normal lymphatics. Lymphatic spaces are usually filled with proteinaceous eosinophilic fluid and supporting stroma is composed of collagen and may contain lymphocytes and lymphoid aggregates. Their endothelial cells are positive for D2-40 immunohistochemical marker. Another differential diagnosis is with angiolipoma which is a rare benign tumor consisting of mature adipose tissue and blood vessels.The strengths of this report is rarity of mediastinal cavernous hemangioma; a bias is the lack of images  that help readers to grasp the anatomy of the lesion in relation to adjacent tissues.Vascular malformations are benign structures, however some lesions may have invasive behavior, determining complications such as hemorrhage or asphyxia. Complete surgical resection is a radical treatment. Most of them have a complete capsule and are easy to dissect, so VATS can be used to remove lesions. Sometimes tumors are huge, or are closely stuck to large blood vessels or pericardium with an abundant blood supply making dissecting during thoracoscopy challenging. When the lesion is difficult to remove, the chest should be opened in time to ensure the safety of the operation. Percutaneous vascular embolization is used in the treatment of hemangioma, and, even though microinvasive surgery, is safe and effective. One of the most demanding topic is difficulty to obtain a pathological diagnosis before surgery.In summary, when dealing with mediastinal masses, remember: (1) differential diagnosis between the more frequent solid antero-superior mediastinal tumors and vascular malformation should be always considered, especially in presence of abnormal vessels feeding into the mass (2) CT and MRI may not be conclusive and biopsy maneuvers are quite never definitive, sometime they could also be dangerous (3) preoperative DSA should not be spared in case of uncertain diagnosis (4) coil embolization should always be considered to reduce potentially fatal bleeding during surgery (5) histologic differentiation with other thymic neoplasms must be always considered (6) multidisciplinary approach is the key to guarantee the best and safest outcomes.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available on request.FR and MS: performed the operation, collected information of patient, revised the literature, and drafted the manuscript. LM: performed the pathologic examination. MC: performed radiological examination. AB, AG, and UC: revised the literature and revised the manuscript. 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.


Intracranial undifferentiated pleomorphic sarcoma remains a rare pathology within the sarcoma literature that may arise primarily or secondary after radiation therapy. Despite first-line treatment with maximal surgical resection, followed by nonstandardized adjuvant chemotherapy/radiation regimens, clinical prognosis remains exceedingly poor. Furthermore, there is a lack of genetic or molecular characterization to guide potential for targeted therapies. We present genomic analysis of a radiation-induced intracranial undifferentiated pleomorphic sarcoma in an 83-year-old woman with notable KIT and PDGFRA alterations. Further similar genomic studies of intracranial pleomorphic sarcoma are needed to develop better therapies for this rare but challenging disease entity. Undifferentiated pleomorphic sarcomas (UPS) comprise a subset of malignant mesenchymal tumors, accounting for 15–20% of soft tissue sarcomas and typically affecting patients older than 50 years of age. , 4 The lAn 83-year-old woman presented with a growing solid right frontal scalp lesion over the past month that had not been present two months prior. Her past medical history was significant for diagnosis of a right frontal anaplastic astrocytoma, resected 18 years earlier, followed by adjuvant temozolomide and external radiation therapy (60 Gy in 30 fractions). She also underwent complete resection of stage IA lung adenocarcinoma four years prior. On examination, she was neurologically intact and cognitively at her baseline of mild dementia.Magnetic resonance imaging (MRI) of her brain demonstrated a bilobed homogeneously enhancing right frontal scalp, measuring up to 4.5 cm, with 2.8 cm of intracranial extension . There wThe tumor was gross totally resected via a right frontal craniectomy with mesh cranioplasty to replace the bony defect, followed by complex scalp closure that involved rotation of a vascularized forehead flap and inset of a harvested split-thickness skin graft from the thigh. Pathologic review of the specimen revealed a densely cellular spindle cell malignancy composed of highly pleomorphic cells in a partly fascicular or storiform pattern with areas of necrosis Figures . The Ki-A targeted cancer gene panel  was performed on the surgical specimen and peripheral blood, the latter serving as a normal, germline control specimen. This assay examines tumor DNA for mutations and/or amplifications in 146 cancer-related genes, as well as tumor RNA for the presence of gene fusion transcripts involving 44 oncogenic driver genes. This assay revealed somatic variants within the tumor, predicted to be deleterious based on SIFT  and Poly∗18, Q556Rfs∗8) and one malignant peripheral nerve sheath tumor (C906R). The KIT V603D mutation observed in our patient was located in the protein tyrosine kinase domain and plotted alongside data from the TCGA database with MutationMapper [These results were cross-referenced with The Cancer Genome Atlas (TCGA) sarcoma cohort , comprish tumor C06R. The Intracranial UPS remains a rare entity within the sarcoma literature. First-line treatment is maximally safe surgical resection. Postoperative chemotherapy and/or radiation have been reported in cases, but there remains no histopathological or molecular framework in which to guide adjuvant therapy , 11. MosGiven sarcomas as a whole represent a highly heterogeneous group of cancers, a diverse array of oncogenic mutations and/or copy number changes has been described . HoweverSomatic activating mutations in KIT and PDGFRA have been well-described and are mutually exclusive in gastrointestinal stromal tumors , 21, leaWe also detected a missense variant of the tumor suppressor TP53, predicted to be deleterious and located in a previously reported hotspot domain. This variant has been previously reported to be a recurrent somatic mutation in cancer, as well as a pathogenic variant associated with Li–Fraumeni syndrome. Loss of TP53, despite its prominence across many cancers, is relatively under-represented among sarcomas . DespiteTaken together, this study reports novel genomic findings of intracranial UPS, which remains severely lacking in molecular characterization to guide clinical decision-making. While further genetic reports are necessary, our findings suggest potential actionable targets against KIT and PDGFRA alterations that represent promising therapeutic interventions for this rare but challenging disease entity.


Dermatomyositis (DM) is an idiopathic condition characterized by inflammation of muscles and skin lesions. It is often a paraneoplastic manifestation of internal malignancy. Hence, early recognition of this disorder is important. Although not all dermatomyositis are associated with malignancies, the ones with such association regress with the treatment of associated malignancy. In clinical practice, symptoms of muscle weakness can be vague, and skin lesions can be dismissed as sunburn. We present a case of an elder adult female who presented with dermatomyositis as a paraneoplastic syndrome secondary to an underlying Mullerian malignancy. Paraneoplastic syndromes are non-malignant disorders arising from tumor secretion of peptides, hormones, or cytokines or from immune cross-reactivity between malignant and normal tissues. Paraneoplastic syndromes may affect dermatologic, endocrine, neurologic, rheumatologic, and hematologic systems and are commonly associated with gynecologic tumors, small cell lung cancer, breast cancer, and hematologic malignancies .Dermatomyositis can present as a paraneoplastic dermatosis and may present as a characteristic erythematous rash distributed in a “shawl” pattern over the neck, upper back, chest and shoulders.We present a case of a 69-year-old female who had visited our clinic with a diffuse rash over the upper part of the chest wall and upper back. The patient reported that she has had sunburns in similar locations before, but she had not been out in the sun lately. A series of investigations revealed her condition to be far more complicated and, in fact, related to her underlying malignancy.Our patient is a 69-year-old Caucasian female with a past medical history of type II diabetes, hypertension, hyperlipidemia, obesity, obstructive sleep apnea, and seborrheic dermatitis. She presented to the Family Medicine clinic for evaluation of abdominal pain after a fall on the ice at home. She developed symptoms of abdominal discomfort and bloating in an area where she had an abdominal hernia repair five years prior. The hernia repair had been complicated by wound dehiscence and infection that required skin grafting and subsequent surgical repair. Past surgical history also included cholecystectomy and hysterectomy for uterine fibroids. She is a nonsmoker and rarely drinks alcohol.Considering numerous abdominal surgeries and abdominal pain, a CT scan of her abdomen and pelvis with and without contrast was ordered. CT scan revealed innumerable bilateral hepatic lesions Figure  concerniA positron emission tomography (PET) scan was then ordered that revealed a hypermetabolic soft tissue lesion in the anterior mediastinum measuring 4 cm, mildly hypermetabolic subpleural nodules were noted in the right lung, and there was also hypermetabolic lymphadenopathy in the porta hepatis. Multiple hypermetabolic hepatic metastases were seen Figure .Lab work, including complete metabolic panel (CMP), complete blood count (CBC) with differential, lactate dehydrogenase (LDH), carbohydrate antigen 19-9 (CA 19-9), cancer antigen 125 (CA 125), alpha-fetoprotein (AFP), and a pathology slide review was ordered. Her white blood cell (WBC) was elevated at 18.5, with a left shift. Her LDH was elevated at 501, and CA 125 tumor marker was elevated at 1096. Her peripheral smear result revealed absolute neutrophilia, absolute monocytosis, absolute lymphopenia. Other labs were unremarkable, including liver enzymes.The patient returned after four weeks to the clinic to review test results and evaluation. At this visit, she reported the development of a new rash over the last 2-3 weeks, which started at the hairline and spread down the neck, upper shoulders, and across her chest and that it was itching and burning. During the exam, she was noted to have a well-demarcated maculopapular rash to her chest wall, forehead, posterior upper back, and upper shoulders. She had attributed it to her seborrheic dermatitis spreading from her scalp region. She denied any recent sun exposure, new medications, or other exposures . She had been using clobetasol ointment she had at home with no relief to the rash , which could easily be overlooked as sunburn when presenting as an isolated manifestation. Muscular manifestation at this age could be confused with aging or statin use and overlooked. Given the rarity of cases, a standard screening guideline is unlikely. A clinician should use clinical gestalt and consider dermatomyositis as a differential diagnosis for skin rash, especially in the patients who are at high risk or have an established diagnosis of malignancy.


Cutaneous horns are uncommon lesions that occur as conical projections in various sun-exposed parts of the body. They are made of hyperkeratotic material and look similar to animal horns. These lesions lack a central bony core that differentiates them from the animal horns. They are frequently associated with various benign, premalignant, and malignant lesions, and therefore carry a clinical significance. We present a case of a 58-year-old gentleman who presented with a conical projection over the center of the forehead, which was clinically diagnosed as a cutaneous horn. Excision of the horn along with the base was done, and the histopathology revealed benign seborrheic keratosis as the underlying lesion. The excision of small lesions along with their bases or biopsy of the base of large lesions is of paramount importance in the management of cutaneous horns. Cutaneous horns (cornu cutaneum/devil’s horn) are unusual epidermal hyperkeratotic lesions resembling an animal horn . Most ofA 58-year-old gentleman, who is an agricultural laborer by occupation, presented to the outpatient department with a conical lesion over the center of his forehead Figure  for the The lesion was slowly increasing in size to attain the present size. The lesion was painless. He had no history of trauma and did not give any history of similar complaints. He was a chronic smoker for the past 15 years. He is a known case of well-controlled hypertension on regular medication. Owing to his daily outdoor working conditions, he had a prolonged history of sun exposure.On examination, the lesion was 1.5 cm in length. It was non-tender and firm to hard in consistency. He had no other similar swellings over his body. Excision of the lesion along with the base was performed following which the histopathology examination showed features of benign seborrheic keratosis. There were no features of malignancy.In the year 1588, cornu cutaneum was first documented in an elderly Welsh lady, Mrs. Margaret Gryffith . They arThese lesions were previously associated with historic perplexity, and patients with these cutaneous horns were exhibited by money. Yu et al. had reported a totality of 643 patients with cutaneous horns over a period of 10 years with an annual frequency of 32 cases . At arouThe diagnosis is mostly clinical, and they are usually seen in association with several benign and malignant lesions at their bases. The horn being just an epidermal outgrowth of dead keratin is of little significance, but a striking aspect of this lesion is the underlying condition at its base which may be benign , premalignant , or malignant (verrucous carcinoma , squamouCutaneous horns are relatively common in Caucasian populations compared to African-Asian populations. Although most of these lesions are benign, there is a potential chance of these lesions harboring a malignant condition at their base that occurs in almost one-third of the cases.Thus, excision of the lesion with its base along with histopathological examination forms the mainstay of the treatment.


She had a 10 × 10 cm mass on her buttock that showed 2-[fluorine-18] fluoro-2-deoxy-d-glucose (FDG) accumulation on FDG-positron emission tomography-computed tomography examination . A blood culture examination was performed to rule out bacteremia, however, no bacteria were identified. We then performed a needle biopsy and confirmed the diagnosis of UPS; subsequently, the patient underwent a wide-margin resection. A few days after the surgery, her CRP, leukocyte, and neutrophil levels decreased to 0.305 mg/dL, 2.83 × 103/uL, and 50.1%, respectively. This case demonstrated that UPS with inflammation should be treated surgically as soon as possible after ruling out other sources of infection to achieve a favorable prognosis.Undifferentiated pleomorphic sarcoma (UPS) is major type of soft tissue sarcomas. UPS presenting with inflammation is rare, and its pathophysiology remains unclear. Herein, we report a rare case of UPS with prolonged fever. A 91-year-old female complaining of high fever was referred to our hospital because of a high C-reactive protein (CRP) level of 12.51 mg/dL. She had been experiencing intermittent fevers for approximately 10 years. The fever of unknown origin worsened with time and went into remission with repeated antimicrobial therapy. She also had a mass on her central lower back over the sacral region for 6 years, which showed a gradual increase in size. The blood tests showed that the leukocyte count and neutrophils were 6.51 × 10 There are numerous histological types of soft tissue sarcomas (STSs), and more than 60 types have been defined . The malThe patient was a 91-year-old woman. She had been experiencing fever of unknown origin intermittently for approximately 10 years. She also had a tumor in the central lower back over the sacral region for 6 years. Recently, during hospitalization in another center, she was being treated with antibiotics and blood infusion for high fever and anemia. However, the fever did not improve, and she was referred to our hospital.3/uL, and neutrophils at 70.3%  level of 12.51 mg/dL, white blood cell count of 6.51 × 10at 70.3% .We performed a blood culture test that revealed no evidence of bacteremia. Radiography of the chest showed no infiltrative shadow suggestive of pneumonia. Urine culture revealed no evidence of bactereia. The 10 x 10 cm tumor mass on her buttock was elastic, hard, and immobile. Magnetic resonance imaging (MRI) showed a low-intensity mass adjacent to the sacrum bone on T1-weighted and low- and high- intensity areas on T2-weighted images c. No susSubsequently, the patient underwent wide-margin resection. The surgical margin of the resected specimen was microscopically positive . LymphocImmunostaining was partially positive for smooth muscle antigen and slightly positive for myogenin e. Immuno3/µL, and 57.9%, respectively. No recurrence was observed at one year after surgery.However, the immunostaining results were negative for CDK4, MDM2, CD31, CD34, S-100, desmin, AE1/AE3, Myf4, and calponin (data not shown). The inflammation markers of the blood improved a few days after the surgery ; the patInflammatory malignant fibrous histiocytoma (IMFH) is a rare neoplasm and was first reported in 1976 . ApproxiOver the last few years, major advances have been made in the characterization of the tumor microenvironment of soft tissue sarcoma, with the description of “hot tumors” massively infiltrated by immune cells and “cold tumors” with no significant immune infiltration . MoreoveThese findings suggested that the tumor was a “hot tumor,” and there was a relationship between the tumor microenvironment and systemic inflammation. The current case could be further classified as immune-high (D and E), and/or highly vascularized (C) groups. Rapid growth and early metastasis have been observed in IUPS, and the involvement of G-CSF, IL-6, IL-7, IL-8, SCF, TGB, and G-CSF have also been suggested ,14,15. IDiagnostic delays for STS have been reported previously and remain a huge issue that require better patient and doctor awareness . Cancer High uptake of FDG indicates higher tumor cellularity, biological behaviors of the tumor cells, and the composition and proportion of inflammatory cells . MoreoveThe basic treatment for STS is wide-margin resection . STS witThe present study had some limitations. First, the excluded diagnoses were due to the absence of an in-situ hybridization specific test for each tumor ,32,33.However, we were able to make a definitive diagnosis with HE staining and immunostaining.In addition, we did not measure the blood levels of systemic inflammatory cyto-kines such as IL-6.However, we were able to suggest the possibility of an association between tumor microenvironment and systemic inflammation from the histopathology. Moreover, we did not investigate several immune molecules, such as CD3, CD8, CD20, CD34, PD-1, and PD-L1, to confirm the immune-based classification . If thisIn conclusion, we encountered a rare case of IUPS in a very elderly patient with high CRP. IUPS can be diagnostically confused with other infections, such as bacteremia, and even if there is no indication of bacteremia, blood cultures should be collected immediately to rule out infection. In addition, after ruling out such infections, prompt wide-margin resection should be performed to obtain a good patient prognosis.


Distal Intestinal Obstruction Syndrome is a rare complication in patients with cystic fibrosis, which characterized by the accumulation of viscid fecal material, combined with sticky mucous secretions located in the distal ileum adhere to the intestinal wall, causing complete bowel obstruction.We report a case of a 45 years old patient with cystic fibrosis, who presented bowel obstruction secondary to accumulation of fecal material, combined with mucous secretions, in the mid-jejunum. A diagnostic laparoscopy was performed where a dilated jejunum was encountered with impaction of fecal content. Surgery was converted to open surgery, where a longitudinal enterotomy of 5 cm after the transition zone was created, evacuating manually the fecal material with mucous secretion. The patient evolved favorably, without complications.We present a case of a patient with cystic fibrosis presenting with bowel obstruction due to a proximal intestinal obstruction syndrome, which can be diagnosed with the DIOS definition, with the only distinction of a more proximal location in the gastrointestinal tract, such as the stomach, the duodenum, or the jejunum.It is important for the clinician to know the existence of this syndrome at its different locations in the small bowel to treat accordingly. •Proximal Intestinal Obstruction Syndrome is a rare complication in patients with cystic fibrosis.•It is the accumulation of viscid feces with mucous secretions in the small bowel.•It is important to know the existence of this syndrome to treat accordingly. It is an autosomal disease caused by mutation of the cystic fibrosis transmembrane conductance regulator (CFTR) protein, a cell membrane channel for the transport of chloride ions .Distal Intestinal Obstruction Syndrome (DIOS) is a rare complication in CF patients characterized by the accumulation of viscid fecal material, combined with sticky mucous secretions located in the distal ileum, adhered to the intestinal wall ,3. The EOnly a few cases of DIOS have been reported in the literature. To our knowledge, no cases occurring in the proximal portion of the gastrointestinal tract have been reported before. The objective of this study is to report a case of a 45-year-old male patient with cystic fibrosis, who presented with intestinal obstruction in the jejunum due to impaction of viscid fecal material with sticky mucous secretion, treated in an academic hospital. A review of the literature is also performed. The work has been reported in line with the SCARE guidelines .23 leukocytosis, hemoglobin 12 g/dl, platelets 223 × 103/μl, C-reactive protein 15.28, glucose 117 mg/dl, and all other laboratories values were within normal parameters.We present a 45-year-old male patient diagnosed with cystic fibrosis at three years of age, with no history of meconium ileus and no other relevant medical or surgical history. The patient's regular treatment included albuterol, multivitamins and pancreatic enzymes. He arrived at our emergency department due to dyspnea. Upon admission, an anteroposterior chest x-ray showed bronchiectasis and atelectasis due to chronic pneumopathy. A consolidation of the left inferior lobe and left pleural effusion was also seen, compatible with pneumonia. At that moment, heart rate was 82 beats per minute, respiratory rate 35 breaths per minute, and blood pressure 125/75 mmHg. Laboratory studies reported 12.4 × 10 was founded, clinicians have witnessed significant advances in the quality and quantity of life for patients living with cystic fibrosis . We are In conclusion, small bowel obstruction in cystic fibrosis patients is often attributed to DIOS; however, whenever the obstruction occurs at the gastrointestinal tract's proximal portion, this syndrome should be rename as PIOS. Medical treatment should be the initial treatment, leaving surgical intervention whenever the conservative management fails, performing enterotomy and washout or intestinal resection if the bowel becomes compromised. It is important for the clinician to know the existence of this syndrome at its different locations in the small bowel to treat accordingly.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.All procedures performed in this study were reviewed by Ethics Committee of Tecnologico de Monterrey under No. 22A and complied with the principles laid down in the Declaration of Helsinki.This research received no external funding.Carlos Antonio Morales Morales—conception of the work, drafting of manuscript, final approval and agreement for the accountability of work. Luis Fernando Morales Flores—data interpretation, revising the manuscript, final approval and agreement for the accountability of work. Mauricio Gonzalez-Urquijo—data interpretation, revising the manuscript, final approval and agreement for the accountability of work. Eduardo Giasi Gonzalez, Eduardo Alberto Guzman Huerta and Martin Mauricio Virgilio Hernandez Torre—data interpretation, revising the manuscript, final approval and agreement for the accountability of work.Name of the registry: Proximal Intestinal Obstruction Syndrome (PIOS) in a Patient With Cystic Fibrosis: A New SyndromeUnique Identifying number or registration ID: NCT04613063https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000ACKO&selectaction=Edit&uid=U0002XNC&ts=7&cx=-f901h8Hyperlink to your specific registration (must be publicly accessible and will be checked): Mauricio Gonzalez Urquijo.Written informed consent was obtained from the patient for publication of this case series and accompanying images.Not commissioned, externally peer-reviewedsThe authors declare no conflict of interest.


Primary neuroendocrine tumor (NET) originating from the extrahepatic bile duct is rare, although liver metastasis from gastroenteropancreatic NET is frequently observed. We herein report a case who successfully underwent repeat hepatectomy for liver metastases from bile duct NET grade 2 (G2).A 75-year-old man presented with jaundice and was suspected of perihilar cholangiocarcinoma by computed tomography (CT) and magnetic resonance imaging (MRI). He underwent extended left hepatectomy, extrahepatic bile duct resection, and hepaticojejunostomy. Pathological findings showed a NET G2 of the biliary tract arising from the common bile duct. Two years and 11 months after surgery, a liver metastasis was detected and hepatectomy was performed. During the surgery, another liver metastasis was detected, and limited liver resection for the two lesions was performed. Pathological findings showed four liver metastases of NET G2. Five years and 4 months after the first surgery (2 years and 5 months after the second hepatectomy), four liver metastases were detected. Thereafter, he received somatostatin analogues for 1 year. Although the size of tumors increased slightly, the number did not change. He underwent limited liver resections and was diagnosed with 7 liver metastases of NET G2. Finally, another hepatectomy (fourth hepatectomy) was performed and long-term survival without recurrence was obtained for as long as 8 years after the first surgery.Repeat hepatectomy is a good option to obtain long-term survival for liver metastases from bile duct NET G2 in select patients. A primary neuroendocrine tumor (NET) of the bile duct is rare. It has been reported that NETs originating from the extrahepatic bile duct account for only 0.2–2% of the primary NET sites in gastroenteropancreatic NET , 2.The most common metastatic site of all NETs is the liver. Liver metastasis is an important prognostic factor in patients with NET. In terms of treatment, debulking surgery and radical resection are recommended . There hA 75-year-old man presented with upper abdominal pain. The blood biochemical tests showed the following: total bilirubin, 2.3 mg/dL; direct bilirubin, 1.6 mg/dL; gamma-glutamyl transferase (γ-GTP), 194 u/L; alkaline phosphatase (ALP), 1057 u/L; aspartate aminotransferase (AST), 56 u/L; and alanine aminotransferase (ALT), 54 u/L; without abnormalities in amylase. Computed tomography (CT) showed dilation of the intrahepatic and extrahepatic bile ducts, soft tissue density in the common bile duct, wall thickening of the common bile duct, and atrophy of left lobe of the liver , four liver metastases were detected by CT , four liver metastases were detected. After 6 months of everolimus (10 mg/day) administration, all tumors shrank Fig. . AlthougNET of the extrahepatic bile duct reportedly accounts for only 0.2–2% of primary NET sites , 4, 5. APathologically, NETs may arise from argentaffin or Suschitzky cells, which are believed to be endodermal in origin –9. TheseThe liver is the most common site for NET metastasis. At initial diagnosis, about 65–95% of gastroenteropancreatic NET shows hepatic metastasis . Indeed,We reviewed cases involving the bile duct NET G1 or G2 with liver metastasis to study the treatments and prognoses. Literature review using PubMed was employed using the following keywords: [carcinoid] [Neuroendocrine tumor] [Neuroendocrine carcinoma] and [bile duct] [biliary tract] [cystic duct] . In the second recurrence, multiple liver metastases were detected by CT and MRI, which were avid on the OctreoScan. To confirm that the number of tumors was not increasing rapidly, or the metastases were limited to the liver, we chose somatostatin analogues (SSA) for the second liver recurrence, including octreotide LAR and lanreotide depot/autogel. According to the previous report, SSA achieved stable disease in 87% of the patients and a partial response of 5–8% for gastroenteropancreatic NET . This efIt is important to resect as many tumors as possible for long-term survival. CE-IOUS may be effective to find new tumors that are difficult to identify via CT, EOB-MRI, or CEUS before surgery . CEUS waLiver resection can contribute to long-term survival in the context of a multidisciplinary approach in patients with liver metastases of NET. In selected patients, repeat hepatectomy should be considered for liver metastases originating from bile duct NET G2 as well as other gastroenteropancreatic NETs.


Mesenteric fibromatosis-desmoid tumor of mesentery is a rare benign soft tissue tumor of mesentery. On CT, it mimics gastrointestinal stromal tumor (GIST).A 44-year-old female with small intestinal mass, preoperatively diagnosed radiologically and pathologically as GIST.Mesenteric fibromatosis is a rare tumor often mistaken for GIST. Histopathology and immunohistochemistry is the key as management of both the tumors differs. Mesenteric fibromatosis, also known as desmoid tumor of mesentery is a rare benign soft tissue proliferative tumor having its origin in the mesenteric tissue. It is a locally aggressive tumor. Though it lacks malignant potential, recurrences have been documented in the literature. It is important to differentiate mesenteric fibromatosis from GIST  as it is its closest differential on radiology as well as on histopathology. The management of both tumors is completely different. Mesenteric fibromatosis is treated by surgical resection. R0 resection minimizes the chances of local recurrence. Treatment of GIST is surgery along with Tyrosine Kinase inhibitors. Misdiagnosis can lead to hazardous therapeutic management.We report a case of 44-year-old female presenting with small intestinal tumor preoperatively suspected as GIST.A 44-year-old female presented to us with history of vague abdominal discomfort. She was previously operated for total abdominal hysterectomy for multiple fibroids and was on regular follow up. On follow up ultrasonography, the radiologist reported small intestinal soft tissue lesion and histopathological correlation was suggested. Transabdominal CT-guided biopsy was done and was reported as benign spindle cell neoplasm suspicious of GIST and was advised for immunohistochemistry (IHC) for confirmation of diagnosis. However, patient being unaffordable IHC was not performed and the patient was directly referred to us. The CECT reported the same radiological finding as that of ultrasonography revealing small intestinal soft tissue mass, well-circumscribed homogenously hypoechoic measuring approximately 11 × 7.5 × 6 cm probably originating from intestinal wall suspicious of GISTFigs. .Fig. 1CTThe patient underwent exploratory laparotomy. Intraoperatively to our surprise, there were multiple soft tissue masses, largest dumbbell-shaped mass measuring approximately 11 × 7.5 × 6 cm attached to the wall of small intestine and invading the surrounding mesentery. The tumor was close to the root of mesentery; however, no gross invasion was seen. Also, there were two small nodules similar in appearance at separate sites in the same intestinal segment. For attaining R0 resection, a large segment of small intestine had to be resected measuring approximately 60 cm. Intraoperative and postoperative period was uneventful, and the specimen was sent for histopathological examination.On gross examination the intestinal segment measured approximately 60 cm in length, with a dumbbell-shaped tumor measuring approximately 11 × 7.5 × 6 cm arising from the intestinal wall and extending deep into the surrounding mesentery Fig. . AnotherThe tumor was well circumscribed, and the cut surface showed a solid, homogenous mass with whirling pattern without areas of hemorrhage or necrosis. Representative sections were taken for histopathological diagnosis.On microscopy, the sections showed well-circumscribed benign spindle cell tumor arising from the serosa with cytologically bland spindle cells, stellate-shaped cells forming fascicles and storiform pattern. Prominent sclerosed blood vessels were seen with collagenized fibers. Intestinal mucosa, submucosa, muscularis propria, and subserosal fat were unremarkable Figs.  and 5.FiFor confirmation of diagnosis, IHC was performed which showed immunoreactivity for nuclear beta catenin, vimentin, and variable SMA positivity while tumor cells were negative for CD-117, DOG-1,CD-34, and ALK-1 ruling out the differentials of GIST and inflammatory myofibroblastic tumor (IMFT). MIB 1 labeling index was 1%.Immediately after 2 months of surgery, the patient presented with diarrhea because of short bowel syndrome and was managed symptomatically. The patient is post 1 year of surgery and on regular follow up with the operating surgeon and presently asymptomatic.The patient underwent colonoscopy for evaluation of familial adenomatous polyposis (FAP); however, it was unremarkable.Mesenteric fibromatosis is a benign tumor arising from the fibroblasts of mesentery. It is postulated that its occurrence may be due to previous surgical trauma, handling of the intestine and also is often related to hormonal influence. Familial adenomatous polyposis (FAP) and Gardner syndrome patients are often at risk of developing mesenteric fibromatosis.Approximately 10% of patients develop mesenteric desmoids. FAP-associated fibromatosis have an aggressive clinical course with increased rate of recurrences. APC (adenomatous polyposis coli) gene mutations in FAP lead to overexpression of nuclear beta catenin .Clinical course of mesenteric fibromatosis is usually uneventful after surgical resection. Rate of recurrence in sporadic cases is very low.However, large tumors not resected for long can often cause intestinal obstruction or can lead to mesenteric ischemia. Treatment modality of mesenteric desmoids is individualized, with surgical resection done only in well-circumscribed tumors and tumors which do not invade the root of mesentery. Fifty-three to 67% of mesenteric desmoids are resectable .Radiation and chemotherapy is not found useful in cases of R0 resection and patients with sporadic desmoids. Doxorubicin is given in cases of recurrent tumors and tumors with genetic mutation. Tumors which are resistant to doxorubicin have been tried with imatinib, which is most commonly useful in cases of GIST; however, its utility has not been proven in large studies Table  6].Tabl.Tabl6].TThe present case report documents an unusual case of mesenteric fibromatosis.IHC-proven histopathological diagnosis is mandatory for mesenteric fibromatosis as other closest differentials have a completely different surgical and therapeutic management. MRI is a preferred modality of diagnosis than CT. Usually, mesenteric fibromatosis is diagnosed as GIST on radiology and tissue diagnosis followed by IHC is mandatory.R0 resection is vital to prevent recurrences.


Multiple Symmetric Lipomatosis (MSL) is a rare disorder related to fat metabolism and lipid storage. The condition results in characteristic depositions of fat, especially around the cephalic, cervical, and upper thoracic subcutaneous. It is much more common in adult males who live in the Mediterranean region and has only rarely been reported in Asian females. In this report, we present a case of an Asian female with MSL and also review the clinical features of the condition, including radiological and histological findings required for proper diagnosis and management.A 59-year-old Korean female came in with a chief complaint of palpable mass present in shoulder and upper back regions. Images showed diffuse non-encapsulated adipose tissue in the subcutaneous layer of the suboccipital, posterior neck area. The patient wanted to remove the mass for cosmetic reasons and discomfort. Excisional biopsy was planned. Preoperative blood analyses showed deteriorated liver function, and the computed tomography findings were consistent with liver cirrhosis. Detailed history taking revealed that she consumed highly levels of alcohol. Lipectomy was performed and the histological findings demonstrated large dystrophic adipocyte morphology. The patient was recovered uneventfully.When patients have multiple symmetric lipomatous lesions, clinicians should suspect MSL and survey possible associated conditions, such as alcoholism, liver cirrhosis, dyspnea, and neuropathy in detail. Multiple Symmetric Lipomatosis (MSL), also known as Madelung’s disease, is a rare disorder related to fat metabolism and lipid storage. The condition results in characteristic depositions of fat, especially around the cephalic, cervical, and upper thoracic subcutaneous regions , 2. AfteAlthough the exact mechanism of MSL is unknown, the condition is thought to be closely related to alcohol abuse. In this context, it is frequently reported in male in their 40’s to 70’s, and affects males up to 30 times more frequent than females . Due to A 59-year-old Korean female came in with a chief complaint of palpable mass present in shoulder and upper back regions Fig. . She hadIn this report, we have described a case of a middle-aged East Asian female with MSL. MSL is a rare adipocyte metabolic disorder , with onAn association between alcohol overconsumption and the disease has also been reported. There is no clear mechanism for alcohol and localized fat accumulation. However, it is known that alcohol damages adrenergic lipolysis by affecting enzyme processes in mitochondria. It can be a cofactor inducing a change in the number and function of b-adrenergic receptors. Alcohol abuse is likely the cause of uncontrolled accumulation in adipose tissue , 16–19..Daniel et al. sub-divided MSL into three types. The morphologic features of this patient’s mass corresponded to type Ib, based on the presence of a mass in the posterior neck region and both shoulders  Table 22. The diTreatment is usually performed for cosmetic reasons or to alleviate symptoms such as dyspnea or dysphagia caused by mass-associated compression. Surgery can be performed to obtain symptomatic relief , 30, andEvidence that MSL is directly related to life expectancy is not clear, but a long term follow-up study showed incidences of somatic neuropathy and sudden death due to fat occupation in mediastinal space . Motomu In conclusion, a better understanding of the clinical features related to this rare disease may be important to identify the characteristics of an accurate diagnosis and effective management. The findings of possible associated conditions, such as alcoholism, liver cirrhosis, dyspnea and neuropathy, and the prevention of unnecessary surgery should be considered.


Neurofibromas can develop as part of neurofibromatosis or as a solitary tumor. Although solitary neurofibromas generally grow slowly, they rarely grow for more than 10 years, and such tumors have not been described in the hand.A 60-year-old woman presented with a mass on the dorsum of the proximal phalanx of the right thumb that had been enlarging since more than a decade.Preoperative imaging revealed a moderately defined soft tissue mass, which measured 1.5 cm × 1.5 cm × 0.7 cm, with no bone and joint abnormalities on the right thumb. The final diagnosis of the tumor was solitary neurofibroma without evidence of neurofibromatosis.En bloc resection of the tumor was performed through a longitudinal skin incision.After surgery, the patient had no complaints of pain but had a temporary tingling sensation. After 14 months of follow-up, no signs of recurrence of the tumor were observed and she was highly satisfied with the results of the surgery.Solitary neurofibroma is quite rare, especially one in the hand. However, in dealing with soft tissue tumors of the hand, particularly those with neurologic symptoms, neurofibroma should be included in the differential diagnosis. Solitary neurofibromas typically develop asymptomatically as slowly-enlarging soft growths in the second or third decade of life. However, a solitary neurofibroma slowly growing over a decade is extremely rare, and such a tumor has not been described in the hand. This paper reports a case of neurofibroma that grew slowly along the dorsal digital branch of the radial nerve of the thumb.Although neurofibromas consist of hamartomatous proliferations of neuro-mesenchymal components, including Schwann cells, fibroblasts, perineural cells, and mastocytes, the proportion of the cell types varies between cases.2A 60-year-old woman presented with a slow-growing mass on the proximal phalanx of the right thumb for over a decade Fig. . The masUnder general anesthesia, we performed complete surgical excision of the tumor. A longitudinal incision was made through the dorsal side of the proximal phalanx. The tumor appeared to be well-circumscribed and progressed along the dorsal digital branch of the radial nerve of the thumb. The tumor was removed entirely by delicate dissection Fig. .Histopathological examination showed randomly oriented spindle cells with wavy, hyperchromatic nuclei and thin and thick collagen strands Fig. A. ImmunoAfter surgery, the patient did not complain of pain but had a temporary tingling sensation. After 14 months of follow-up, no signs of recurrence of the tumor were observed Fig. .We obtained the patient's medical records and reviewed the related literature. Informed written consent was obtained from the patient for publication of this case report and accompanying images. This study was approved by the Institutional Review Board of Chonnam National University Hospital (CNUH-2019-011) and was conducted in accordance with the principles of the Helsinki Declaration II.3 Lee et al reviewed the medical records of patients diagnosed as having a solitary neurofibroma between January 2005 and June 2010. Only one patient had a disease duration of more than a decade, and the location of the tumor was the right ankle. In addition, only one case developed in the hand. A solitary neurofibroma growing over a decade in the hand, as observed in this case, has not been reported so far.Solitary neurofibromas usually develop from small nerves and show a slow growth pattern, often without obvious symptoms. In this case, the clinical diagnosis based on the results of CT and US, was ganglion cyst or giant cell tumor of the tendon sheath. These results suggest that the tumors may not be differentiated from solitary neurofibromas radiologically and that they occur more frequently than solitary neurofibroma.Because solitary neurofibromas do not cause unusual symptoms that can be distinguished from other tumors such as ganglion cyst, giant cell tumor of the tendon sheath, epidermal inclusion cyst, lipoma, neuroma, fibroma, and glomus tumor, differential diagnosis is necessary. Although radiological examinations such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging are important modalities for determining the morphology and location of the soft tissue masses, they are likewise limited in terms of offering a specific diagnosis. However, the histological appearance varies according to the amount of mucin and myxoid tissue present. In immunohistochemistry, S-100 protein, cholinesterase activity, vimentin, and myelin basic protein are positive markers. In the present case, the histological features typical of neurofibromas, and expressions of S-100 protein, vimentin, and myelin basic protein were noted.Histological examination is indispensable for definitive diagnosis, and immunohistochemical staining is important. On histopathological examination, solitary neurofibromas demonstrate wavy, spindled nuclei, fine collagen fibers, and a myxoid stroma with an abundance of mast cells. However, most benign nerve sheath tumors are asymptomatic. Hence, it is a treatment dilemma for surgeons whether to attempt surgical excision or to manage with close observation. In this case, the patient did not complain of pain; however, she complained of numbness of her right thumb, which is a neurological symptom and led to the decision to perform complete excision.Pain, neurological symptoms, increase in size, and/or functional impairment are indications for surgical treatment.Solitary neurofibromas, especially those in the hand, are rare. However, while dealing with soft tissue tumors of the hand, particularly with neurologic symptoms, neurofibroma should be included in the differential diagnosis.Conceptualization: Kwang Seog Kim.Data curation: Dong Gyu Lee, Do Hun Lee.Formal analysis: Jae Ha Hwang, Sam Yong Lee.Investigation: Dong Gyu Lee, Do Hun Lee.Methodology: Jae Ha Hwang, Sam Yong Lee.Project administration: Kwang Seog Kim.Writing – original draft: Kwang Seog Kim, Dong Gyu Lee, Do Hun Lee.Writing – review & editing: Kwang Seog Kim.


A six-year-old multiparous Angus cow was presented for dystocia. Vaginal and rectal examinations revealed an approximately 360° counterclockwise uterine torsion. The torsion was corrected by rolling the cow counterclockwise (three episodes) with the aid of a plank coupled with manual detorsion via the vagina. The placement of obstetric chains followed by manual traction ultimately delivered a stillborn male calf with evidence of vertebral aplasia, arthrogryposis, and abdominal organ herniation. Patient history and subsequent parentage verification revealed that the calf was the result of a consanguineous (mother to son) mating. Tissue samples from the affected calf and blood samples from the dam, sire, and ten half siblings were collected for genetic testing and parentage verification. Necropsy, radiographic, and computed tomography examinations all supported a diagnosis of perosomus elumbis. Perosomus elumbis is a congenital abnormality of unknown origin(s), and this is the first report of a case associated with a consanguineous mating. Perosomus elumbis (PE) is a congenital abnormality of unknown origin(s) that is characterized by aplasia of the lumbar vertebrae and spinal cord. Perosomus elumbis has been reported in several domestic species, including cattle. While this condition has been reported in Holsteins and Herefords, it has not yet been reported in Angus cattle. One case of PE was associated with a Holstein calf infected with bovine viral diarrhea virus (BVDV). This is the first report of PE associated with a consanguineous mating.A six-year-old female multiparous Angus cow, weighing approximately 800 kg with a history of five parities, presented at the farm of origin on emergency for dystocia. The cow had begun stage two labor earlier that morning but failed to progress at which time the owner contacted the University of Tennessee Veterinary Medical Center (UTVMC). Upon arrival at the farm, the cow was restrained in a chute. She was bright, alert, and responsive with a normal and relaxed posture. To facilitate vaginal and rectal examination, the attending veterinarian administered a caudal epidural anesthetic of 5 mL of lidocaine HCl . The labia and perineum were cleaned, and an obstetric sleeve and lube were used for manual vaginal examination. On vaginal palpation, the cranial vagina was more narrow than expected and the cervix was dilated approximately 6 to 8 cm. Gentle digital pressure allowed for the passage of a hand through the cervix where two forelimbs and a tightly constricted uterus were palpated. “Rifling” of the vagina was not appreciated. Subsequent transrectal palpation of the uterus revealed that the right broad ligament was felt as a taught band and traced dorsally from the right side, ventrally to the left. Based upon the manual vaginal and transrectal palpation examinations , the cow was diagnosed with an approximately 360° left  uterine torsion.The cow was sedated with intravenous administration of 40 mg of xylazine HCl  and 20 mg of acepromazine maleate , casted using the double half hitch method, and placed in left lateral recumbency. The uterine torsion was partially corrected by rolling the cow counterclockwise with the aid of a plank (three episodes) and ultimately completely corrected  by manual detorsion via the vagina. A vaginal examination of the cow revealed a partially dilated cervix (8 to 10 cm), a moderately contracted uterus, and a fetus in cranial longitudinal presentation and dorsosacral position, with the head, neck, and forelimbs extended. A 10 mg injection of epinephrine HCl  was administered intravenously to the cow as a tocolytic to better allow for manipulation of the fetus and placement of obstetric chains and snare to the forelimbs and head, respectively. Manual traction, for a duration of approximately thirty minutes by two individuals, completely dilated the cervix and ultimately delivered a stillborn male calf presumptively diagnosed with PE. A vaginal examination revealed no additional fetuses and minimal partial thickness uterine and vaginal tears. A single 5.3 g injection of ceftiofur crystalline free acid  was administered subcutaneously in the base of the left ear, and a single dose of 1.5 g of flunixin meglumine  was administered intravenously to the cow to provide prophylactic broad-spectrum antimicrobial and anti-inflammatory/analgesic treatment, respectively.The cow recovered uneventfully from the dystocia, and thorough history revealed that the calf was the result of an unintentional, consanguineous, mother to son mating. Tissue samples from the affected fetus and blood samples from the dam, sire, and ten half siblings were collected. Relational status was confirmed via parentage verification utilizing the commercially available SeekSire™ parentage assay (Neogen Genomics) which compares over 200 single nucleotide polymorphism genotypes to confirm identity by descent. No history of teratogen exposure was reported, and testing of the calf by antigen capture enzyme-linked immunosorbent assay for BVDV was negative. The herd was maintained as a closed herd, receiving annual routine immunizations as are recommended for the region, with breeding practices including fixed timed artificial insemination followed by exposure to bulls for natural breeding.The stillborn calf was submitted for necropsy to the UTVMC. Gross necropsy observations revealed a 19.2 kg male calf . The calPerosomus elumbis is a congenital bovine fetal anomaly characterized by a group of defects including agenesis of the lumbosacral and caudal vertebra, spinal cord agenesis, arthrogryposed or ankylosed hypoplastic caudal limbs, and malformations of the abdominal viscera and urogenital and anorectal systems . Well kn


Papillary thyroid cancer (PTC) is the most common form of well-differentiated endocrine malignancy. Distant metastases of PTC are rare and usually occur in the bones, lungs, and thoracic lymph nodes despite the common locoregional metastases to the lymph nodes of the neck. The metastasis of PTC to the pancreas is extremely rare. Here, we present a patient with PTC that had simultaneously metastasized to the pancreas, liver, and diaphragm.A 47-year-old male patient suffering from mild abdominal pain for 2 months was admitted to our hospital. The ultrasound (US) and computed tomography (CT) scan of the abdomen revealed a pancreatic space-occupying lesion and pancreatic duct dilatation, and the patient underwent exploratory laparotomy. Intraoperative examination identified a hard mass (approximately 4.0 cm × 3.0 cm) in the body and tail of the pancreas and a mass (1.5 cm in diameter) in the diaphragm. Three light masses were also noted on the surface of his liver. The patient underwent radical distal pancreatectomy, splenectomy, diaphragm, and liver mass resection. After surgery, the pathological report revealed that the masses resected from the pancreas, liver, and diaphragm were PTC metastases. Then, the patient had a thyroid US and an endoscopic US-guided fine needle aspiration biopsy of the thyroid mass. Pathology showed papillary cancer. Subsequently, the patient received a complete thyroidectomy, a cervical lymphadenectomy, bilateral parotidectomy, and bilateral submandibular gland resection.Aggressive surgeries, such as pancreaticoduodenectomy (PD), should be considered for selected patients with metastatic diseases from PTC to alleviate the symptoms and prolong their survival. Papillary thyroid cancer (PTC) is the most common form of well-differentiated endocrine malignancy . The maiA 47-year-old male patient suffering from mild abdominal pain for 2 months was admitted to our hospital in February 2018. He was diagnosed with “acute pancreatitis” first before transferring to our department. The ultrasound (US) and computed tomography (CT) scan of the abdomen revealed a pancreatic space-occupying lesion and pancreatic duct dilatation Fig.  and 4. TPTC has no early typical symptoms due to its anatomic location. Therefore, a delay in clinical diagnosis is inevitable, which leads to the advanced stage of this neoplasm. Thus, the primary tumor in the thyroid is always not diagnosed until the symptoms of secondary metastatic tumor appear. Pancreatic metastases also remain asymptomatic for a long time before diagnosis or manifest pancreatitis symptoms, as seen in our patient. The first and main manifestation of this patient is abdominal pain for 2 months. If a patient does not have thyroid examination and has no history of thyroid disease, the primary thyroid cancer is always ignored. Conventional inspection tools (CT and US) may fail to distinguish the type of tumor in the pancreas. Positron emission tomography–CT can detect the primary neoplasm of the body and pancreatic lesions sensitively, but it has not been performed on our patient because the diagnosis of the pancreatic neoplasm is primary.Whether the pancreatic metastatic tumor surgery is beneficial to the prognosis of patients is disputed because of the high rate of morbidity and mortality after pancreatectomy. We have reviewed the previous cases and performed surgery when the metastases are limited and causing symptoms. The primary tumor is resected first, followed by the metastatic tumor. This procedure relieves the symptoms and may increase the survival of patients. The selection criteria for surgery may be that the primary tumor has good prognosis, and the primary tumor can be resected. The metastasis is also isolated to the pancreas, and the patient can tolerate pancreatectomy . Our patIn conclusion, from this case report and from the few previous cases documented in literature, aggressive surgeries, such as pancreaticoduodenectomy, should be considered in selected patients with metastatic disease from PTC to alleviate the symptoms and prolong the survival.