Giant inguinal hernias are defined as inguinal hernias that extend below the midpoint of the inner thigh when the patient is in the standing position or an anteroposterior diameter of at least 30 cm or a laterolateral diameter of ~50 cm with non-reducibility for >10 years. This article presents a 39-year-old male with a five-year history of a giant left inguinal hernia that was treated with left inguinal hernia repair with mesh, orchiectomy, complicated scrotoplasty, intraoperative ultrasound and aspiration of 3.9 L of fluid from the hernia sac. Surgical repair of giant inguinal hernias can be challenging and is associated with a variety of complications. Various modalities have been described to assist in hernia reduction including debulking, or, as in this case, aspiration of the hernia sac and a preperitoneal incision. Although the Lichtenstein tension free repair is commonly used, no standard approach has been accepted. Abdominal wall hernias are extremely common with an estimated prevalence of 1.7% for all ages. With roughly 75% being inguinal in nature, repair of said hernias is one of the most common surgical operations performed. However, if left untreated, simple inguinal hernias can lead to many complications. One of which is the development of a giant inguinal hernia.This is defined as an inguinal hernia that extends below the midpoint of the inner thigh when the patient is in the standing position or an anteroposterior diameter of at least 30 cm or a laterolateral diameter of ~50 cm with non-reducibility for >10 years. Contents of giant inguinal hernias are usually peritoneal fat and bowel but reports of inclusion of stomach, ovaries, bladder and kidneys have also been noted. Complications are common with giant inguinal hernias and include urinary retention, reduced mobility, pressure sores, social isolation and intestinal incarceration/strangulation.Problems associated with surgical management of giant inguinal hernias are not uncommon and include loss of domain, abdominal compartment syndrome, cardiorespiratory complications, recurrence and wound breakdown. Though several repair techniques have been suggested in published case reports, no single treatment has been adopted as the standard approach to dealing with this unusual disease.This article is an examination of a 39-year-old Hispanic male with a rare giant left-sided sliding inguinal. This patient underwent intraoperative ultrasound with the aspiration of hernia, orchiectomy, complicated scrotoplasty and repair with mesh.The patient is a 39-year-old Hispanic male who presented to the surgery clinic with a five-year history of a giant left inguinal hernia. On physical exam, he had a left-sided ‘basketball-sized’ inguinal hernia shown in . Bowel sTesticular ultrasound revealed a large left inguinal hernia with a fluid-filled hernia sac surrounding one or more segments of the intestine within the scrotum, measuring >15 cm. The left testis could not be identified. The right testis appeared normal on imaging but was displaced superiorly and medially by the large left scrotal hernia sac. The right testis demonstrated color Doppler signals and arterial Doppler waveform. Computed tomography (CT) revealed a large left inguinal hernia sac with bowel, fluid and Left ureter within it associated with left-sided hydronephrosis and severe cortical thickening. The patient underwent left inguinal hernia repair with mesh, orchiectomy, complicated scrotoplasty, intraoperative ultrasound and aspiration of 3.9 L of fluid from the hernia sac. General surgery and urology were both present for the operation. A generous left inguinal incision was initially used and eventually extended as a hockey stick down to his scrotum, lateral to the penis. The hernia sac was taken off the left spermatic cord and testicle. The testicle was inspected and appeared atrophic, with severe elongation and splaying of the spermatic cord from prolonged stretching due to the hernia. Thus, a left orchiectomy was performed by urology. Ultrasound-guided aspiration of the hernia fluid was then performed, yielding 3.9 liters of hernia fluid. A comprehensive literature review of giant inguinal hernia cases was performed to demonstrate the various surgical approaches to managing this disease  was aspirated from the hernia sac to facilitate manual reduction of the hernia contents. Third, a total extraperitoneal abdominal incision was made to aid in reduction the hernia into the abdominal cavity.Surgical repair of giant inguinal hernias can be challenging and is associated with a variety of complications. Various modalities have been described to assist in hernia reduction including debulking, or, as in this case, aspiration of the hernia sac and a preperitoneal incision. Although Lichtenstein’s tension free repair seemed to be the most common technique (utilized in this case), no single treatment has been adopted as the standard approach to managing this uncommon presentation.None declared.None.


Jejunal lymphatic malformations are congenital lesions that are seldom diagnosed in adults and rarely seen on imaging.A 61-year-old Caucasian woman was initially diagnosed and treated for mucinous ovarian carcinoma. After an exploratory laparotomy with left salpingo-oophorectomy, a computed tomography scan of the abdomen and pelvis demonstrated suspicious fluid-containing lesions involving a segment of jejunum and adjacent mesentery. Resection of the lesion during subsequent debulking surgery revealed that the lesion seen on imaging was a jejunal lymphatic malformation and not a cancerous implant.Abdominal lymphatic malformations are difficult to diagnose solely on imaging but should remain on the differential in adult cancer patients with persistent cystic abdominal lesions despite chemotherapy and must be differentiated from metastatic implants. Lymphatic malformations, previously known as “lymphangiomas,” are developmental anomalies of lymphatic ducts that are more commonly found in the head, neck, or axilla. Abdominal lymphatic malformations are exceptionally rare and account for less than 1% of all lymphatic malformations . A definA 61-year-old Caucasian woman presented with 5-year history of abdominal pain and distension, fatigue, and 1-year history of abnormal uterine bleeding. Initial workup revealed a carcinoembryonic antigen value of 8.1 ng/mL , cancer antigen-125 value of 134 U/mL , and a large left adnexal mass on ultrasound. Preoperative CT of the patient’s abdomen and pelvis without oral contrast initially revealed hypodense, ovoid lesions in the left lower quadrant mesentery adjacent to a short segment of small bowel  and completed two treatment cycles. Trastuzumab was then added, and the patient underwent an additional three cycles of FOLFOX–trastuzumab. A repeat abdominopelvic CT 4 months after the exploratory laparotomy showed resolution of ascites, but redemonstrated unchanged findings in the short segment of small bowel and adjacent mesentery in the left lower quadrant. These findings were again thought to represent persistent peritoneal and serosal tumor implants despite chemotherapy.Shortly after the repeat CT, the patient underwent extensive tumor debulking. Intraoperatively, an 8-cm segment of jejunum with rubbery-like texture and adjacent mesentery was excised Fig. . HistoloLess than 1% of lymphatic malformations occur in the small bowel . While nWhen imaged on CT, lymphatic malformations are typically described as cystic mesenteric structures filled with hypodense fluid that compress immediately adjacent bowel . ContrasOur patient’s lymphatic malformation had several features that mimicked peritoneal and serosal mucinous tumor implants. Tumor implants typically show thicker walls and septa, “scalloping” of visceral surfaces due to compressive forces from mucin produced by the peritoneal implants, and heterogeneous internal densities . The ovoGiven the rarity of lymphatic malformations of the bowel and mesentery, there are few radiology studies devoted to diagnosis and characterization; however, contrast-enhanced magnetic resonance imaging may be a potentially useful test in distinguishing lymphatic malformations from mucinous tumor implants . LymphatGastrointestinal lymphatic malformations are typically treated with surgical removal considering their potential for mass effects, although sclerotherapy  and lympLymphatic malformations of the small bowel are exceptionally rare anomalous developments of the lymphatic system. In the setting of mucinous tumors, lymphatic malformations with their variable presentation and nonspecific imaging appearance can present a diagnostic challenge as they mimic tumor deposits. Increased awareness of this entity may help improve patient care.


Neuroblastoma (NB) metastasized into the mandible and spinal extradural region was rarely reported. We present a case with metastatic NB to the mandible and the spinal extradural regions. The patient received chemotherapy using NB 97 regimen and was tumor free after 8 months, but 9 months after the treatment, the patient presented with lower limb paralysis and persistent pain in maxillofacial region as well as swelling in the left mandibular area. Metastasis to the mandible and the spinal extradural regions was diagnosed based on the spinal and maxillofacial magnetic resonance imaging. Radiotherapy with a density of 2 Gy per day was given via a linear accelerator. The total dose of the intraspinal occupying lesion was subject to radiotherapy with a regimen of 30 Gy (10 fractions). For the management of the maxillofacial pain, tumor in the maxillofacial region was subject to a density of 50 Gy (25 fractions). The maxillofacial pain disappeared after a density of 10 Gy and soft tissue tumefaction was eliminated after a density of 50 Gy, and the maxillofacial appearance was much better than before. Finally, the patient died from tumor progression 2 years after diagnosis for NB. In clinical practice, the criterion standard for NB diagnosis is histology based on biopsy. The symptoms were usually related to the location of the primary or metastatic lesions, such as malaise, abdominal mass and pain, back pain, fever, anemia, and weight loss. Currently, the treatment of NB is depending on the staging by International Neuroblastoma Staging System (INSS) or International Neuroblastoma Risk Group (INRG), and usually involves a combination of surgery, chemotherapy, and/or radiation. Unfortunately, many patients showed poor outcome after the treatment due to metastasis. NB metastasis via both hematogenous and lymphatic routes may spread to a variety of locations including lymph nodes, bone marrow, cortical bone, dura, the orbits, liver, and skin. However, rare cases with NB metastasized into the mandible and spinal extradural region have been reported. In this case, we report a child suffering from metastatic NB to the mandible and the spinal extradural areas.Neuroblastoma (NB) derived from neural crest cells of the adrenal medulla or sympathetic ganglia2A 4-year-old female child presented to the Pediatric Department of our hospital due to anemia lasting for 1 month. Abdominal ultrasonography revealed a medium echo area measuring 68.8 × 44.5 × 76.8 mm. Abdominal computed tomography (CT) showed a mass (6.8 cm in size) with irregularly shape in the right adrenal gland. The thickness of the renal parenchyma was not even. Chest CT showed pleural effusion and thickening, as well as thoracic bone destruction.Right adrenal gland biopsy and bone marrow biopsy were carried out to establish a definitive histological diagnosis, which revealed poorly differentiated NB. Stage IV NB was diagnosed based on the histology, INSS, or INRG. Hematoxylin and eosin staining revealed dense proliferation of small round tumor cells with sparse cytoplasm and hyperchromatic nuclei Fig. .2 per day days 1–4 [96 h], etoposide 24 hours 100 mg/m2 per day days 1 to 4, vindesine 1 hour 3 mg/m2 per day 1; doxorubicine 4 hours, 30 mg/m2 per day, days 6–7) to complete within 5 months according to the previous description. Meanwhile, abdominal surgery was performed to remove tumor remnants, followed by radiotherapy (DT: 40 Gy/25 F). Afterwards, the patient received 3-month maintenance chemotherapy . Eventually, complete remission was obtained.For the treatment, chemotherapy was given using German NB 97 regimen which was consisted of 6 cycles of chemotherapy with some dose reductions  revealed a dorsal epidural mass from T6 to T8 levels Fig. A. Axial After taking the previous treatment dose and the organs at risk into consideration, radiotherapy with a density of 2 Gy per day was given via a linear accelerator (6 MV photons). For the management of intraspinal tumor, the total dose of the intraspinal occupying lesion was subject to radiotherapy with a regimen of 30 Gy × 10 fractions. To relieve the maxillofacial pain, the tumor in the maxillofacial region was subject to a density of 50 Gy × 25 fractions. The maxillofacial pain disappeared after a density of 10 Gy and soft tissue tumefaction was eliminated after a density of 50 Gy, and maxillofacial appearance was much better than before Fig. . MRI ind3,6; however, rare cases showed involvement in the head and neck region.,8 In this case, we presented a rare case of an adrenal NB with metastasis to the mandible and spinal extradural regions.Dissemination of NB to bones, skull, and lymph nodes has been well described Localization and histopathological characteristics may vary among NB patients. The disease is known for its wide variety of clinical manifestations. NB metastasis by both hematogenous and lymphatic routes and my spread to a wide variety of locations including lymph nodes, bone marrow, cortical bone, dura, the orbits, liver, and skin. Moreover, mandible and spinal metastasis is rare in general. In this study, a literature review was performed to summarize the cases of mandible metastasis, together with the treatment regimen and outcome (Table ,8,10–16The incidence of the disease was 10.5 per 1 million children aged <15 annually.–19 In the literature review, 14 cases with NB metastasized to the mandible region were included, and the treatment was highly depending on the chemotherapy, surgery and radiotherapy. In this case, the patient showed metastatic NB to the mandible and the spinal extradural areas, and radiotherapy is a treatment option for the disease after taking the previous treatment dose and the organs at risk into consideration.Up to now, no approved standard guidelines have been established for treating NB. The treatment of NB is mainly depending on the surgery, radiation therapy, chemotherapy, bone marrow transplantation, and immunotherapy.In this case, we reported a case of metastatic NB to the mandible and the spinal extradural areas. The radiotherapy may serve as a treatment option. In future, further studies are needed to validate the efficiency of radiotherapy in the NB metastasis to the mandible and the spinal extradural areas.Conceptualization: Hui Xu.Data curation: Hui Xu.Formal analysis: Hui Xu.Resources: Kai Xin.Software: Kai Xin.Supervision: Kai Xin.Writing – original draft: Xiaomei Sun.Writing – review & editing: Bo Sun.This article originally published incorrectly under the article type Observational Study and has since been corrected to Case Report.


In 2018, Hepatocellular carcinoma (HCC) was predicted to be the sixth most commonly diagnosed cancer. Extra-hepatic metastasis due to HCC is a poor prognostic factor, depending on the stage of the disease.We report a case of a 52-years old male who had undergone Segment 5 (S5) hepatectomy for HCC of 4.7 × 2 cm. Transcatheter arterial chemoembolization (TACE) four times postoperatively was performed based on a preoperative diagnosis of a recurrent tumour at the S1. After 2 years, the solitary tumour (7.5 × 2.5 × 3.5 cm) is located behind the right lobe of the liver and the head of the pancreas. The tumour was abnormally supplied with blood from the superior mesenteric artery (SMA) and the gastroduodenal artery (GDA). The patient was underwent pancreaticoduodenectomy (PD) to remove a large tumour. Postoperative pathology and immunohistochemical staining showed metastatic HCC. There was no tumour recurrence after 6 months.The organs in the body that liver cancer cells most often spread to are the lungs (44%), the portal vein (35%), the hepatobiliary ganglion (27%), and a small number of cases of bone, eye socket, bronchus metastases. Otherwise, recurrence of lymph nodes (LNs) after hepatectomy for HCC is very rare.HCC can metastasize to the hepatic pedicle LN after hepatectomy and maybe confused with recurrent liver tumours in the S1. Indications for PD are feasible for solitary metastatic at peri-pancreas. Pathology incorporating immunohistochemistry can determine the origin of metastases. •Recurrence of lymph nodes after hepatectomy due to HCC is very rare at only approximately 1% to 2.5%.•HCC can metastasize to the hepatic pedicle lymph node after hepatectomy and is easily confused with recurrent liver tumours in the S1•Indications for pancreaticoduodenectomy are feasible for solitary metastatic at peri-pancreas BesidesStaging and treatment regimens for primary liver cancer have been updated according to We report a case of an old man who underwent a S5 hepatectomy for HCC. After 23.5 months, the patient underwent PD to remove LN recurrence. This is the first clinical case reported in Vietnam. This report may be useful for both education and clinical practice purposes.This case report was prepared following SCARE Guidelines 2020 .2We present a case of an 52 years old elderly man and had a history of chronic hepatitis B virus infection. The patient had no history of jaundice, fever, nausea, vomiting and allergies reactions. A liver tumour was detected 3 years prior, and TACE was performed 2 times . On Sept2. The patient explained right lower rib pain.At the clinical re-examination at 23.5 months post-operatively, parameters were as follows: 2.1Laboratory measurements were as follows: red blood cells 6.2, platelets 191 G/L, white blood cells 7.04 G/L, prothrombin (%) 110, fibrinogen 4.27 g/L, glucose 6.6 mmol/L, creatinine 80 g/L, albumin 42.1 g/L, total bilirubin 7.9 μmol/L, GOT 38 U/L, GPT 20 U/L, total Computed tomography (CT) showed that a solitary density reduction mass of 34 × 60 mm, located behind the head of the pancreas and the portal vein . The tum2.2A second surgical procedure was performed on 4/9/2020. The operation was performed by a hepatobiliary surgeon with more than 7 years of experience and two resident doctors at Bach Mai Hospital - one of the largest hospitals in Vietnam.The liver was cirrhotic, and no superficial metastases were found. The tumour was completely located under the right hepatic lobe, behind the portal vein and infiltration to the pancreatic head. Therefore, we decided to PD procedure standardized lymphadenectomy, and reconstruction with Child method instead of LN resection . EspeciaPancreaticojejunostomy was performed by modified Blumgart anastomosis with a stent plastic placed in the pancreatic duct . Histopa2.3The patient was admitted to the hospital for 9 days and discharged with no post-operative complications.After 6 months, the patient has been re-examined 2 times since postoperative including: clinical examination, blood test, CA19.9, AFP, computed tomography. Until now, the patient was still alive with no recurrence.3HCC is one of the most common malignancies in the world. Mortality is high due to rapid recurrence and distal metastasis ,11. AccoSingle LN recurrence at the hepatoduodenal ligament and/or peri-pancreatic head usually has a good prognosis. Utsumi et al. reported two cases of PD with a survival time of 25 and 27 months, but one patient had a liver tumour recurrence after surgery. The remaining patient lived longer than 27 months and this was a very rare liver cancer case . WojcickErcolani et al. found a rate of 7.5% lymph node invasion for HCC, 14.0% for colorectal metastasis, 40.0% for metastasis from other sites, and 40.0% for intrahepatic cholangiocarcinoma. The survival time of lymph node metastases after hepatectomy is highly variable ,18. AuthHCC receives most of its blood supply from branches of the hepatic artery, accounting for its characteristic enhancement pattern: early arterial enhancement with early “washout.” Hence, small foci of HCC may be seen within a regenerative liver nodule as foci of arterial enhancement. Interestingly, in this case, the tumour was at a very close position to S9 (or S1r) according to Kumon . The tumThere were some ways for treatment, such as simple right liver resection, right hepatectomy + PD, excision of the pancreatic mass by PD, or mere LN removal. Preoperative biopsy under ultrasonic guidance or computed tomography may be applied to determine the nature of the tumour cells . To our knowledge, when a large tumour is located behind the head of the pancreas, a biopsy is very difficult and dangerous because large blood vessels can be damaged, increasing the risk of metastasis in the abdomen. Recent studies using 18F-FDG PET/CT to identify extra-hepatic metastases have reported a sensitivity of up to 79%, with 83% detection of tumours >1 cm, and 13% detection of tumours less than 1 cm .Treatment options for recurrent ectopic metastatic lesions remain controversial, mostly regarding the symptomatic treatment of the whole system with the drug sorafenib. Surgery to remove metastatic lesions beyond the liver is limited to single, localized lesions. Results show that the removal of metastatic LNs alone is beneficial in selected patients, even though the prognosis of long-term postoperative survival is limited when the tumour has spread beyond the liver. Therefore, options should be chosen according to each case .The current patient had a large tumour located completely behind the hepatic pedicle and surrounded by important vascular structures, adhering to the superior mesenteric vein, portal vein, and the head of the pancreas but also mobilization. In particular, no signs of peritoneal metastasis or liver metastasis were observed. Therefore, this was a rare case in which resection was possible but required major and risky surgery, potentially involving bleeding, and pancreatic fistula , Fig. 7.Limitations of the study: there were only 6 months of follow-up after the second operation. It is necessary to continue chemotherapy according to the regimen, follow up regarding signs of recurrence by ultrasound, tomography, or PET-CT, and monitor complications of the bile-intestinal anastomosis.In conclusion: HCC may recur in the posterior portal vein and posterior lymph nodes. Although treatment for distant metastases is controversial, surgery should be carried out when the tumour is solitary. PD in this situation is similar to that for a periampullary Vater tumour. After surgery, the patient should continue to follow up to detect recurrence and metastasis.PET-CTPositron Emission Tomography and Computed TomographyBMIBody Mass IndexAASLDAmerican Association for the Study of Liver DiseasesAFPAlpha-FetoproteinCase report concept and design acquisition of data, analysis and interpretation of data; Dr. Tran Que. Son: literature review, writing-original draft and editing; Asso.Prof.PhD. Tran Hieu Hoc: literature review, critical revision of the manuscript; Dr. Vu Duc Long: literature review, discussion; Dr. Nguyen Toan Thang: case description and discussion, resources; Pharmacist Tran Thu Huong: resources, edit English language; MD. Pham Van Tuyen: read pathology template.All authors have no conflict of interest about this study.


Herein, we report a case of primary small cell neuroendocrine tumor (NET) of the gallbladder in a 45-year-old female who presented with complaints of fever accompanied by abdominal pain on the right upper quadrant for one month. Contrast-enhanced computed tomography abdomen showed a large gallbladder mass. It was infiltrating the segments IVa, IVb, and V of the liver. Ultrasound-guided fine-needle-aspiration-cytology was performed. Based on preoperative pathological and immunohistochemical investigations, it was diagnosed to be a primary small cell NET of the gallbladder. The patient underwent radical cholecystectomy after three cycles of cisplatin-based neoadjuvant chemotherapy. She had an uneventful recovery and received adjuvant chemo-radiotherapy. The patient was well at the 18-month follow-up. The primary small cell variety of neuroendocrine tumor (NET) of the gall bladder is a rare subtype of NET with approximately 40 cases reported in the English literature . It accoA 45-year-old lady presented with a one-month history of on and off fever with occasional chills and rigors relieved by taking oral paracetamol. She also complained of dull aching abdominal pain in the right upper quadrant which had no relation with food intake and not relieved by passage of stool and flatus. There was no history of cough, breathlessness, jaundice, weight loss, and easy fatigability. There were no urinary symptoms. Physical examination revealed significant pallor. Abdominal examination revealed a 4 x 2 cm gallbladder mass.Preliminary laboratory investigations showed hemoglobin of 6.5g/dl, WBC count of 12400 cells/cu.mm, and platelets of 2.1 lakhs. Serum bilirubin, transaminases, and alkaline phosphatase levels were within normal limits. CA-19-9 and CEA were normal. Initial ultrasonography (USG) abdomen showed a space-occupying lesion (SOL) in the right lobe of the liver which was continuous with the multiseptate cystic SOL in the gallbladder. Chest X-ray was normal. Contrast-enhanced computed tomography (CECT) showed an ill-defined heterogeneously enhancing wall thickening in the fundus of gall bladder extending into the segment IVa, IVb, and V of the liver Figure .She and her family were counseled regarding the available treatment options and prognosis. After taking informed consent, she received cisplatin + etoposide-based chemotherapy for three cycles. Repeat CECT and PET-CT showed shrinkage of the tumor suggesting a partial response to chemotherapy Figure . She undNeuroendocrine tumors can occur anywhere in the body which is made up of enterochromaffin cells. The etiological identifiers of these tumors in the gallbladder are as follows: (1) The undifferentiated stem cells of the gallbladder separate into neuroendocrine cells; (2) the presence of cholelithiasis causes pathological gastric metaplasia due to chronic inflammation of the gallbladder mucosa. In an advanced state, this inflammation produces neuroendocrine cells, eventually leading to the development of a gallbladder NET .These tumors of the extrahepatic bile ducts and the ampulla region are highly malignant due to poor differentiation and hence have a bad prognosis . The comGallbladder neuroendocrine tumor is a very rare malignancy with an extremely poor prognosis. Due to its rarity, very few cases have been reported in the English medical literature. Early diagnosis and prompt surgical intervention can give the patient best outcome. Neoadjuvant and adjuvant chemotherapy provides a definable survival advantage to the patient but is without a well-defined standard of care protocol. Randomized, blinded trials have to be performed to validate one regimen of chemotherapy as the gold standard.


Langerhans’ Cell Histiocytosis is a rare disease of unknown etiology, the pathogenesis of which involves both reactive and neoplastic processes. Despite potential resolution with conservative management, a rare recurrence in a distant site after 3 years from presentation in this case highlights the variability in the course of the disease and the need for larger studies to enable recognition and evidence-based management.We present an unusual case below of a 25-year-old gentleman who presented with sternal pain and tenderness. Imaging showed a lytic lesion in the sternum which resolved spontaneously with oral analgesia. He presented 3 years later with back pain and a similar lytic lesion in the iliac bone was found and diagnosed as recurrent Langerhans Cell Histiocytosis with a biopsy.There is a diverse array of documented presentations of Langerhans Cell Histiocytosis involving single or multiple systems, while its progression and outcomes are equally unpredictable from the current literature. In order to facilitate wider recognition, Langerhans Cell Histiocytosis should be considered in the differential diagnosis of recurrent lytic bone lesions.Although this is a rare disease, there is currently an unmet need for understanding the determinants of recurrence and response to treatment. •Langerhans Cell Histiocytosis is a rare disease of reactive and neoplastic pathologies.•Spontaneous remissions can be followed by recurrences in distant sites.•It should be considered in the differential diagnosis of recurring lytic bone lesions. The resulting local or systemic effects can involve multiple systems in the body, most commonly the skin, lymph nodes, central nervous system, bone and lungs . Althoug2A previously healthy 25-year-old Middle Eastern male self-presented to our general hospital three years ago with sternal chest pain of a gradual onset, without any associated symptoms. He had no family history of inheritable conditions and no history of drugs or allergies. The patient was a non-smoker without any alcohol intake. On physical examination his vital signs were within the normal range and sternal tenderness was elicited on palpation. No other sites of pain were reported, and review of systems was unremarkable. A posterior-anterior (PA) chest radiograph showed no abnormalities. A computed tomography (CT) scan of the chest was performed, which showed a lytic bone lesion in the sternum A and B. He presented again 3 years later with a 1-month history of lower back pain without neurological deficits or other symptoms. Basic laboratory tests including a complete blood count, renal function tests, and liver function tests were within normal range. Plain radiographs of the lumbar spine and pelvis were unremarkable. Given his history, a CT scan of the pelvis was obtained which revealed a lytic bone lesion of the right posterior inferior iliac spine A which wFurther evaluation with an MRI scan was conducted, which revealed an increased signal intensity in the right posterior inferior iliac spine on T2 STIR sequence A The patThe histopathologic examination revealed large histiocytes with irregular, vesicular, grooved and folded nuclei with a dense infiltrate of eosinophils. Occasional giant histiocytic cells were also seen C. Immuno3We present a case of a previously healthy 25-year-old man who presented initially with a sternal lytic lesion which resolved within a year and recurred in the right posterior inferior iliac spine which was confirmed by the histopathology examination as LCH. This rare presentation of LCH is worthy of discussion.Featuring an uncontrolled proliferation of histiocytes, Histiocytosis comprises a range of diseases which present with single or multisystem involvement, including skin, central nervous system, lung, gastrointestinal tract, and bone . Based oLCH can present at any age group but is most commonly encountered in children aged less than 15 years old, when the incidence is estimated to be 3–5 cases per million per year . WhereasThough the incidence of remission has not been formally quantified in the literature, the highest rates are generally seen in unifocal disease, with documented remissions of bone lesions occurring in sites such as the femur, orbit, intracranial bones, maxilla and mandible ,12. Recu4Spontaneous remission of LCH is a previously documented phenomenon. However, there is possibility for recurrence of single bone lesions in the same site or a different site as in our case. Although LCH is considered a rare disease, it should be included in the differential diagnosis for a recurring lytic bone lesion. In addition, familiarity with the radiological findings of LCH is vital in evaluating the potential multisystem involvement of the disease.Not commissioned, externally peer-reviewed.None.The study type is exempted from ethical approval at our institution: case report.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.AA: conducted literature review, drafted the manuscript. KK: Provided histopathology slides and diagnosis. MH: Editing and revision of the manuscript. MS: conceptualised and critically revised the manuscript. All authors approved the final manuscript as submitted.Not Applicable.Mohammad Alsayegh.None.


The most common causes of small bowel obstruction (SBO) are adhesions, Crohn’s disease, neoplasms, and hernias. Internal hernias are rare, and they occur when the small bowel herniates through a defect in the abdominal cavity. The occurrence of internal hernias due to a broad ligament defect is very rare and accounts for 4%-7% of cases of internal hernia.We present a case of a 71-year-old female who was previously healthy with no significant past medical or surgical history and who presented with symptoms of small bowel obstruction. Imaging with X-ray and computed tomography (CT) confirmed the diagnosis, but not the etiology. A decision was made to perform a laparoscopy to manage the obstruction, which revealed a healthy small bowel loop that herniated through a defect in the right broad ligament.Acute abdominal pain due to intestinal obstruction is a relatively common surgical emergency. Internal hernias are the consequence of the herniation of a bowel loop, most commonly the small bowel, through a peritoneal or mesenteric defect into a compartment in the abdominal and pelvic cavity, and they have a high mortality rate than can be higher than 50%. CT imaging is very useful in the diagnosis of internal hernias, although it may not always reveal the etiology. To facilitate wider recognition, broad ligament hernia should be in the differential diagnosis of internal hernias evident in the pelvis on CT imaging.Early recognition of small bowel obstruction caused by broad ligament internal hernia allows for prompt surgical management and vastly facilitates postoperative recovery. Although most surgeons opt for a laparotomy approach to manage such cases, a laparoscopic approach is feasible. The most common causes of small bowel obstruction (SBO) are adhesions, Crohn’s disease, neoplasms, and hernias . The occ9/L. An erect abdominal radiograph showed distended small bowel loops with multiple air-fluid levels  count of 15 × 10Abdominal ultrasound was done outside the hospital and revealed a distended stomach and bowels. Abdominopelvic computed tomography (CT) showed dilated small bowel loops with a closed loop zone of transition suggestive of mechanical SBO secondary to internal hernia Figures , 3.A decision for diagnostic laparoscopy was made to discern the etiology of the mechanical obstruction. The laparoscopy showed a small bowel loop herniating through the right broad ligament Figure . The heaWe present a case of a previously healthy 71-year-old female with no significant past medical or surgical history who self-presented with symptoms suggestive of SBO. With the aid of imaging modalities such as erect abdominal radiograph and CT scan of the abdomen with intravenous (IV) contrast, a provisional diagnosis of internal hernia was made. Upon laparoscopic surgery, it was found that the internal hernia was caused by a defect in the right broad ligament.Acute abdominal pain due to intestinal obstruction is a relatively common surgical emergency diagnosed in 15% of emergency department presentations ,7. The nIn 1984, a classification that consists of three types of broad ligament hernias according to the degree of the defect was proposed by Hunt. The most common type is fenestra, which involves the two peritoneal layers of the broad ligament as seen in our case. The second type is the pouch type; it occurs when only one of the two layers is involved, which results in the entrapment of visceral structures in the parametrial tissue. The last type is the hernia sac type, in which the herniated bowel is lined by a double layer of peritoneum resulting in a true internal hernia .A new classification by Cilley et al. was introduced according to the anatomical location of the defect and has three types: a defect posterior to the round ligament, a defect superior to the broad ligament, and a defect between the round ligament and the remaining broad ligament, through the mesoligametum teres . Our casIt is not necessary to reach a diagnosis of broad ligament hernia before surgery owing to the fact that complete or closed loop bowel obstruction requires surgical intervention. CT has precedence in the diagnosis of SBO and investigating its etiology. Findings of broad ligament herniation on CT include the presence of a transition zone in the pelvis, lateral herniation of dilated small bowel loops to the pelvic cavity, and an increased distance between the uterus and one of the ovaries ,10.In our case, we did not reach a diagnosis of broad ligament hernia prior to surgery and only anticipated that the etiology was pelvic in origin based on CT imaging. Most surgeons address SBO by performing a laparotomy . AlthougThe differential diagnosis of internal hernia through a defect in the broad ligament, although rare, should be considered when a female presents with intestinal obstruction. Early recognition of SBO caused by broad ligament internal hernia allows for prompt surgical management and considerably facilitates postoperative recovery. CT plays an important role in identifying SBO and may or may not indicate the etiology. Although most surgeons opt for a laparotomy approach to manage such cases, a laparoscopic approach is feasible.


Sacral chordomas are malignant, locally aggressive, and rare tumors. Its presentation can be diverse on the entire spine, being more frequent in the sacrococcygeal region. The main treatment is complete surgical resection, which can be performed using different approaches depending on the case. We present the case of a 44-year-old woman with a history of a complex adnexal mass, with an imaging finding of a presacral mass displacing the uterus and rectum, with a histological report of an image-guided biopsy suggestive of a soft-tissue myoepithelioma-like tumor, which was managed with a combined approach: anterior transabdominal laparoscopic and posterior approach, achieving complete tumor resection, without postoperative complications and with the benefits of minimally invasive surgery. The pathology report of the surgical piece was compatible with sacral chordoma. Sacral chordomas are malignant, locally aggressive, and slow-growing tumors, originating in a notochord remnant . They weIts incidence varies between 0.18 and 0.84 per one million inhabitants per year . In ColoComplete surgical resection of the sacral chordoma is the main treatment of both primary and recurrent localized disease . The surCurrently, there are reports of cases that use a combined and laparoscopic approach, achieving complete tumor resection with lower morbidity .No clinical benefits have been reported with the use of chemotherapy. Radiotherapy has been described in the neoadjuvant or adjuvant setting combined with surgical resection or as a primary treatment for patients with unresectable disease, or those who cannot tolerate surgery .Next, we report the first case in our institution and the country of a combined transabdominal laparoscopic approach and a posterior approach with sacrectomy in a patient diagnosed with sacral chordoma.3 with its epicenter in the presacral fat, displacing the uterus and rectum, and infiltrating the S2, S3, and S4 vertebral bodies  was performed guided by computed axial tomography. The histological study reported fragments of dense fibroconnective tissue with groups of epithelioid-like cells, broad eosinophilic cytoplasm, and slightly atypical/hyperchromatic central nucleus; cells arranged in nests with a slight overlap, some with the presence of nucleolus and focal stromal myxoid change, which are findings compatible with a soft-tissue myoepithelioma-like tumor (parachordoma). The patient was evaluated by a multidisciplinary board with the participation of oncologist surgeons, soft-tissue tumor surgeons, neurosurgeons, clinical oncologists, radiation oncologists, oncologic pathologists, and radiologists, establishing a treatment surgical approach combined with neurosurgery service.Surgical techniqueIn supine decubitus, under general anesthesia, an umbilical incision was made by open technique; the procedure consisted of the insertion of a 10-mm laparoscopic trocar, insufflation of the pneumoperitoneum, and insertion under direct vision of a 10-mm trocar in the right flank and a 5-mm trocar in the left iliac fossa and the right iliac fossa. The uterus and adnexa were tractioned anteriorly for better exposure. Dissection was initiated by mobilizing the sigmoid colon until entering the presacral space. Right and left ureters were identified with no evidence of involvement of the venous or arterial iliac vessels, or the pelvic walls. The avascular plane was identified; entering the presacral space, mesorectal dissection was performed exposing the tumor lesion Figure , freeingIn the immediate postoperative period, the patient was monitored in the intensive care unit for two days and in a general hospital room for four additional days, for a total hospital stay of six days with satisfactory evolution.The pathological study of the surgical piece reported compromise due to chordoma-type notochordal neoplasia with negative resection margins for tumor involvement. After five months, the patient does not present sensory or motor deficits, she has adequate sphincter control, and there is no evidence of relapse on control images.The treatment of sacral chordoma is a surgical challenge, due to its location, size, infrequent presentation, and histological findings difficult to classify, which pose the need for a differential diagnosis from chondrosarcoma, plasmacytoma, giant cell tumor, or metastatic disease that may require a different therapeutic approach; thus, it must be treated in reference centers and by multidisciplinary groups .Complete tumor resection is the main prognostic factor, with an impact on overall survival and disease-free survival, which is why adequate imaging studies are required for its planning, including magnetic resonance imaging or computerized axial tomography. The appropriate surgical approach is recommended according to tumor location and size; thus, for small and localized tumors below S3, the posterior approach is proposed, while for tumors located above S3 a combined or anterior transabdominal approach is suggested, depending on the need for bone resection and the experience of the surgeon.Thanks to the experience gained from laparoscopic colon and rectal resections, the high anatomical knowledge and multidisciplinary work of the institution, as well as the characteristics of the tumor; the laparoscopic approach allowed an adequate visualization of the structures and magnification of the resection, which is difficult to achieve with a traditional open surgical approach. Additionally, it has been associated with lower morbidity, less postoperative pain, shorter hospital stay, and improved quality of life ,12.When a tumor occurs in the sacrum, it is important to perform an adequate histological classification; thus, the patient must be referred to an oncological institution that has experience in the management of these types of tumors. The laparoscopic approach should be considered for tumor resection since it allows obtaining satisfactory results in relation to pain, morbidity, and hospital stay while ensuring adequate oncological margins.


Pharyngeal abscesses require urgent management as they have thepropensity to cause severe and life-threatening complications. Theintroduction of antibiotics has led to a dramatic decline in theincidence of these infections. Regardless, abscess formation continuesto be observed in the peritonsillar, parapharyngeal, andretropharyngeal spaces. Oropharyngeal and hypopharyngeal abscessesthat cause airway obstruction are scarcely reported and tend to besecondary to other processes. Herein, we describe the case of an83-year-old man presenting with an idiopathic, obstructive,oropharyngeal wall abscess, extending from the infratonsillar regionto the hypopharynx, which recurred after initial surgical management12 years prior for the same process. He required reintervention duringboth episodes for rapid reaccumulation. A detailed electronicliterature search of PubMed and MedLine was performed for studiesreporting on recurrent pharyngeal abscesses and their management.Results were limited to articles published in English from inceptionto August 2021. The timely management of pharyngeal infections acutelyobstructing the airway is crucial. Physicians should adopt close andfrequent monitoring and have a low threshold for reimaging shouldsymptoms worsen or fail to improve after the initial surgicalintervention. Early detection and treatment of such deep neck infections arecritical, but often complicated by the intricate head and neck anatomy. In the postantibiotic era, clinicians have seen a dramatic decline inthe incidence of pharyngeal infection. Regardless, otolaryngologists continue to routinely observe andmanage abscesses in the peritonsillar, parapharyngeal, and retropharyngealspaces.Pharyngeal abscesses are distinctive among infectious processes given theirpropensity to develop severe, life-threatening complications. Management guidelines for recurrent deep neck abscesses are lackingfurther still and may reflect the complex etiology and rarity of such cases.The current literature has proposed predisposing factors to recurrent deepneck infection, such as diabetes and smoking behavior, but the underlying etiology remains unclear.Airway obstruction due to abscesses in the oropharyngeal and hypopharyngealspaces is very scarcely reported, and thus, evidence-based guidelines forcontemporary management are lacking. Generally, surgical drainage isconsidered the mainstay of treatment, but recent studies have proposedconservative management with antibiotics for cases of uncomplicated deepneck abscesses.Herein, we describe the case of an 83-year-old male that presented with anobstructive, infratonsillar oropharyngeal abscess extending to thehypopharynx, which recurred after initial surgical management 12 yearsprior. We also review the current literature on etiology and management ofrecurrent pharyngeal abscesses. The following case was reported inaccordance with the CARE case report reporting guidelines.An 83-year-old man presented to the emergency department in April 2020 with8 days of left-sided neck pain, sore throat, dysphagia, odynophagia,dysphonia, and worsening of his baseline dyspnea. Past medical history waspertinent for poorly controlled type 2 diabetes, obstructive sleep apnea, apacemaker for symptomatic bradycardia, and severe coronary artery diseaserequiring percutaneous coronary intervention for nine stents. He had a40-pack-year history of smoking but had been an ex-smoker for 22 years.He reported a history of a similar constellation of upper airway obstructivesymptoms in 2008 that resulted from an oropharyngeal abscess. Onpresentation in 2008, an oropharyngeal abscess causing airway compromiserequired9/L). CT withcontrast confirmed a 3.0 × 2.2 × 2.9 cm oropharyngeal abscess effacing theleft vallecula and causing a mass effect on the aryepiglottic folds  withouttonsillar/peritonsillar edema, exudate, or erythema. Flexiblenasolaryngoscopy revealed a large oropharyngeal mass with normal overlyingmucosa in the same location as his 2008 abscess. The mass displaced theepiglottis to the right, obstructing 80%–90% of the airway. The epiglottisand base of the tongue appeared within normal limits. A complete blood countwas significant for mild leukocytosis airway reobstruction. This time, a combination of endoscopic scissors and alaryngeal microdebrider was used to partially resect the abscess wall towidely open the collection until it was flush with the pharyngeal wall.Intravenous antibiotics were broadened to piperacillin/tazobactam.Postoperatively, cultures showed no growth and pathology revealed noabnormalities. After full recovery, the patient was discharged onpostoperative day 4. Repeat flexible nasolaryngoscopy in August 2020demonstrated complete normalization of the pharynx.In this case, we report an unusual presentation of a recurrent, obstructive,oropharyngeal abscess on two separate occasions. The etiology of therecurrent infections remains unclear.511The studies were published from 1997 to 2020. The studies were publishedfrom 1997 to 2020. Recurrent oropharyngeal abscesses were predominantlyreported in age 18–65 years. All abscesses were investigated with CT andrequired surgical drainage for management.We performed a detailed search of the literature for studies reporting onrecurrent pharyngeal abscesses and their management. Electronic databases(MEDLINE) were searched with a trained librarian from inception until 23August 2021, without language restrictions. The following keywords and MeSHterms were used in varying combinations: recurrent, relapse, reinfection,oropharyngeal, parapharyngeal, infratonsillar, abscess, infection, and cyst.The search identified a total of 585 potential studies. We excludednon-English articles from title and abstract screening and further excludedstudies based on relevance to our search. References of systematic reviewsand key articles were screened for potentially relevant articles. A total ofseven studies were included in the qualitative synthesis. of hypopharyngeal retention cysts, the authors noted that these casesare likely underestimated as 50% of the lesions are not easily visible onendoscopy due to their submucosal origin and normal overlying mucosa. Incontrast to this case presentation, it is suggested that these pharyngealcysts rarely become secondarily infected and that recurrence after surgicalmanagement is uncommon. Abscesses originating in the hypopharyngeal wall are extremely scarceand unlike this case, and are typically secondary to a foreignbody,1315 phlegmonous esophagogastritis,17or as a complication of cervical osteophytes. Likewise, a pharyngeal infection may be an initial presenting symptomof hypopharyngeal cancer, due to necrotic lymph nodes and subsequent abscess formation. Branchial anomalies can lead to pharyngeal and deep neck infections.Third and fourth branchial pouch abnormalities, arising from the pyriformsinuses and extending to the upper thyroid lobes have the lowest incidence.2123 Incompleteobliteration of these pouches can lead to cysts, sinuses, and fistulas, ormay present as pharyngeal infections in adults.2224 Interestingly,and in parallel with our case, the majority of these sinus tracts arepresent on the left side.2527 However, therewas no history or evidence of branchial anomalies identified in thiscase.The recurrence of an identical abscess 12 years after initial drainage suggestsa possible underlying unascertained etiology. Retention cysts are the mostcommon benign lesions of the pharynx, albeit rare. In a recent literature review6 The 12-year recurrence time observed in the caseherein suggests a complex constellation of contributing factors, as outlinedpreviously, and underscores the unique presentation of this case.Interestingly, the recurrence time reported in the literature is typically lessthan 1 year.2831 However, thereare rare reports of peritonsillar abscesses of the inferior pole in theliterature, which should be considered in the differential diagnosis forthis case. In addition, isolated cases of atypical oropharygneal abscesses havebeen reported previously in the literature: infratonsillar abscessesresultant from infection of the lingual tonsils,3336 palatinetonsils3741as well as peritonsillar abscesses posttonsillectomy. However, the majority of these patients were pediatric and none ofthem presented with severe life-threatening airway obstruction due to theirlocalization in the peritonsillar region. Noninfectious, congenitaloropharyngeal cysts have been reported in the literature that have beenlarge enough to cause dysphagia and intermittent airway obstruction. However, these have been limited to the pediatric population.Contextualization of our case regarding recurrence is challenging, as theaffected anatomical space is unique in the literature. The reported case waslocalized to the infratonsillar region and extended down to the level of thehypopharynx, which differs from the more commonly observed peritonsillarabscess. Peritonsillar abscesses, the most common deep neck spaceinfections, refer specifically to infection of the Weber glands, whichresults in a nidus of pus accumulation between the capsule of the palatinetonsils and the superior constrictor muscles of the pharynx localizedsuperior to the tonsil. suggesting that it might be playing a role in the underlyingpathophysiology. In line with this, diabetes-induced immunosuppressiondecreases the antibacterial neutrophil function, easing infection and abscess formation. Furthermore, smoking has beenshown to alter oral mucosa and microbiome, predisposing individuals toperitonsillar abscess formation. Given the association between smoking behavior and peritonsillar abscess, our patient’s smoking history may have also contributed to therecurrence of the abscess.An immunocompromised state secondary to concomitant type 2 diabetes might havecontributed to the occurrence and recurrence of the abscess in our patient.It has been shown that patients presenting with deep neck infections haveover a threefold incidence of diabetes when compared to the rest of the population, Established treatments are only available for recurrent abscessesthat arise from congenital anomalies, such as branchial cleftanomalies79 and pyriform sinusfistulas.11 For these cases,surgical management of the underlying congenital anomaly successfullyprevents further abscess recurrence. Furthermore, while tonsillectomy mightseem like a reasonable approach to mitigate recurrence, evidence suggeststhat adult patients having received the surgery are at a higher risk ofpharyngeal infections. Likewise, a nation-wide epidemiological study has found an inverserelationship with the decline in elective tonsillectomy and pharyngeal infections.Oropharyngeal abscesses are traditionally managed with a transoral approach butoptimal techniques and postoperative management, particularly for recurrentabscesses, are lacking.4852 cannot be appliedto oropharyngeal abscesses. The rationale behind wound packing revolvesaround placing enough material to keep the walls of the abscess separated,allowing further drainage, and preventing the formation of a subsequentpyogenic pocket. Without the ability to place packing or a drain to maintainthe patency of the abscess, extensive incision, and drainage is needed toreduce reaccumulation. Indeed, the current literature highlights incisionand drainage with antibiotic therapy to be useful in the management ofrecurrent abscesses. The antibiotic therapy, however, lacks consistencybetween studies as there is currently no established guideline to informantibiotic selection for recurrent abscesses.6The case presented here highlights the need for surgeons to exercise vigilancein monitoring patients with transoral approaches to oropharyngeal abscessespostoperatively, given their increased propensity to reaccumulate rapidly.The widely accepted treatment algorithm for abscesses that are drained witha cutaneous incision, that is, incision, drainage, and packing the woundwith gauze to permit healing to take place by secondary intention orplacement of a subcutaneous drain to reduce reaccumulation of the infectiousmaterial,In the case presented herein, wide incision and drainage of the oropharyngealabscess, with partial resection of the overlying oropharyngeal mucosa, wasrequired for definitive management. This technique allowed the wound tocontinually drain and prevents its premature closure and subsequentreaccumulation. The use of a laser can also be considered as some surgeonshave found it to be useful at creating a wide opening to incise pharyngeal abscesses.This case presents a patient with a recurring obstructive abscess of theoropharynx. The timely management of pharyngeal infections acutelyobstructing the airway is crucial. Special consideration must be given todiabetic patients, as their capacity to fight the infection might becompromised. Furthermore, the identical recurrence of a lesion should promptfurther imaging and work-up for congenital etiologies, as branchialanomalies might be the underlying cause. A review of current literaturereveals a paucity of evidence on recurrent abscesses and their management.However, prompt extensive drainage of the abscess followed by antibiotictherapy is suggested to prevent rapid reaccumulation. Finally, physiciansshould adopt close and frequent monitoring and have a low threshold forreimaging should symptoms worsen or fail to improve after the initialsurgical intervention.


To report the diagnostics, surgical treatment, and outcome of a juvenile foal with solitary osteochondroma (SO) interfering with the podotrochlear apparatus.Case reportOne 36‐day‐old Arabian colt.Clinical, radiographic, ultrasonographic, computed tomographic, and histopathologic examinations were required to characterize and treat an SO located at the palmar aspect of the diaphysis of the second phalanx of the left forelimb. This SO caused severe distal interphalangeal joint (DIPJ) inflammation, marked interference with the podotrochlear apparatus, and associated lameness.Despite the small size of the foal's foot, complete resection of the SO was possible via palmar DIPJ arthroscopy by using motorized equipment. Full resolution of the lameness was achieved within 3 months of surgery.Atypical SO located on the palmar aspect of the second phalanx can cause marked nonseptic inflammation of the DIPJ and interference with the podotrochlear apparatus and should be considered among the differential diagnoses for severe lameness in juvenile foals. Arthroscopic resection of the SO led to an excellent outcome. In horses, they are most commonly found in the distal radiusSevere lameness in young foals is usually attributed to an infectious systemic cause with local manifestations such as septic arthritis/physitis or noninfectious causes such as congenital malformations, fractures, or severe forms of developmental orthopedic disease.In this report, we describe a juvenile Arabian colt with severe forelimb lameness in which P2 SO interfering with the podotrochlear apparatus was diagnosed by using radiography, ultrasonography, computed tomography (CT)‐arthrography, and histopathology and was treated successfully by using a minimally invasive surgical technique.22.1All work was performed at the Equine Veterinary Medical Center, Doha, Qatar.A 36‐day‐old Arabian colt was referred to the Equine Veterinary Medical Center with a grade 4 of 5 . Digital pulses were moderately increased, and pain was evident when the LF pastern region was palpated and passive flexion of the digit was performed. Hoof testing of this small foot (88 × 43 × 69 mm) was negative.On dynamic examination, a grade 4 of 5 LF lameness was observed. The colt exhibited a preference for canter and appeared to avoid trotting. Because of the foal's young age, flexion tests were not performed.Bloodwork revealed a mild leucopenia, mild hypoproteinemia, and a mild hypoalbuminemia.2.3A sagittal, spiculated osseous mass at the palmar and mid‐distal aspect of LF P2, immediately proximal to the DSB, was evident on the lateromedial and dorsopalmar views Figure . There w2.4The foal was restrained, and an ultrasound examination was performed . A large volume of hypoechogenic fluid, indicating effusion and synovitis, was appreciated in the dorsal recess of the LF DIPJ. A large (15.9 × 8.5 mm) spiculated osseous mass was noted to protrude from the palmar aspect of P2, surrounded by hypoechogenic fluid Figure . The flu2.5The foal was anesthetized and placed in sternal recumbency for CT examination of both front digits . One‐millimeter helical images processed by using a high‐frequency convolution kernel were acquired from the carpus distally. Computed tomographic images revealed an irregular, heterogeneous mineral mass (~1200 Hounsfield units [HU]) hyperdense to cortical bone (1100 HU) extending in both palmar and dorsal directions from mid‐diaphyseal cortical bone of P2. The palmar component displaced the suspensory ligament of the DSB in a palmar direction. The dorsal component was closely associated with the nutrient foramen in the medullary cavity of P2 Figure .Distal interphalangeal joint CT‐arthrography  revealed that the osseous mass was covered by a thin layer of soft tissue surrounded by the contrast laden synovial fluid , white blood cell count  self‐locking arthroscopic cannula and a conical obturator were then carefully inserted into the joint in a medial‐45° distal‐20° dorsal direction.The joint fluid was hemorrhagic at initial exploration Figure . The irrOn the medial aspect of the joint, an instrumental portal was created as proximally as possible, abaxial to the medial neurovascular bundle. A synovial resector  was used to remove the proliferated synovium as well as the fibrin and blood clots overlying the bone mass. This improved visibility of the margins of the SO, and a full thickness tear through the suspensory apparatus of the DSB could be appreciated, revealing a small communication with the NB medially. The DDFT was visible through the tear.Initial parts of the osseous protuberance were removed by using rongeurs and submitted for histopathology Figure . ThereafThe junction between normal and abnormal bone could be easily identified at the medial and distal aspects but was difficult to distinguish laterally and proximally. Debridement was continued until healthy‐appearing margins were encountered, characterized by bleeding when irrigation was discontinued. Intraoperative radiographs were taken to confirm removal of the entire mass Figure . High‐vo2.8Excised osseous exostoses were fixed in 10% formalin and subsequently decalcified, embedded in paraffin, and stained with hematoxylin and eosin. Microscopic examination revealed hyaline cartilage, clusters of chondrocytes, fibrovascular tissue with foci of mineralization, and signs of endochondral ossification. The tissue was continuous, with dense and avascular connective tissue. The hyperplastic chondrocytes did not express any atypical shape or mitosis, providing evidence of a benign origin. The histological architectural pattern supported a diagnosis of SO Figure .43Postoperatively, the foal received pentosan 3 mg/kg IM once, ceftiofur 2.2 mg/kg IV twice daily for 5 days, and flunixin 1.1 mg/kg IV twice daily for the first 2 days. A 12‐hour dosing interval for flunixin  was warranted to ensure proper analgesia in the immediate postoperative phase. Then, meloxicam 0.6 mg/kg orally once daily was administered for 1 day, followed by half doses for 2 days. Daily bandage changes were performed until day 4 postoperatively at which time the arthroscopic portals had sealed, and subsequently the bandage was changed every other day. The foal returned to full weight bearing on the affected limb 24 to 36 hours after surgery. Flexor tendon laxity resulting in fetlock drop developed progressively, likely due to bandaging. For support, a palmar heel extension was applied to the foot, and the bandage was reduced to cover only the pastern and foot region.The colt was discharged on day 8 postsurgery, with recommendations to change the bandage every other day until day 12 (when sutures were removed) and to continue IM pentosan injections. The heel extension was left in place for 2 weeks after discharge. Box rest with 5 minutes hand walking twice daily was recommended until recheck.The foal was rechecked at 6, 12, and 20 weeks postsurgery. By 6 weeks, the LF fetlock angle had normalized. No effusion of the DIPJ was palpable. The skin over the surgical sites was thickened, but there was normal range of motion of the phalangeal joints and absence of pain when the palmar pastern region was palpated. Mild pain was elicited by full passive digital flexion at 6 weeks, but this resolved by 12 weeks. No lameness was noted at walk or trot in a straight line on a hard surface from 6 weeks postsurgery. Small paddock turnout for short periods daily was recommended from 6 weeks postsurgery, and unrestricted exercise was allowed by 12 weeks.Radiographs of the left thoracic limb Figure  revealed4Surgical debridement of an SO in a juvenile Arabian colt at the level of the mid‐diaphysis of P2 resulted in an excellent outcome. The exact nature of the osseous mass was unknown prior to surgery, but radiography and CT findings provided evidence of an SO, despite the atypical presentation.10 suggested that SO should be classified as developmental lesions, not benign tumors. Unlike in man and in dogs, malignant transformations into chondrosarcoma or osteosarcoma have not been reported in horses.Initial differential diagnoses included congenital malformation, exostosis, and malignant osteochondral tumors. The location can be used to differentiate between true exostosis and SO.13 and multiple hereditary exostosis (HME) have been described in horses. Multiple hereditary exostosis is a rare autosomal dominant genetic disorder characterized by the development of multiple benign osteocartilaginous masses on the skeleton.Bilateral radial SOOn the basis of the initial evaluation, SO was considered the most likely diagnosis. Computed tomography allowed thorough presurgical planning, which included mapping the mass in detail, anticipating the potential for soft tissue damage, and selecting a minimally invasive arthroscopic approach over an open approach. Because of risk of postoperative sepsis and surgical trauma to the surrounding structures, an open approach was not considered in this foal. The lateral/medial approach, similar to that described by Fowlie et al,7 in 1998, arthroscopic debridement through a modified lateral/medial palmar approach of the palmar proximal recess of the DIPJ with motorized equipment allowed extirpation of all the abnormal bone. An excellent outcome was obtained with complete resolution of lameness and DIPJ inflammation by 6 weeks postoperatively. Although long‐term follow up is required, the weakened palmar cortex of P2 will likely fully heal by the time the horse enters athletic activity.This SO originating from P2 growth plate impinged markedly on the suspensory apparatus of DSB and caused severe lameness in this foal. It was associated with a marked nonseptic inflammation of the DIPJ and should be considered as a differential in juveniles. Computed tomography‐arthrography played a key role in presurgical planning and histopathology for diagnostic confirmation. In contrast to what was described by Easter et alYsebaert MP, DVM: Acquired and analyzed clinical data, prepared illustrations, drafted the manuscript, and critically revised the manuscript final version; Johnson JP, DVM, DECVS, DVMS: Acquired and analyzed clinical data and critically revised the manuscript final version; Abbas G, DVM: Acquired clinical data and critically revised the manuscript final version; Cavalcante PH, DVM: Acquired clinical data and critically revised the manuscript final version; King R, AWCF: Acquired clinical data and critically revised the manuscript final version; Oikawa M, DVM, DJCVP, PhD: Acquired clinical data and critically revised the manuscript final version; Puchalski S, DVM, DACVR: Acquired and analyzed clinical data and critically revised the manuscript final version; David F, DVM, DACVS, DECVS, DACVSMR, DECVSMR, ECVDI Assoc.: Designed original work, acquired and analyzed clinical data, prepared illustrations, and critically revised the final manuscript version.The authors declare no conflicts of interest related to this report.Additional supporting information may be found online in the Supporting Information section at the end of this article.AppendixS1: Supporting informationClick here for additional data file.


Choroidal metastasis is the most common malignant intraocular tumor. Its diagnosis in a patient with known lung cancer is usually easy. However, without any context of already known cancer, further elements are needed to guide the diagnosis. We report the case of a 47-year-old patient with a history of smoking who presented a choroidal metastasis of left lower pulmonary lobe adenocarcinoma discovered on imaging. Imaging techniques, mainly ultrasonography, CT scan, and MRI can help guide the diagnosis of choroidal metastasis even in the absence of a known origin initially. The lung constitutes approximately 30% of choroid metastases. The incidence of metastasis of lung carcinomas into choroid is 2%-6.7% . The symA 47-year-old man with a history of smoking was admitted for exploration of a dry chronic cough with decreased visual acuity in his left eye. Ocular examination revealed retinal detachment in the left eye. The right eye was normal. Ocular ultrasound showed a uveal juxtapapillary echogenic process responsible for retinal detachment which was consistent with enhanced choroidal thickening on the CT scan Figure . MRI shoThe incidence of intraocular metastases is about 8-10% . After bOn ophthalmoscopic examination, CM often have overlying subretinal fluid and lipofuscin that typically appear as scattered clumps of brown pigment. Autofluorescence shows hypoautofluorescence of the tumor with overlying areas of bright 3+ hyperautofluorescence correlating to the deposits of lipofuscin and 2+ hyperautofluorescence of subretinal fluid .Ultrasonography shows flat or slightly curved lesions, often multilobular, with an irregular surface, with a heterogeneous echogenicity (medium-high), and often associated with serous retinal detachment, unlike choroidal melanomas which are rather homogeneous and moderately echogenic . In our MRI is more sensitive and specific than CT in the detection of intraocular tumors. MRI often shows a well-demarcated choroidal mass that appears isointense on T1 weighted images and hypointense on T2 weighted sequences . In our The treatment of choroidal metastasis depends on the systemic status, number of choroidal tumors, location, and laterality. Ocular radiotherapy is considered a standard treatment option for intraocular metastatic tumors . SystemiThe lung is the second most common primary site of choroidal metastasis. The diagnosis of CM can be difficult if the primary tumor is unknown, and imaging has a major role in the orientation of the diagnosis and the search for primary cancer through CT scan and MRI.


Few multifocal hand chondrosarcomas have been reported. To our knowledge, this report is the first to describe multifocal hand chondrosarcoma in a patient with no evidence of prior enchondroma, Ollier's disease, or Maffucci syndrome. Few multifocal hand chondrosarcomas have been reported. To our knowledge, this report is the first to describe multifocal hand chondrosarcoma in a patient with no evidence of prior enchondroma, Ollier's disease, or Maffucci syndrome. We report a multifocal hand chondrosarcoma with no evidence of prior enchondroma. Malignant tissue was resected with wide margins, and there was no recurrence or metastasis at 28 months.Chondrosarcomas are the third most common primary malignant bone tumors behind myeloma and osteosarcoma.Chondrosarcomas have been reported in the hand, but are seen much less frequently.Primary bone tumors are rarely found in the wrist and hand.En bloc surgical resection is the current gold standard of treatment for low‐, middle‐, and high‐grade chondrosarcomas.Chondrosarcomas are most often singular and do not typically arise in a multifocal pattern. At times, chondrosarcomas of the hand occur secondary to conditions such as Ollier's disease, Maffucci syndrome, or hereditary exostosis.In a 352 patient series, Douis et al found that less than 1.6% (3 cases) of all chondrosarcomas demonstrated multifocal distribution.2A 32‐year‐old man was referred to our clinic with slowly increasing pain and swelling over the PIP joint of the 5th digit in his left hand. The patient stated that he had jammed his finger in a basketball game 16 years ago, and the pain had gradually gotten worse to the point that he could no longer flex his small finger at the PIP joint.MRI at the time of presentation showed a 2.2 × 1.1 × 4.1 cm mass extending along the volar 5th digit from the mid proximal portion to the base of the distal phalanx between the bones and the fifth flexor tendon. This lesion had induced cortical thinning and scalloping in the distal half of the fifth middle phalanx. (Figure After initial evaluation, the decision was made to proceed with further imaging including: radiographs Figure , bone scRepeat MRI showed a lesion within the hook of the hamate measuring approximately 6 mm Figure , as wellA subsequent biopsy of the mass in the proximal phalanx and metacarpal identified these as low‐grade chondrosarcoma with features including: hypercellularity, chondrocytes with mild nuclear atypia, and binucleated chondrocytes.After consultation with an oncologist‐hematologist, wide resection with clear margins was recommended as smaller margins may leave residual tumor, and these tumors are typically unresponsive to chemotherapy and radiation. The patient elected to undergo partial hand amputation which would include resection of the fifth ray and the affected portions of carpals and metacarpals, as well as a groin flap for closure.Ray resection of the 5th digit was performed, and the proximal portion of the 4th metacarpal containing the tumor was removed. The hamate and an affected portion of the capitate were also removed, with all malignant tissue removed en bloc. The radiocarpal joint had become unstable secondary to resection and was stabilized with percutaneous pins. Two screws were placed from the residual 4th metacarpal to the 3rd metacarpal to provide stability. Next, the groin flap was lifted, and the hand was positioned and sewn into place. One month later, the groin flap was transected and inset.Two months after the initial surgery, the patient returned to the OR for removal of hardware. While the patient was under anesthesia, the wrist, index, and middle fingers were manipulated to reduce stiffness. After the pins were removed, final radiographs were taken Figure . The patSubsequently, he continued to have stiffness and functional deficits as he was unable to attend scheduled therapy visits for an extended period of time. At 14 months, MRI showed an absence of residual chondrosarcoma Figure . SurgeryTwenty months after the initial resection and reconstruction, tenolysis, capsulectomy, and rotational osteotomy were completed. At this time, we did not find any evidence of recurrence or metastasis intraoperatively or on radiographs Figure .3Twenty‐one months after the initial operation, the patient was progressing as expected. He reported minimal pain and had returned to work without issue. At this visit, he lacked 60° range of motion at the MCP with 2.5‐cm pulp‐to‐palm deficiency, but was still improving. Fluoroscopic images confirmed that all hardware remained in place, and there was no evidence of recurrence and/or metastasis at this time Figure .Twenty‐six months post‐resection, the patient was seen in the urgent care clinic for an infected blunt laceration wound to his left hand sustained 1 month prior to this visit. He was given bactrim and scheduled to follow up in clinic.At 28 months, the patient returned to clinic for follow‐up regarding the aforementioned wound. Radiographs taken at this visit showed that the hardware was well aligned with healing of the osteotomy, and there was no evidence of recurrence or metastasis Figure . Grip st4Given their infrequent occurrence, multifocal chondrosarcomas continue to present both diagnostic and prognostic challenges. The histological criteria of chondrosarcoma and enchondroma are not easy to distinguish. This often leads to the misdiagnosis of chondrosarcoma as enchondroma.While local resection has been described in the literature, hand chondrosarcomas in these cases present with high rates of recurrence. The metastatic potential chondrosarcomas in the hand are low compared to other locations.At 26 months post‐resection, no such recurrence has been documented in our patient. The findings of our case align with several hand chondrosarcoma cases treated by ray resection and/or digital amputation, which found no evidence of recurrence 5‐34 months after the primary procedure.Of three patients identified by Douis et al with multifocal chondrosarcoma, two had Ollier's disease.We were able to find only two cases of multiple chondrosarcomas of the hand in the literature, both of which originated from enchondromas that underwent malignant conversion.5Due to the rare nature of this case, it is unlikely that a single institution will have a sufficient number to perform a study on this particular pattern of chondrosarcoma. As such, we recommend that institutions collaborate to form a case series investigating prognostic factors and treatment modalities for multifocal chondrosarcomas.Though they are not directly funding this case report, the authors would like to disclose the following support for BM: Paid teaching for TriMed. Paid teaching and consulting, as well as research support from AxoGen. Paid consulting for Baxter/Synovis and GLG. The remaining authors have nothing to disclose.HBJ: served as a primary author; JRS and BOO: drafted the manuscript; JM, SR, and CTC: analyzed the manuscript; BJM: served as corresponding author.This case report was prepared using the appropriate ethical guidelines for human subjects.This is a case report, and no informed consent is applicable given that no identifying information was used.


Renal cell carcinoma (RCC) metastases to Meckel’s cave (MC) are a rare condition. To the best of our knowledge, we present the first case of an RCC metastasis to MC successfully treated on two consecutive occasions with stereotactic radiosurgery (SRS). A 57-year-old man presented with new-onset facial pain and numbness. Magnetic resonance imaging (MRI) revealed a lesion invading MC. He was treated with Gamma Knife SRS successfully, resulting in both symptomatic improvement and radiologic tumour regression. Thirteen months after treatment, he presented with a recurrence of trigeminal nerve symptoms. He was treated with hypofractionated SRS successfully, with a follow-up MRI revealing resolution of the disease. While RCC metastases to MC are a rare phenomenon, published literature to date recommends surgical resection in combination with radiotherapy and systemic therapy. Metastatic disease to MC has only been treated once before with radiosurgery alone. Our case demonstrates that repeat SRS is feasible and efficacious. This approach may be favourable in patients wishing to avoid risks of surgical resection, or for those with unresectable disease. Metastases of RCC to MC are a rare occurrence and typically present with facial pain and/or hypoesthesia. This case demonstrates that repeat radiosurgery may be an effective alternative to surgical resection. Clear cell renal cell carcinoma (RCC) represents 85% of all primary renal malignancies and has a propensity to metastasise . TypicalMeckel’s cave (MC) is a dural pouch in the middle cranial fossa, which contains the trigeminal ganglion. Lesions invading the trigeminal ganglion within MC are usually benign tumours such as meningiomas or trigeminal schwannomas . MetastaA 57-year-old man presented in April 2017 with non-specific headaches and a short history of left facial numbness and pain. He had no other visual nor cranial nerve symptoms such as ophthalmoplegia nor paraesthesia. He had a longstanding history of stage 4 clear cell RCC. He underwent a left nephrectomy in 2008 with metastatic recurrence demonstrated in 2010. He was initially treated with a right adrenalectomy and stereotactic radiotherapy to a lung lesion. In terms of systemic therapy, he received first-line sunitinib from June 2011 and dendritic cell vaccine therapy from July 2011, followed by nivolumab.Magnetic resonance imaging (MRI) of his brain revealed a left-sided lesion centered in MC with extension into the cavernous sinus. It measured 17 x 12 x 18 mm and enhanced with gadolinium. There was no intra-axial involvement. Based on the clinical features and imaging, the provisional diagnosis was metastatic disease. There was no prior MRI available for comparison, and prior staging compute tomography (CT) scans including cranial imaging did not reveal the lesion. A four-week-interval MRI demonstrated progressive growth in keeping with metastatic disease  SRS to a dose of 20 Gy in one fraction prescribed to the 50% isodose in May 2017.Clinical follow-up at two months post-GK SRS showed marked symptomatic improvement in facial pain and paraesthesia. The patient was able to cease analgesic medication. Radiological follow-up at six months post-GK SRS showed substantial tumour reduction on MRI; however, he had recently developed facial numbness and wasting of his muscles of mastication in keeping with a trigeminal nerve palsy. His lesion showed a partial response, reducing in size to 16 x 9 x 14 mm six months post-SRS with persistent residual enhancing changes seen one year following SRS.Just over 13 months post-GK SRS, he presented to clinic with a recurrence of facial pain, paraesthesia and new-onset diplopia consistent with a right sixth nerve palsy. MRI confirmed recurrent disease in the left MC with extension into the cavernous sinus Figure . CT stag The patient was recommenced on sunitinib, which showed an initial partial response, but subsequently, his systemic disease progressed again in October 2019 with enlargement of the MC lesion to 24 x 20 x 18 mm Figure , a rightAs of his MRI in August 2020 (nine months after repeat SRS), the MC metastasis was stable and post-treatment effect enhancement in the adjacent temporal lobe was noted Figure . From hiTo the best of our knowledge, no previous report has described a metastasis to MC that has been treated with radiosurgery on two occasions. RCC metastases to MC are a rare occurrence, with only four documented cases in the literature, each presenting with facial pain or hypoesthesia ,2,4. TheTreatment options for metastatic disease to MC include surgical resection, radiotherapy or SRS and/or systemic therapy ,4. SurgiRCC is considered radioresistant to traditional fractionated radiotherapy, whereas SRS is a highly effective option for local control . In thisRepeat SRS for brain metastases has been previously demonstrated to be feasible, efficacious and tolerable ; howeverRCC metastases to MC are a rare occurrence and typically present with facial pain and/or hypoesthesia. Previously reported treatments include surgical resection in combination with radiotherapy and systemic treatment. Our case has demonstrated both symptom relief and tumour control with SRS on two separate occasions in combination with systemic therapy, while avoiding the risks of surgical resection. Radiosurgery is a feasible treatment option for metastases to MC, particularly in the setting of recurrent local disease.


Congenital bowel malrotation resulting in midgut volvulus is traditionallyregarded as a diagnosis of infancy. Rarely, congenital bowel malrotation isdiagnosed in adolescents or adults and requires a high index of suspicion.Presentations can be acute or chronic, and physical examination findings arenonspecific. Diagnosis is primarily achieved through abdominal computedtomography (CT) or during exploratory laparotomy. The pathophysiology inlate-onset malrotation is similar to neonatal malrotation, with a divisionof Ladd’s bands – peritoneal fibrous bands that connect thececum to the right lower quadrant retroperitoneum – as thedefinitive treatment. We present a case of congenital bowel malrotation inan adolescent with persistent and worsening migratory abdominal pain.An 18-year-old female presented to the emergency department with two days ofpoorly localized abdominal pain and nausea. Initial evaluation wasunremarkable and she was discharged home with a diagnosis of constipation.She returned two days later with worsening abdominal pain and new onsetemesis. Given her persistent and worsening symptoms an abdominal CT wasperformed, which revealed malrotation of the bowel. Taken together, her CTfindings and abdominal symptoms were concerning for symptomatic congenitalbowel malrotation and she underwent a Ladd procedure. She remainedasymptomatic both at discharge and at two-week postoperative follow-up.Symptomatic congenital bowel malrotation is more common in older children andadults than has traditionally been thought. Physicians must consider thisdiagnosis in their differential when working up a patient for acute orchronic intermittent abdominal pain to prevent potentially severesequelae. An 18-year-old female presented to the emergency department (ED) with acute onset ofdiffuse abdominal pain and nausea without vomiting. Initial differential diagnosisincluded etiologies of abdominal pain that are commonly considered in this age groupin the emergency setting, such as appendicitis, constipation, obstruction,inflammatory bowel disease, urinary tract infection, pregnancy, cholecystitis,ovarian cyst, and ovarian torsion. The ED evaluation, including ultrasound imagingof the appendix was reassuring, and she was discharged to home with treatment forconstipation. She returned to the ED two days later with severe right lower quadrant(RLQ) abdominal pain and non-bloody, nonbilious vomiting. A thorough workup wasnotable for congenital bowel malrotation; symptoms were relieved following surgicaltreatment. This case demonstrates that, while traditionally thought of as adiagnosis of infancy, congenital bowel malrotation should be considered in thedifferential diagnosis of older children, adolescents, and adults with abdominalcomplaints. Surgical management is the definitive treatment and leads to resolutionof abdominal symptoms.An 18-year-old girl with a history of migraine headaches, allergic rhinitis, ovariancysts, and multiple food allergies was referred to the ED with complaints of poorlylocalized abdominal pain and nausea without vomiting. She had presented to herprimary care physician (PCP) earlier in the day with similar complaints and wasnoted to have decreased bowel sounds and diffuse abdominal tenderness to palpation.At that time, her PCP recommended she proceed to the ED for further evaluation. Shehad been started on omeprazole one month prior for presumed gastroesophageal refluxdisease and endorsed a longstanding history of constipation. In the ED, shecomplained of two days of intermittent, migratory, cramping abdominal painassociated with diarrhea. Vitals signs were within normal limits. Her exam wasnotable for tenderness in the epigastrium and RLQ. Gallbladder and appendixultrasounds (US) were negative for cholelithiasis, cholecystitis, or appendicitis.The patient’s abdominal pain improved over a matter of hours, and she wasdischarged home with instructions to return to the ED if her symptoms returned.The patient returned to the ED two days later with worsening abdominal pain. It wasrated at a 10 of 10 in severity, stabbing in nature, located in the RLQ, withassociated nausea and non-bloody, nonbilious vomiting. She was afebrile,tachycardic, and had flushing of the face, neck, and chest. She had an intrauterinedevice (IUD) and noted two days of bright red vaginal bleeding that she felt wasdifferent in quality than her typical menses. She reported having a bowel movementthe previous day without blood in the stool, and her diarrhea had resolved. On exam,she had tenderness to palpation in the RLQ and right flank. Physical exam wasotherwise unremarkable. Differential diagnosis at this time included gallbladderpathology, such as cholelithiasis or cholecystitis, or appendicitis not seen oninitial US, inflammatory bowel disease, irritable bowel syndrome, pancreatitis,urinary tract infection, pyelonephritis, abdominal migraine, or pelvic pathologysuch as ovarian torsion, ovarian cyst, or ruptured ectopic pregnancy.What do we already know about this clinical entity?Congenital bowel malrotation resulting in midgut volvulus is typicallyregarded as a diagnosis of infancy and can result in bowel necrosis, asurgical emergency.What makes this presentation of disease reportable?Congenital bowel malrotation is rarely considered in the differentialdiagnosis of patients presenting with a chief complaint of abdominalpain.What is the major learning point?It is a rare but increasingly reported cause of abdominal pain inadolescents and adults. The presentation is highly variable and may includeacute or chronic abdominal pain.How might this improve emergency medicine practice?Emergency clinicians should consider congenital bowel malrotation in thedifferential diagnosis, particularly for patients who present multipletimes.Initial labs were obtained and included complete blood count, C-reactive protein,hepatic function panel, lipase, coronavirus disease 2019, and urine pregnancy test,all of which were negative or unremarkable. Laboratory studies were notable for abicarbonate of 18 milliequivalents per liter (mEq/L) (reference range: 23–30mEq/L) and an anion gap of 16 mEq/L (3–10 mEq/L). Transabdominal andtransvaginal pelvic US were negative for ovarian torsion, cysts, or ectopicpregnancy. Her IUD was noted to be in the proper position. Given progression ofsymptoms and prior unremarkable abdominal US, an abdominal computed tomography (CT)with intravenous (IV) contrast was performed. Abdominal CT demonstrated congenitalbowel malrotation with small bowel on the right side and colon on the left side ofthe abdomen . The appThe patient was given IV fluids, morphine for pain control, and ondansetron fornausea. Pediatric surgery was consulted for consideration of surgical intervention.The patient was admitted to the hospital for pain control and brought to theoperating room three days after her initial presentation for a laparoscopicLadd’s procedure given her CT findings of bowel malrotation withoutalternative diagnosis. Her abdominal pain was thought to be secondary tointermittent volvulus. Intraoperatively, the gallbladder, uterus, and ovaries werenormal in appearance. The appendix was grossly normal; however, an appendectomy wasperformed and sent for pathology. There were few adhesions noted between the rightcolon and the right abdominal wall. The duodenum had numerous adhesions between theliver and small bowel. She tolerated the procedure without any complications.The patient’s symptoms of abdominal pain and nausea improved postoperatively,and she was discharged to home two days after the procedure. On post-hospitalfollow-up two weeks after discharge the patient reported complete resolution ofgastrointestinal symptoms. Pathology demonstrated an appendix with minimal focalmucosal inflammation and without perforation or fecalith.Congenital bowel malrotation results from a disruption of normal embryologicdevelopment of the intestine when the midgut fails to rotate around the superiormesenteric vessels.11Malrotation of the bowel can be identified on abdominal CT with IV contrast byidentification of the ascending colon on the left side of the abdomen with smallbowel on the right.11The definitive treatment for bowel malrotation is a Ladd’s procedure, inwhich the Ladd’s bands, the mesenteric bands extending from the colon acrossthe duodenum, are divided. Associated adhesions are lysed to broaden the base of themesentery, and in some cases a concomitant appendectomy is performed.13Some clinicians suggest that patients with chronic symptoms or asymptomatic patientswith incidental discovery of congenital malrotation should undergo a Ladd’sprocedure as there is no way to determine who may go on to develop futurecomplications including midgut volvulus.While symptomatic congenital bowel malrotation has been traditionally thought of as adisease of infancy, this case illustrates that it must also be considered as a partof the differential diagnosis of abdominal pain in older children and adults. Giventhe lower degree of suspicion for this diagnosis in these populations, delays indiagnosis may result in increased morbidity as intestinal necrosis can result fromvolvulus secondary to bowel malrotation, and the time to surgical intervention iscrucial in preventing this complication. This case further illustrates that uncommonetiologies for a common chief complaint must be considered when a patient presentson multiple occasions despite an unremarkable initial evaluation.


Mesenchymal chondrosarcoma is an uncommon malignant mesenchymal tumor with an aggressive behavior. Diagnoses of mesenchymal chondrosarcoma are established based on histomorphological, immunohistochemical, and molecular findings. Only one case of extraskeletal mesenchymal chondrosarcoma (EMC) of the uterus has been reported. This article presents the second case of primary uterine EMC, occurring in a 33-year-old woman. We describe the histological and immunophenotypical features of EMC. Our observations will help pathologists and clinicians perform accurate histological diagnoses of uterine EMC and plan appropriate treatment strategies for this rare tumor. Mesenchymal chondrosarcoma (MC) is an uncommon type of malignant soft tissue tumor, representing fewer than 10% of all chondrosarcoma cases ,3,4. TheA 33-year-old woman presented with an abdominal mass. Abdominopelvic magnetic resonance imaging revealed a well-circumscribed, solid mass in the right uterine wall . Her medSS18-SSX fusion and SYT-SSX reverse transcriptase–polymerase chain reaction (RT-PCR) assays were performed. We also performed next-generation sequencing (NGS)-based RNA sequencing to detect relevant gene fusions [Immunostaining was performed using an automated immunostainer  ,17,18,19 fusions .SS18-SSX fusion and SYT-SSX RT-PCR assay were negative. The absence of an immunoreaction towards pan-cytokeratin, desmin, STAT6, CD34, hormone receptors, CD10, and cyclin D1 ruled out uterine carcinosarcoma, leiomyosarcoma, solitary fibrous tumor, and endometrial stromal sarcoma. NGS analysis revealed the fusion of HEY1-NCOA2, one of the desirable diagnostic criteria for MC. No SS18-SSX, EWS-FLI1, or EWS-ERG fusion was identified. A final pathological diagnosis of primary uterine EMC was made.Representative photomicrographs showing histological features are shown in The patient received postoperative whole-pelvic radiation therapy. She is currently alive without evidence of recurrent disease three months after treatment.Our literature search revealed 18 cases of uterine chondrosarcoma, with some of them showing both mesenchymal and cartilaginous components . HoweverThe clinical course of MC is frequently protracted and relentless, requiring a long-term follow-up. Some MC patients have developed distant metastases even after 20 years ,4. In thHEY1-NCOA2 fusion, confirmed the diagnosis of EMC. We anticipate that our comprehensive clinicopathological, immunohistochemical, and molecular analyses will develop better understanding of this unique tumor and help pathologists to perform accurate diagnoses.In summary, we have presented the second case of EMC of the uterus. We noted a biphasic histomorphology of EMC, characterized by undifferentiated small round or spindle tumor cells and islands of hyaline cartilage. An HPC-like staghorn vascular pattern was frequently observed. Positive immunoreactivities for Bcl-2 and CD99 in the undifferentiated component and for S100 in the cartilaginous component, together with the detection of