We present a case of splenosis of the abdomen and pelvis complicated by torsion of a splenic implant in a young female patient clinically mimicking an acute bowel ischemia. Splenosis is a benign condition defined as heterotopic auto-transplantation of splenic tissue throughout different body areas. It may occur after rupture of the spleen, either traumatic or secondary to surgical procedures. Although the presence of heterotopic splenic tissue is often asymptomatic and an incidental finding, it may present with sudden abdominal pain and bleeding. CT and MRI play a critical role in the detection of splenosis-related complications, such as torsion of the vascular pedicle and infarction. Splenosis torsion is extremely rare and it is still a diagnostic dilemma; the complication of abdominal splenosis should be considered in the differential diagnosis in patients with previous splenectomy. Splenunculi are usually fewer in number, and in contrast to splenosis, in which the implants are supplied from nearby vessels; splenunculi are supplied by the splenic artery and are usually found near the splenopancreatic or gastrosplenic ligament.2 Symptoms are vague and vary according to the location of the splenic tissue. Although the presence of heterotopic splenic tissue is often asymptomatic and an incidental finding, it may present with sudden abdominal pain and bleeding and confused with various acute or chronic disorders.5,6k Splenosis is usually an incidental finding at ultrasound as well, which cannot define the splenic origin of the lesions. CT plays a critical role in the diagnosis of splenosis7 because it is fast, relatively non-invasive and readily available. Conversely, MRI has better soft tissue characterization than CT,8 but has some limitations such as longer acquisition times and lack of prompt availability on an emergency basis in several institutions, which further limits its potential role in the acute setting.Splenosis is a benign condition defined as heterotopic auto-transplantation of splenic tissue throughout different body areas. It may occur after rupture of the splenic capsule, either from trauma or surgery.A 29-year-old Caucasian female presented to the emergency department complaining persistent pain in the left iliac fossa of 3 days duration, soprapubic pain during micturition, nausea and vomiting. Her past medical history included splenectomy for hereditary spherocytosis at the age of 6 and cholecystectomy at the age of 22. On examination, her vital signs were normal. Physical examination revealed direct and rebound tenderness in the pelvis as well as abdominal distension.−1), increased C-reactive protein , and increased platelets count ; renal function and serum beta human chorionic gonadotropin (hCG) levels were within the normal range. Gynaecological and surgical referral was advised.Laboratory tests showed metabolic acidosis, elevated serum lactate and amylase, neutrophilic leukocytosis  demonstrated no evidence of bowel obstruction or perforation. Dual phase arterial and portal venous CT scan of the abdomen and pelvis , showed several contrast-enhancing masses up to 5 cm in transverse diameter , a mass According to the clinical presentation and imaging findings, the differential diagnosis includes endometriosis, torsion of a pedunculated fibroid and ovarian torsion. Owing to the past medical history of splenectomy for hereditary spherocytosis, splenosis should be also taking into account.The ischemic splenic implant was removed by laparoscopic surgery. The remaining lesions were not removed because they were not ischemic. Surgical specimen showed a twisted vascular pedicle with venous engorgement and ischemia . PatholoThe post-operative course was uneventful, and the patient was discharged from the hospital in good condition at day 8. She was followed up as outpatient conjointly by general practitioners and ambulatory surgeons. During follow-up (3 months), she remained asymptomatic.This case of torsion of a splenic implant in a context of abdominopelvic splenosis in a young adult female patient was managed as an acute abdomen. Clinically, the patient’s symptoms were highly suspicious for an acute bowel ischemia. Given this clinical scenario, rapid evaluation was necessary to identify any intra abdominal pathology requiring timely surgery. Thus, contrast-enhanced dual phase CT was the first-line imaging modality in our case.1 Torsion of pedunculated fibroids is a rare complication, which is difficult to diagnose pre-operatively because the twisted pedicle is often extremely thin and the absence of contrast enhancement is not pathognomonic for ischemia. In our case, the presence of multiple masses led to rule out this condition. Similarly, adnexal torsion is commonly unilateral, with a slight (3:2) right-sided predilection.9 CT has lesser specificity for the diagnosis of endometriomas than MRI and thus plays a limited role in the evaluation of endometriosis. However, ovarian endometriomas may be cystic and often contain blood, whereas the appearance of the endometrial implants is generally non-specific.9 At contrast-enhanced CT, splenosis has comparable attenuation to that of normal splenic tissue  images, color-Doppler ultrasound may be useful to identify the twisted pedicle when it is not extremely thin.c tissue . The intT1, shading on T2, and poor to absent enhancement on post-contrast T1.7On unenhanced MRI weigthed sequences, endometriomas show very high signal intensity on 99mTc sulphur colloid, 99mTc heat-damaged erythrocytes or 111In-labeled platelets.1Although MRI using superparamagnetic iron oxide (SPIO) is specific for the diagnosis of splenosis, the current diagnostic tool of choice is scintigraphy with reticuloendothelial agents such as 10The use of ICG-enhanced fluorescence agent during laparoscopy plays a confirmatory role in the diagnosis of perfusion abnormalities of solid and hollow viscous organs, and as in our case, to confirm an ischemic process of the splenic implant.Splenosis torsion is extremely rare and it is still a diagnostic dilemma; the complication of abdominal splenosis should be considered in the differential diagnosis in patients with previous splenectomy. MPR images may assist in the identification of the vascular pedicle. Finally, comparison with previous imaging studies is helpful and should be sought whenever available.CT is useful in the emergency setting in the detection of splenosis.T2 and T1 weighted fat-suppressed MRI sequences as well as post-contrast T1 weighted sequences play a critical role in the detection of splenosis infarction.Appearance of the splenic implants at ultrasound is non-specific. However, color-Doppler ultrasound may be useful to identify any twisted pedicle.ICG-enhanced fluorescence agent during laparoscopy plays a confirmatory role in the diagnosis of splenosis ischemia.


Micronodular thymoma with lymphoid stroma is a rare subtype of thymoma. Here we report a case of micronodular thymoma with lymphoid stroma that was completely resected after incomplete resection 10 years earlier.A 70-year-old Japanese woman who had undergone resection for a thymic cyst 10 years earlier was found to have a solid nodule with a multilocular lesion at the site of the previous operation. We suspected that the tumor was a malignant tumor and performed trans-sternal radical thymectomy and diagnosed the lesion as micronodular thymoma with lymphoid stroma pathologically. When we reassessed the thymic cyst that had been resected 10 years earlier, a few lesions of micronodular thymoma with lymphoid stroma were found in the cyst wall. Based on these findings, we concluded that only the cystic component of micronodular thymoma with lymphoid stroma had been removed, and that the residual lesion grew locally over the next 10 years before being completely resected by reoperation.We experienced an unusual case of micronodular thymoma with lymphoid stroma, which is a rare subtype of thymoma. Greater care should be taken to exclude a thymoma with a cystic lesion, even if a thymic cyst is strongly suspected on computed tomography and magnetic resonance imaging. Micronodular thymoma with lymphoid stroma (MNT) is a rare subtype of thymoma . Only a A 70-year-old Japanese woman who had undergone resection of a thymic cyst by video-assisted thoracic surgery via the left thorax 10 years earlier was found to have a solid nodule with a multilocular lesion at the site of the previous operation. She had no remarkable medical history aside from the tumor and was not taking any medications. She had no tobacco smoking or drinking of alcohol habits, or significant family history. In addition, she was a clerical worker with no exposure to cancer-causing agents. Her physical examination and laboratory findings, including tumor markers, were within normal ranges. Contrast-enhanced computed tomography (CT) of her chest revealed a solid nodule with a multilocular lesion (30 × 30 × 15 mm) at the anterior mediastinum. The solid component was heterogeneously enhanced, and the cystic component was not , we performed trans-sternal radical thymectomy. The tumor was located at the left inferior pole of the thymus, and the cystic component contained serous fluid. There was no dissemination or adhesion. A pathological examination showed that the tumor size was 3.7 × 2.5 × 1.0 cm. On microscopic examination, the tumor was composed of small nodules and abundant lymphoid stroma (Fig. The residual lesion was completely removed with the thymus, and there was no recurrence at 2 years after the operation.This is a case of MNT that had been misdiagnosed as a thymic cyst at a previous operation 10 years earlier and was completely resected after local recurrence. To the best of our knowledge, this is the first report of recurrence, and no previous reports of MNT have included a follow-up exceeding 10 years.First reported in 1999 , MNT is MNT grows slowly, and approximately 95% of cases are pathological stage I or II. There have been no reports of recurrence after operation, distant metastasis, or cancer death due to MNT, so no additional treatment is thought to be necessary after complete resection , 5, 6. IRegarding the difference between thymic cysts and a cystic lesion of MNT, Suster and Moran reported that a thymic cyst has a layer of epithelial cells that line the wall, while such a layer is absent in the cystic lesions of MNT . HoweverThis case report describes a case of MNT that regrew after incomplete resection 10 years earlier, and is the first case report to describe recurrence of MNT. MNT is a rare subtype of thymoma, and we could completely resect the tumor at reoperation because it is of low-grade malignancy and is a slow-growing tumor. In some cases, it is difficult to distinguish thymoma with a cystic lesion from a thymic cyst, as in the present patient. However, it is important to assess the presence of a malignant component in the wall of a cyst in order to avoid a misdiagnosis.


Following investigation, he was diagnosed with a large rectal tumour with multiple metastases. 7 days later, the patient presented again with fevers, bilious vomiting, abdominal pain and distension. On examination, he had a generally tender abdomen,= although no peritonism, but an enlarged, extremely tender hemiscrotum with no cough reflex. Imaging revealed a perforated rectum and subsequent abscess formation, which tracked  A repeat CT scan was ordered to investigate the cause of the scrotal swelling (A 59-year-old cachectic male was referred to the surgical outpatient department with intermittent haematochezia and a longstanding change in bowel habit with associated weight loss and anaemia. He underwent flexible sigmoidoscopy, which showed a large rectal tumour. A staging CT scan confirmed malignancy in the rectosigmoid region with extensive metastases to the liver and spleen together with evidence of para-aortic and mesenteric lymphadenopathy. There was also a loculated collection seen just posterior to the tumour on MRI performed for local staging . A multiswelling .The abscess, in this case, tracked bilaterally in the retroperitoneal space up to the retropancreatic region  and 3. TAn alternative pathway for an abscess to form in the rectal region and present in the right testicle would have been through the peritoneum and inferiorly towards the pelvic cavity through the inguinal canal. However, in such cases the symptoms are usually different, with evidence of peritonitis.Differentials for the clinical presentation would include scrotal abscess, acute testicular torsion, strangulated right inguinoscrotal hernia and Fournier’s gangrene. However, given the prior knowledge of the patient's tumour and imaging, the last three were much less likely.He was initially resuscitated with fluids and given targeted antibiotics as per microbiological guidance. Owing to his large tumour and abscess, it was felt that surgical management would be more appropriate than attempting image-guided drainage. The patient underwent a laparotomy with insertion of a retroperitoneal and pelvic drains to treat the abscess; in addition, an end colostomy was also fashioned with a palliative intent. He remained an inpatient for 4 more weeks and was discharged home with Macmillan nurse follow-up.1 There does not seem to be a strong consensus between tumour stage and perforation;1 however, there is evidence that some chemotherapy agents such as bevacizumab can increase the risk of bowel perforation and have an associated poor outcome.2 Fractionated radiotherapy may also have a role in increasing the risk of perforation of the bowel malignancy. The most common cause of colorectal perforation overall is diverticular disease, with ischaemic colitis and iatrogenic injury being more likely causes over malignancy. Trauma and deep ulcers are less probable.3 Clinical manifestations include abdominal pain, fever, rigors and sepsis. The associated mortality depends on a variety of features such as age, presence of pre-operative sepsis and patient comorbidities.3Colorectal tumour perforations usually present with intraperitoneal collections leading to a clinical presentation of vague abdominal pain and septicaemia. Colorectal tumour perforation is thought to result from tumour necrosis or diastatic perforation, with the incidence ranging from 2.6% to 9%.4 Patent processus vaginalis is present in approximately 80–90% of newborns, but declines to 15–37% in adults; thus scrotal abscesses are less common in adults.4Scrotal swelling as a result of abdominal abscesses is unusual. They may occur more frequently in children, following perforated appendicitis or appendectomies, owing to a patent processus vaginalis.5Other causes of scrotal swelling include Fournier’s gangrene, strangulated or obstructed inguinal hernias, hydrocele, varicocele, spermatocele, localized oedema from insect bites, nephrotic syndrome, testicular torsion and testicular cancer.Intraperitoneal abscesses are associated with high morbidity and mortality and thus require urgent intervention by image-guided drainage or operative management.Tumour perforation can complicate up to 9.6% of colorectal cancers, with necrosis being the main pathological cause and diastatic perforation occurring less commonly.via tracking through the subperitoneal and extraperitoneal spaces into the inguinal canal. This case highlights that the obturator space may also provide an alternative pathway for an intra-abdominal abscess to progress into the scrotum.A patent processus vaginalis can lead to an inguinoscrotal abscess from an intra-abdominal pathology, more commonly in children; however, in adults, this may occur Important differentials of acute scrotal swelling include Fournier’s gangrene, testicular torsion and acute inguinal hernias.Written consent was obtained.


Gastrointestinal stromal tumors represent about 1% of the tumors of digestive tract. Their presentation consists often of indolent symptoms. However, they can present as surgical emergencies in rare cases. This work presents a case of a giant jejunal GIST that required emergent surgical treatment.th duodenal segment and first jejunal segment with approximately 20 × 14 x 13 cm, with apparent intratumoral bleeding. Due to haemodynamic instability, the patient was submitted to emergency laparotomy, in which a large tumor was found arising from the first jejunal segment. A segmental enterectomy was performed and the post-operative period ran without complications. The histopathologic exam showed a gastro-intestinal stromal tumor of epithelioid cell nature, with low mitotic count (<5 per 50HPF), categorized as T4N0 stage IIIA. The imunohistochemical analysis revealed positivity for CD117 (c-kit) and DOG-1. The patient started Imatinib therapy, and is free of disease recurrence for 3 years.A 60-year-old male presented with abdominal pain and acute low gastrointestinal bleeding. During observation a palpable mass was detected in the periumbilical region, left hypochondrium and left flank. A non-total colonoscopy was inconclusive. An Angio-CT showed a large exophytic tumor arising from the 4This case pretends to review an unusual presentation of a giant jejunal intestinal GISTs as well as its management in an emergent context. However, they are the most common mesenchymal neoplasms of the gastrointestinal tract ,2,7. TheIn most cases, GISTs have an indolent clinical presentation and are discovered incidentally during endoscopic or radiologic exams or surgery. They can occasionally present as surgical emergencies such as gastrointestinal haemorrhage, intestinal obstruction or perforation ,9.This work presents a case of a giant GIST of the first segment of the jejunum, which presented with acute massive gastrointestinal bleeding and needed emergent surgical treatment.The work has been reported in line with the SCARE criteria .2A 60-year-old male patient was admitted in the Emergency department of our Hospital with symptoms of abdominal pain with 2 weeks of evolution and progressive worsening and acute low gastrointestinal bleeding. The patient denied nausea, vomiting, fever and weight loss. He didn’t have personal history of medical or surgical diseases. The patient also didn’t have any history of familiar malignant disease.On initial clinical observation the patient was haemodynamically stable. The examination of the abdomen revealed a palpable painless mass in the periumbilical region, left hypochondrium and left flank. There was evidence of low gastrointestinal bleeding (hematochezia). The initial haemoglobin value at admission was 133 g/dl. An emergency non-total colonoscopy showed no gastrointestinal lesions that could cause the bleeding. An Angio-CT was requested and showed a large exophytic mass arising apparently from the 4th duodenal segment and first jejunal segment with approximately 20 × 14 x 13 cm, with vascularization provided from branches from the upper mesenteric artery, with vascular dilatations inside the tumor and apparent intratumoral bleeding, without intraperitoneal bleeding .Fig. 1CTThe patient’s condition deteriorated, and he became haemodynamically instable, with new episode of low gastrointestinal bleeding (hematochezia). The haemoglobin value dropped to 8,6 g/dl, requiring fluid resuscitation and blood transfusion.th duodenal segment. A side-to-side manual anastomosis was performed between the 3rd duodenal segment and the jejunum  e and 3 . jejunum .Fig. 2ImThe post-operative period ran without complications. The patient started oral feeding at the 7th post-operative day, after performing a gastrointestinal oral contrast study that confirmed the integrity of the anastomosis. The patient was discharged at the 11th post-operative day.The histopathologic exam of the surgical specimen showed a gastro-intestinal stromal tumor of epithelioid cell nature, with low mitotic count (<5 per 50HPF), significant mucosal ulceration, high vascularization and tumoral necrosis. The imunohistochemical analysis revealed positivity for CD117 (c-kit) and DOG-1. The tumor was categorized as T4N0 stage IIIA. A mutation on c-KIT was found in exon 9. According to size, location and mitotic count, the tumor was categorized as high-risk GIST.The patient was evaluated by Medical Oncology and started Imatinib therapy (400 mg per day). The follow-up continues, and the patient is free of disease recurrence for 3 years.3KIT or PDGFRα genes. Approximately 95% of GISTs are positive for CD117 [Gastrointestinal stromal tumors (GISTs) are characterized by the presence of activating mutations in or CD117 ,11.th decade of life, with a male predominance.GISTs are usually found during adulthood, and are diagnosed most frequently during the 7These tumors can be more frequently found in the stomach 40% to 60%), followed by the small bowel (25%) ,4,10,11.0% to 60%GISTs are usually indolent tumors. They may be discovered by symptoms, most of them nonspecific, such as abdominal pain and early satiety. They may be responsible for chronic gastrointestinal bleeding, although, in rare cases, acute massive bleeding can occur. The cause of their hemorrhagic potential is the ulceration of the mucosa . The tumThe pre-operative diagnosis may be challenging and is often confirmed during surgery. In cases presented as acute gastrointestinal bleeding, endoscopic exams are usually the first modality to determine the source of bleeding. If it cannot be identified by endoscopy, a CT-scan or angiography is often performed in order to give additional information .This work presents a case of a jejunal GIST that developed acute massive gastrointestinal bleeding and needed emergent surgical treatment. Small bowel GISTs are rare tumors of the gastrointestinal tract, and their presentation as acute massive haemorrhage is also rare. Once GISTs of the small intestine often show an exophytic growth pattern, they tend to be asymptomatic until they achieve large dimensions. Most cases present with chronic intraluminal gastrointestinal bleeding. Occasionally, small intestinal GISTs can present with bowel obstruction, hemoperitoneum secondary to tumor rupture, and peritonitis secondary to tumor perforation .The presumptive diagnosis in this case was made before surgery, while the patient maintained haemodynamic stability, and required both endoscopic and imaging exams.Surgical resection is the basis of treatment of GISTs and treatment with Imatinib, a tyrosine kinase inhibitor, is beneficial after resection surgery of high-risk GISTs ,4,5,9,124Small bowel GIST is an unusual tumour of the gastrointestinal tract and can have various clinical presentations. Its presentation as acute gastrointestinal haemorrhage is unusual, and a high index of suspicion is required for its diagnosis and management. Endoscopic and imaging exams are often indispensable to establish the pre-operative diagnosis.This work describes a case of a giant jejunal GIST causing massive low gastrointestinal bleeding, requiring emergency surgery. The report of this case pretends to review an unusual presentation of small intestinal GISTs as well as its management in an emergent context.The authors report no conflicts of interest.There were no sponsors involved.The study is exempt from ethnical approval in our institution.It was obtained a written and signed consent from the patient to publish this case.Catarina Melo – data collection, analysis and interpretation, writing the paper.Fernando Manata – data collection, analysis and interpretation.António Bernardes – data collection, analysis and interpretation, writing the paper.N/A.Catarina Melo.António Bernardes.Not commissioned externally peer reviewed.


Mesenteric cysts are documented as rare intra-abdominal benign tumors, whose etiology and classification controversy still exists. They are considered the rarest variety between the abdominal cysts and both its low incidence and the mistaken belief that was a trivial process without apparent symptoms, had contributed to their scarce knowledge. This study aimed to present a mesenteric cyst case with focal acute inflammation and four lymph nodes with follicular lymphoid hyperplasia.The study was performed 20-year-old female patient, examined in emergency department for abdominal pain 12 hours of evolution located in flank and left upper quadrant, with mild improvement after analgesic treatment, accompanied with mild fever. The patient presented left paramedian cystic formation measuring 4 cm in size with echogenic content inside. Exploratory laparoscopy treatment of emergency was proposed. The postoperative course was favourable remaining afebrile, no abdominal pain and good tolerance to oral intake, so it was hospital discharged within 72 hours of surgery. The diagnosis was mesenteric cyst with focal acute inflammation and four lymph nodes with follicular lymphoid hyperplasia. In conclusion, the type of surgery depended on the size of the cyst, its location in the peritoneal cavity and the experience of the surgeon. Laparoscopy technique was used as a first option. •Mesenteric cysts are considered the rarest variety within the abdominal cysts.•The type of surgery depended on the size of the cyst, its location in the peritoneal cavity and the experience of the surgeon.•Laparoscopy is the technique used as a first option with less comorbidity and postoperative stay than laparotomy. They ar220 years old woman with no background of interest, who came to the emergency room of the Royo Villanova Hospital due to abdominal pain 12 hours of evolution located in flank and left upper quadrant, with mild improvement after analgesic treatment, accompanied with mild fever. Does not refer nausea or vomiting, or changes in bowel habits.Physical exploration. Temp: 37,6 °C; TA: 123/72; FC: 86 lpm; Sat.O2: 100%. Conscious, oriented, normocolored and normohydrated patient. AC: rhythmic tones to 80 lpm. No audible murmurs or extratones. AP: normoventilated. Abdomen: soft, depressible, painful palpation in the left iliac fossa with no signs of peritoneal irritation. Peristalsis preserved. Bilateral renal succession negative. Femoral pulses present and symmetric. EEII: No edema or signs of DVT. Pedis pulses present.Supplementary tests. CBC: Hb 12,8 g/dl; HCT 37,9%; 216,000 platelets/mm3; Leukocytes 12,100/mm3; Neutrophils 79,4%; Lymphocytes 11,3%. Biochemistry: Glucose 120 mg/dl; Urea 15 mg/dl; Creatinine 0,71 mg/dL; Sodium 140 mEq/L; Potassium 4,3 mEq/L. Coagulation: PT 17,9 seconds; AP 59,3%; INR 1,32; APTT 26,5 seconds; Fibrinogen 358 mg/dl. Urine: No abnormalities. BHCG negative.Abdominal ultrasound. Liver of normal size and morphology with echostructure preserved, without appreciating LOEs. Gallbladder, bile duct, pancreas, spleen and both kidneys in normal size, morphology and echostructure. No lymphadenopathy. No free fluid. Left paramedian cystic formation measuring 4 cm in size with echogenic content inside was identified.Contrast-enhanced CT. Left paramedian cystic injury of 4 cm, at the height of the aortic bifurcation with greater density in its bottom portion. It enhances peripherally with the dye and it does not communicate with the gastrointestinal tract, being compatible with complicated mesenteric cyst. The lesion was accompanied by increased density of mesenteric fat (panniculitis) and small locoregional mesenteric lymph nodes. Discrete amount of free fluid in pelvis . Other manifestations described are nausea and vomiting (45%), abdominal distention 17–61%), abdominal masses palpable (44–61%), constipation (27%) or diarrhea (6%). There have also been cases of compression of adjacent structures, resulting in pyelonephritis, due to ureteral obstruction; acute abdominal because of infection of the tumor; inguinoescrotal tumor; jaundice and anemia due to intratumoral bleeding [2%. Other1%, abdomRegardless of its origin, the treatment of choice is surgical excision, thus avoiding excessive growth or the appearance of serious complications for the patient. Sometimes the cyst closely shares its blood supply with a segment of the intestine so resection intestinal segment involved is required (up to 60% of cases) ,10.4The type of surgery depends on the size of the cyst, its location in the peritoneal cavity and the experience of the surgeon. Laparoscopy was the technique used as a first option, since results similar to laparotomy have been achieved but with less comorbidity and postoperative stay. If surgical resection was not possible, another option was the subtotal or partial resection with marsupialization and sclerosis of the endothelium cyst .The patient gave written informed consent for publication of this case report.Not commissioned, externally peer reviewed.Ethical approval was gained prior to interviews commencing (16/NW/0639).There is no sources of funding.Irene Cantarero Carmona: writing the paper.José Fernando Trebollé: data collection, data analysis or interpretation.Daniel Milian García: writing the paper.a José Luesma Bartolomé: data analysis or interpretation.MName of the registry:Unique Identifying number or registration ID:Hyperlink to the registration (must be publicly accessible):Irene Cantarero Carmona: writing the paper.José Fernando Trebollé: data collection, data analysis or interpretation.Daniel Milian García: writing the paper.a José Luesma Bartolomé: data analysis or interpretation.MWritten 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.There is no conflict of interest.


Papillary fibroelastomas are rare benign primary cardiac tumors. They are typically found on valvular surfaces, most commonly, the aortic valve. In this article, we report a case of papillary fibroelastoma arising from the sinotubular junction of the ascending aorta, a rare and unusual site causing an embolic stroke. They are typically found on valvular surfaces with the aortic valve being the most common location.1 PFEs have also been described arising from unusual locations.2 Reported is a case of a probable PFE arising from the sinotubular junction of the ascending aorta, a rare and unusual site.Papillary fibroelastomas (PFEs) are rare benign primary cardiac tumors, and clinical presentations can be varied. However, embolic events leading to neurological sequelae, such as transient ischemic attacks or strokes, are the most common presentations.A 75-year-old white woman with history of hypertension and endometrial cancer was admitted for radical hysterectomy and hernia repair. Her intraoperative course was uneventful, but on postoperative day 2, she developed acute onset of right-sided weakness and was subsequently diagnosed with a stroke. There was no intracranial bleed on non-contrasted computed tomography imaging, but due to her recent surgery, she did not qualify for thrombolytic therapy and further neurologic workup was initiated. Magnetic resonance imaging of the brain showed multiple areas of restricted diffusion in the occipital and temporal lobes suggestive of acute embolic events.During diagnostic workup to determine the embolic source, a transesophageal echocardiogram revealed no intracardiac thrombus but a 1.2 cm × 0.9 cm echo-density arising from the sinotubular junction of the ascending aorta was discovered. This lesion was in proximity to the left main coronary artery . Long- aSubsequently, a cardiac magnetic resonance imaging was performed for better tissue characterization. T2-weighted images confirmed the presence of a mass at the sinotubular junction, and a prior non-gated computed tomography scan of the chest showed a similar finding. A multidisciplinary team discussion with the patient and her family was held, and it was determined that she was at high risk for curative surgical resection due to multiple comorbidities. Therefore, pathological evaluation of this lesion was not possible. However, given the various imaging modalities used with concordant findings, a general consensus was reached that this lesion was most likely a PFE arising from the sinotubular junction. The patient was subsequently discharged to inpatient rehabilitation on anticoagulation and was unfortunately lost to follow-up.3 It is believed that the incidence of PFEs was previously underestimated until recent advancements in imaging modalities.4 In a retrospective cohort study by Gowda et al, usual locations of PFEs were the aortic valve (36%), the mitral valve (29%), the tricuspid valve (11%), and the pulmonary valve (7%).1 The involvement of extravalvular sites is especially rare.Papillary fibroelastomas are the most common primary tumors of the cardiac valves.5 Advancements in multi-imaging modalities is likely the cause of the increasing incidence of PFEs. In patients with PFEs who present with embolic strokes and who are of acceptable operative risk, excision of the lesions at highly experienced surgical centers has been the standard of care.6 Furthermore, excision of PFEs through minimally invasive approaches have also been described.7There have been limited reports of unusual sites of PFEs in the past, specifically the ascending aorta.In this reported case, an embolic stroke occurred likely secondary to the PFE. Due to this association and her clinical presentation, surgical resection was indicated. Unfortunately, due to her comorbidities, she was deemed high risk for surgery.8 More data are needed to help guide the nonsurgical management of high surgical risk patients with these lesions.It can be challenging to manage patients diagnosed with this cardiovascular tumor. Currently, depending on symptoms, size, and tumor mobility, either surgical resection or anticoagulation regimen is usually offered to those patients.


Primary retroperitoneal serous adenocarcinoma (PRSA) is an extremely uncommon malignancy exclusively reported in females. Due to the rarity of the disease, it is difficult to establish a standardized treatment.We describe a unique case of PRSA in a 71-year-old male who presented with right-sided lower back pain and numbness. Magnetic resonance imaging identified a mass invading the adjacent psoas muscle and twelfth rib. Tissue biopsy confirmed poorly differentiated PRSA. Patient was initially treated with neoadjuvant carboplatin and paclitaxel chemotherapy regimen. This resulted in complete radiological resolution of the tumor. However, 12 weeks later, rapid recurrence was noted on follow-up CT scan. The patient was then treated with external radiotherapy with concurrent nivolumab, an anti-PD-1 antibody. The patient displayed a positive response to treatment with reduction in primary tumor and metastases and had a sustained disease control.Treatment with radiotherapy in combination with anti-PD-1 antibody could be an effective modality of management for PRSA.The online version of this article (10.1186/s12885-019-5934-4) contains supplementary material, which is available to authorized users. Primary retroperitoneal serous adenocarcinoma (PRSA) is a rare clinical entity. To date, a handful of cases have been reported all of which occurring in female patients –8. WhileA 71-year-old male presented to the clinic with lower back pain and numbness on the right side in January 2017. The magnetic resonance imaging (MRI) of the lumbar spine showed a mass in the right retroperitoneum , and described as somatic alterations, with a third somatic mutation, FGFR1, identified. However, there was no plausible therapeutic strategy for PRSA that could target these mutations. Table The analysis of tissue DNA by Tempus  showed two potentially actionable mutations: Additional evaluation with brain MRI identified an asymptomatic 3 mm focal enhancement in the left lateral frontal lobe cortex. Since there was no mass effect, possibility of a metastatic lesion seemed unlikely. Nuclear bone scan highlighted diffusely increased uptake within the right twelfth rib, corresponding to the area where the rib was seen to be involved by the adjacent malignant tissue on prior CT and MRI scans.On the basis of limited information available in the existing medical literature, the most commonly used therapy for PRSA has been surgical resection of the tumor with adjuvant platinum-based chemotherapy, similar to treatment of ovarian serous adenocarcinoma. Hence, the patient was treated with neo-adjuvant carboplatin and paclitaxel combination (Carboplatin AUC 5 every 3 weeks and paclitaxel 80 mg/m2 intravenously every week) for six cycles. Subsequent imaging after 12 weeks demonstrated a reduction in the size of the malignant mass and lymph nodes . The plan is to continue nivolumab with imaging studies at every 12-week interval. Written consent was obtained from the patient for case publication.Primary retroperitoneal tumors account for 0.2–0.3% of all tumors. The common histological patterns include fibrosarcoma, lymphoma and teratoma.  The epitPrimary retroperitoneal mucinous cystadenocarcinoma (PRMC) is one of the subtypes of retroperitoneal neoplasm which also resembles the ovarian mucinous tumors. It is also a rare entity with less than sixty cases reported in current literature . MoreoveSome of the proposed theories to explain pathogenesis of PRSA and PRMC include neoplastic alterations in the metaplastic celomic epithelium, extra-ovarian endometriosis , 11, cysen bloc surgical resection of malignant mass with sufficient tumor-free margins remains the mainstay of treatment given the locally invasive tendency of retroperitoneal epithelial cancer [In light of the striking resemblance in biological and therapeutic behavior between primary retroperitoneal epithelial cancers and ovarian epithelial cancers , 3, bothl cancer , 14–16. l cancer , definitBased on the aforementioned facts, our patient was treated initially with chemotherapy consisting of carboplatin and paclitaxel with an intent to shrink the tumor to a surgically resectable size. The patient exhibited a complete radiological response after six cycles. Out of the eight cases previously described in literature, one patient received upfront chemotherapy with carboplatin and cyclophosphamide as the first line treatment and underwent a partial response . Two patp = 0.01) and complete response rate  when compared to ipilimumab alone [RT affects dead or dying cells that release antigens like calreticulin and high-mobility group protein B1 that activates dendritic cells, which in turn activate the antigen-specific T-cells to mount tumor specific immune response. The surviving irradiated tumor cells display increased expression of death receptor Fas, intercellular adhesion molecule (ICAM-1) and major histocompatibility complex 1 that allows enhanced recognition by activated T-cells. In addition, radiation therapy also upregulates the expression of T-cell inhibitory proteins such as PD-1 and CTLA-4 on tumor cells that suppress the host immunity . Severalab alone . Similarab alone . Thus, pAnother interesting aspect of this case was the estrogen receptor (ER) positivity. ER expression may suggest benefit of adding an anti-estrogenic agent or aromatase inhibitor to the treatment regimen and could be attempted as a next-line therapy. However, there is only one prior case study that reported ER positive PRSA, but no anti-estrogenic therapy was used .We report a unique case of primary retroperitoneal serous adenocarcinoma in a 71-year-old male. A complete radiological response to upfront platinum-based chemotherapy as observed in our patient has not been previously described. However, following rapid recurrence, institution of immunotherapy-radiotherapy combination led to decrease in tumor size followed by durable disease control. This suggests immunotherapy and RT synergy could be further explored as a potential treatment option for the management of PRSA.Additional file 1:Figure S1. Tumor response map illustrating more than 50% decrease in somatic alteration burden following chemotherapy. (DOCX 61 kb)


Intestinal duplication, a congenital malformation, is considered a rare condition, particularly in adults. Although it affects young children, a minority of patients remains asymptomatic until adulthood. Here, we describe a case of an intestinal duplication cyst that caused intussusception by a unique mechanism.A 19-year-old man was admitted to our hospital for intermittent abdominal pain. Computed tomography revealed colonic intussusception induced by a nodular mass in the ileocecal region. Urgent ileocecal resection was performed because of the risk of colonic ischemia. The resected material comprised a stool-filled noncommunicating cyst that protruded into the enteric lumen at the ileocecal valve. Histological analyses revealed that the inner wall of the cyst was lined with colonic mucosa and that the muscle layer of the cyst was shared with that of the original enteric wall; furthermore, the cyst had a vestige of an opening site in the wall. We concluded that the cyst was an intestinal duplication that poured stool into its lumen through the tiny orifice, thereby triggering intussusception.The present case suggests that stool-pouring can cause intussusception into the space of an intestinal duplication lesion. Alimentary tract duplication, a congenital malformation, occurs in approximately 1 out of 10,000 births. Ileac or ileocecal duplication is rather common in this condition. More than 80% of these cases are detectable as an acute abdomen or bowel obstruction before 2 years of age; however, a minority of patients remains asymptomatic until adulthood . IntestiA 19-year-old male was referred to our hospital by a primary care physician for a history of intermittent cramping pain in the right flank persisting for several days. His abdomen was flat and soft; however, he complained of abdominal pain upon pressure in the right lower quadrant. Most laboratory test results revealed normal limits except for elevated white blood count  and serum C-reactive protein level (1.6 mg/dL). Contrast-enhanced computed tomography Fig.  comprisecafe au lait colored or almost colorless [Intestinal duplication was first described by Fitz in 1884 ; in 1937olorless . Lately,olorless , 12.In 2016, Kyo et al. reported a similar cystic lesion filled with stool in an adult colon; however, that cyst was clearly communicating with the original bowel through a tubular twig . They suIn conclusion, this case of an intestinal duplication cyst in an adult suggests that intussusception could be caused by stool pouring into the space of an intestinal duplication lesion that was not an obstacle in childhood. Although such conditions are extremely rare in adults, they have to be considered for a differential diagnosis of acute abdomen.


Cystic lung lesions involving both lungs include a variety of diseases, such as pulmonary Langerhans cell histiocytosis, lymphangioleiomyomatosis and pulmonary metastasis. Primary pulmonary meningioma accompanied with intrapulmonary metastasis was extremely rare and we were not aware of previous studies reporting with cystic radiological manifestation.A 64-year-old female patient was admitted to our department for a mass located in right posterior mediastinum with multiple cystic pulmonary lesions. A thoracoscopic lung biopsy was performed and the diagnosis was confirmed as bilateral pulmonary metastasis from primary pulmonary meningioma.Intrapulmonary metastasis from a primary pulmonary meningioma may manifest as multiple thin-walled cystic lesions on computed tomography. Differential diagnosis of cystic pulmonary disease should include this situation. Our case shows the new CT manifestation of metastatic primary pulmonary meningioma and the importance of immunomolecular analysis. Cystic lung lesions involving both lungs include a variety of diseases, such as pulmonary Langerhans cell histiocytosis, lymphangioleiomyomatosis, Birt Hogg Dubé syndrome and pulmonary metastasis . MeningiA 64-year-old female patient was admitted to our department for multiple pulmonary lesions discovered by health examination for 1 month. She was asymptomatic, in good health, and had no history of pulmonary or neurologic disease. She denied history of tuberculosis, and she was a non-smoker.Chest computed tomography (CT) revealed multiple thin-, smooth-walled cysts or cystic nodules with solid component were scarred within the lung parenchyma, sized from 0.8 cm to 2 cm Fig. a, c. EnhThoracoscopic lung resection was scheduled for this patient. During the operation, the larger mass, which enveloped by fat-like thin films, was located on the surface of right lower lobe rather than the mediastinum. The tumor was stripped out successfully with a right-angle electrode and we also wedge resected two cystic lesions for pathological examination Fig. d.Routine pathological examination of both major mass and cystic lesions revealed the tumor consisting of spindle cells arranged in swirls scattered with a small amount of typical psammoma body Fig. d, X200, The patient underwent an uneventful postoperative course and no additional therapy was added for her.Intrapulmonary metastasis from a primary pulmonary meningioma may manifest as multiple thin-walled cystic lesions on computed tomography. Differential diagnosis of cystic pulmonary disease should include this situation. Our case shows the new CT manifestation of metastatic primary pulmonary meningioma and the importance of immunomolecular analysis.The diagnosis of the PPM depends on pathological and radiological studies, and more importantly, excluding metastasis from central nervous system. It is frequently reported that intracranial meningioma could metastases to the lungs, but only one case reporting multiple primary pulmonary meningioma . The rad4. The results of pathology examination suggested to be benign primary pulmonary meningioma, however, even benign meningioma could metastasize [The initial diagnosis of this patient was considered as mediastinal tumor with multiple thin-walled cysts involving bilateral lungs based on chest CT. These thin-walled cysts were suspected to be lymphangioleiomyomatosis or Langerhans cell histiocytosis for their radiology manifestations. Morphological and histological characters ruled out the possibility of lymphangioleiomyomatosis. And negative expression of IHC staining of CD68 ruled out the diagnosis of Langerhans cell histiocytosis. Other IHC markers, such as KI67/MIB-1, CD34 and PR evaluated at the same time because these markers are correlated with recurrence and metastasis


Dear Editor,. An ultrasound-guided transrectal biopsy was performed,and the histopathological study revealed abundant, benign mature smooth muscle, withscanty bistratified columnar epithelium, consistent with seminal vesicle leiomyoma. Leiomyoma is a benign smooth muscle tumor found in theuterus and in the gastrointestinal tract. Despite the high incidence of leiomyoma in thefemale genital tract, it is uncommon in the male genitourinary tract, only a few caseshaving been reported in the literature(8). Leiomyomas can proliferate in any tissue composedof smooth muscle and separated by any amount of connective tissue. According to somestudies, leiomyoma originates from the Wolffian and Müllerian ducts, and theimmunohistochemical differentiation remains controversial(9).Genitourinary tumors have recently been reported in the radiology literature ofBrazil(10). The most common changes to seminal vesicles areagenesis and cystic anomalies. Primary seminal vesicle neoplasms, which are extremelyrare, include leiomyoma, cystadenoma, angioendothelioma, teratoma, schwannoma, andparaganglioma. Patients with seminal vesicle leiomyoma are oftenasymptomatic, although lumbar pain, polyuria, dysuria, perineal pain, and infertilitymay occur(11).Seminal vesicles are extraperitoneal glands of the male reproductive system that secretefluid containing enzymes(12).Epithelial lesions, including secondary neoplasms such as carcinoma of the prostate,bladder, rectum and primary adenosarcoma, constitute the most common presentation ofseminal vesicle leiomyoma. Typical MRI findings include lesions with a hypointensesignal in T2-weighted sequences, obliteration of adjacent tissues, and loss of thenormal seminal vesicle architecture. The stromal lesions have a solid-cystic compositionand variable signal intensity.Extra-adrenal paragangliomas, which are rare neuroendocrine tumors, present aswell-defined lesions with a hypointense signal in T2-weighted sequences andpost-contrast enhancement, some showing heterogeneity with necrotic areas. Schwannomasshow a hypointense signal in T2-weighted sequences and intense post-contrastenhancement. In contrast, cystadenomas present as a well-defined, usually unilateral,multilocular cystic mass with a hypointense signal in T2-weighted sequences and discreteenhancementSolid seminal vesicles lesions are quite rare and have poorly specific imagingcharacteristics. However, we can rely on the well-established diagnostic parameters ofother abdominal solid lesions, such as ovarian and renal tumors, as a line of reasoningfor the suspicion of benignity.


Adenoid Cystic Carcinoma of larynx is extremely rare location. We herein describe an unusual clinical and radiological presentation of ACCL and review recent literature. We report a case of a 38-year-old woman with history of asthma, presented to our department with acute inspiratory dyspnea that required an emergency tracheotomy. Physical examination revealed a large anterior cervical mass without any lymphadenopathy suspecting thyroid origin. Cervical Computed Scan showed a tumor process between the thyroid lobe, the left edge of the subglottic area and first tracheal rings filling all the lumen, discussing either a laryngo-tracheal or thyroid origin. The patient underwent a panendoscopy under general anesthesia that confirmed a subglottic extension of the tumor and multiples biopsies showed a malignant salivary origin of the mass. After multidisciplinary discussion, the patient underwent total laryngectomy and thyroidectomy with bilateral selective neck dissections (levels II- IV). Anatomopathological examination confirmed the laryngeal location of Adenoid Cystic Carcinoma classified pT4aN0R0. Adjuvant radiation therapy was indicated. In our knowledge, only 10 cases were reported in the literature with this unusual presentation. Moreover, the case we report is in the subglottic floor without invasion of neither vocal cords nor trachea. Total laryngectomy with neck dissection remains the recommended therapeutic procedure for locally advanced ACCL. Adverse features such as close or positive margins, T3-4, intermediate or high grade neural and perineural spread, lymphatic or vascular invasion or lymph node metastases should indicate adjuvant treatment to improve the outcome. The lack of randomized multicentric study, implies the management of ACCL by skilled multidisciplinary team, to suggest adequate personalized treatment. Due to the very low density of minor glands in the larynx (23 - 47 glands/cmA 38-year-old woman with history of asthma, presented to our department with acute inspiratory dyspnea that required an emergency tracheotomy, without a history neither of hoarseness nor difficulty swallowing. Physical examination revealed a large anterior cervical mass without any lymphadenopathy. Cervical and Chest Computed Scan showed a tumor process between the thyroid lobe and the left edge of the subglottic area of the larynx and the first tracheal rings filling all the lumen. This process measures 34*25*50mm it respects the vocal cords and the arytenoids but invades the cricoid cartilage . The patet al. reports that ACCL occurs in both sex with slightly predominance in men [Minor salivary gland tumors are rare, they represent less than 4% of all head and neck neoplasms -7 . Adene in men , the mede in men ,8. We ree in men . In our e in men -13. Treae in men  even if e in men  as ACCL e in men . Howevere in men . This obe in men ,18. In fe in men  that supe in men . AdjuvanAdenoid cystic carcinoma of the larynx is an extremely rare malignant neoplasm. Surgical resection with neck dissection is the main treatment of non-metastatic tumor, however combined modality treatments greatly improves loco-regional outcome.The authors declare no competing interests.


Gallstone ileus (GSI) is a rare form of small bowel obstruction (SBO) in patients with cholelithiasis, which is often poorly managed. Enhanced abdominal computed tomography (CT) with contrast is considered the most helpful diagnostic tool, as it is highly sensitive, specific, and accurate. We report an interesting case of recurrent GSI that was not detected by CT but diagnosed intraoperatively.  A 49-year-old female with a previous history of choledocholithiasis and ERCP presented to the emergency department following episodes of sudden cramping, epigastric pain, and nausea. An abdominal CT revealed evidence of SBO with clear evidence of GSI and a cholecystoduodenal fistula. Laparoscopic exploration of the small bowel revealed a large, calcified 3.5 cm × 3 cm gallstone with evidence of pressure necrosis; segmental bowel resection with stapled anastomosis was performed and patient recovered appropriately after surgery. Cholecystectomy was not performed due to multiple co-morbidities and absence of gallbladder stones. However, she presented two months later with signs and symptoms of SBO. A repeat abdominal CT showed dilated bowel with no clear transition point. This was suspected to be due to adhesions. After an initial conservative treatment which produced mild improvement, laparotomy was performed which revealed a second large non-calcified gallstone and necrotic small bowel with a pocket of abscess.  The most sensitive diagnostic tool for GSI is enhanced abdominal CT but dilemma arises when GSI is not detected on CT. A high index of suspicion and further exploration are required in order not to miss other vital findings. Gallstone ileus (GSI) is a rare form of bowel obstruction that occurs in 0.4–1.5% of patients with cholelithiasis [Gallstones which enter the GI tract through a cholecystoduodenal fistula often become mechanically obstructed at the ileum due to its reduced diameter and the ileocecal valve. Patients present with small bowel obstruction symptoms including severe abdominal pain, nausea, vomiting, and abdominal distention. Differential diagnosis is completed by CT scans that reveal the presence of calcified gallstones in the lumen of the bowel at the transition point. Treatment includes minimally invasive surgery if possible or laparotomy to remove the stones and resect bowel if indicated. We report an interesting case of recurrent GSI that was not detected by CT scan but diagnosed intraoperatively. The clinical presentation, investigative findings, and management are discussed along with relevant literatures.2. Given her comorbidities, the plan during her ERCP visit was to perform her cholecystectomy at the same time she will undergo her gastric bypass, after optimizing her cardiopulmonary disease. At presentation, her abdominal computed tomography (CT) revealed evidence of small bowel obstruction with clear evidence of gallstone ileus  where three gallstones were removed from the common bile ducts . Before ne ileus . A cholene ileus . Evidencne ileus  and a clne ileus . A largene ileus  with eviA month later, she presented with signs and symptoms of small bowel obstruction. On physical exam, her abdomen was distended but with no tenderness. Patient was also noted to be in septic shock requiring vasopressors and unable to tolerate surgery; she was treated conservatively with Gastrografin challenge test , which revealed contrast in the colon. Her symptoms completely resolved; she tolerated oral intake and was discharged from the hospital.Patient presented again one month later with similar symptoms. At this presentation, she had an abdominal CT scan, which showed dilated bowel with no clear transition point. She was treated conservatively for five days with mild improvement where she tolerated liquids but not solid food. During the same hospital stay, she developed sudden severe abdominal pain, shortness of breath, tachycardia, and hypoxia. Another CT scan was performed with pulmonary embolism (PE) protocol which was negative for PE, but positive for free air . PatientGallstone ileus (GSI) is defined as bowel obstruction resulting from the impaction of one or more gallstones due to a cholecystoduodenal fistula. It is an uncommon complication of cholecystolithiasis; a rare cause of obstruction; and accounts for 1% to 4% of cases of mechanical obstruction of the bowel . There aEnhanced abdominal CT with contrast is considered the most helpful tool for diagnosis of gallstone ileus, as it is highly sensitive, specific, and accurate . The finThe surgical dilemma in this case lies in the fact that despite the occurrence of a second bowel obstruction, GSI was not clearly noted in the CT scan. In addition, a decompressed gallbladder was not noted as well. It is accepted that the second stone was not calcified which is why it was not detected on the CT scan. It is recommended that these be checked upon initial surgery to prevent recurrent gallstones. Although the bowel was examined in the initial surgery for presence of additional stones in this case, it is probable that the second stone was in the gallbladder or duodenum. While the limitations of bowel examination by laparoscopy cannot be discounted, laparotomy was avoided in the initial surgery due to her significant cardiopulmonary disease and BMI. Recurrence of GSI can happen if the cholecystoduodenal fistula has not been closed, and this is more likely if a second stone is present in the gallbladder. It is fairly controversial in the literature whether to proceed with cholecystectomy or not in the presence of a cholecystoduodenal fistula, but there are substantial data to avoid cholecystectomy due to the high morbidity, though it is not considered a contraindication , 8. RecuEnhanced abdominal CT remains the most helpful diagnostic tool for GSI. Disproportionate symptoms and signs of a small bowel obstruction, in a patient with a history of gallstone disease or previous GSI, should alert the surgeon to suspect GSI as a possible cause despite the absence of radiologic findings. Further exploration is indicated to detect the presence of other vital findings such as noncalcified gallstones in the small bowel, pressure necrosis, bowel perforation, and abscess formation. Surgery is often indicated to relieve intestinal obstruction quickly and to minimize morbidity and mortality.


Clinically, it is often asymptomatic. When they exist, these symptoms are less specific and generally due to the large size of the tumour . Imaging, especially TDM and MRI are an important step of the preoperative diagnosis. In imaging as in anatomopathology, lipoma-like liposarcoma is the main differential diagnosis. A differential diagnosis with lipoma-like sarcoma must be done.•Treatment: Treatment is surgical. However, there are variations in the surgical procedures. Some authors had carried out lumpectomy. In our case, we carried out a left colectomy removing the tumour and the mesocolon, as well as the satellite lymph nodes. Each approach has its arguments, i.e. a conserving treatment exposing to repetition if the histological and/or immunochemistry data come out less reassuring, and a more secure and less invasive treatment. There is no consensus on the procedure which depends on the teams. Abdominal masses are common in digestive surgery and gastro-enterology units. However, meso-intestinal lipomas remain rare and lipoma of the left colon uncommon. We report a case of giant lipoma of the left mesocolon whose diagnosis was highly guided by radiological examinations.A female patient aged 56, consulted for left subcostal abdominal pains. The clinical examination showed an abdominal mass occupying the left hemiabdomen. The abdominal-pelvic CT scan highlighted a large abdominal-pelvic mass in the left abdomen. Abdominal-pelvic MRI revealed a large fatty mass spreading from the front subphrenic space up to the level of the left iliac fossa, non-suspected and compatible with lipoma. FDG-Pet Scan had not revealed pathological fixing. The mass appeared like a total gap space. Exploratory surgery revealed a lipoma mass in the left mesocolon. Hemicolectomy was performed taking away the mass. Histology confirmed the diagnosis of lipoma and the outcome was favourable.Our case represents the fourth case of mesocolon lipoma described in the literature. Imaging, especially TDM and MRI are an important step of the preoperative diagnosis. The surgery consists of either a lumpectomy or a colectomy.Lipoma of the left mesocolon is exceptional. Radiological examinations provide most arguments to suggest lipoma. However the organ’s diagnosis is provided by surgical exploration and the certainty diagnosis by pathological examination. Treatment is surgical. They arThe management of this case as well as literature search was performed and the work has been reported in line with the SCARE criteria .2Patient, aged 56 years, mother of five children consulted for left subcostal pains for several months. The pains were more intense in a sitting position. These pains were followed by episodes of nausea/vomiting and even a subocclusive syndrome. She also mentioned rare and episodic rectal bleeding. The examination revealed an abdominal mass covering all the left hemiabdomen, from the left costal edge and the xiphoid process to the pubis. Upon palpation, it was somewhat painful, less mobile and soft. It measured about 28 cm long and 15 cm wide. Colonoscopy done was normal. The scan revealed a fatty mass in the left hypochondrium, similar to a fatty subcutaneous tissue . It was The mass appeared like a total gap space.We performed left hemicolectomy to remove in one piece the mass with the descending colon. The inferior mesenteric artery is not attached to its root. We attached its branches (upper left colonic artery and descending colon artery). Cutting of transverse colon and sigmoid colon was done after a colo-parietal detachment and release of the left colonic angle. Restoration of continuity was done through colo-colonic termino-terminal anastomosis by 2 hemisurjets with prolene 4/0. The mesocolonic breach was also closed with Prolene 4/0.Macroscopic examination revealed an adipose tumour of 39 cm located in the mesocolon and whose histology did not show any sign of malignity. A full exeresis was carried out. Given its size and location, an opinion was requested from the Sarcoma Expertise Centre, which helped exclude the hypothesis of well-differentiated lipoma-like liposarcoma. Postoperative follow-ups were uneventful. The patient’s recovered his bowel motility on the third day. He left hospital on the fifth day. After a period of 8 years, he made no complaint and no recurrence was noticed.3Lipomas are benign connective tumours which develop at the expense of fat tissue ,2,7. TheDiagnosis is based on clinical, radiological and histological examinations ,3,8. Thi4Lipoma of the mesocolon is a rare tumour less described in the literature. It generally involves large masses. Clinically, it is often asymptomatic. When they exist, these symptoms are less specific and generally due to the large size of the tumour . Imaging, especially TDM and MRI are an important step of the preoperative diagnosis. In imaging as in anatomopathology, lipoma-like liposarcoma is the main differential diagnosis. Treatment is surgical, but procedures depend on the teams. Our case represents the fourth case of mesocolon lipoma described in the literature. Its dignostic and therapeutic procedures must be known signifies its importance for reporting in the English literature.The authors declare that they have no competing interests regarding the publication of this manuscript.No sponsors to declare.Ethical approval is not needed for this case report as patient consent and we are not trialing a new device.Written and signed consent by the patient to publish a case report has been obtained.Case report concept and design: Koama A, Zongo N, Nde/Ouédraogo NA.Acquisition of data: Koama A, Zongo N, Kambou/Tiemtoré B, Lompo OM.Statistical analysis and interpretation of data: Koama A, Sanou A, Diallo O, Lougué/Sorgho C, Cissé R.Drafting of the manuscript: Koama A, Sanou A, Lougué /Sorgho C, Cissé R, Houry S.Critcal revision of the manuscript for important intellectual content: Koama A, Sanou A, Diallo O, Lougué /Sorgho C, Cissé R.All authors approved the final version of this publication.It is not a clinical trial.Dr Adjirta Koama.Dr Nayi Zongo.Not commissioned, externally peer-reviewed.


The patient is a 74-year-old female previously diagnosed with an ovarian tumor at age 55. No changes were noted for one year; however, she was lost to follow-up. Eighteen years later, she presented to a local clinic complaining of diffuse abdominal and flank pain. Abdominal and pelvic ultrasound, CT, and gynecological examination showed a fatty pelvic tumor of approximately 12 cm in diameter. A left ovarian teratoma was suspected, and per the patient's request, she was transferred to Kobe Adventist Hospital for further evaluation and treatment. Pelvic MRI revealed no ovarian enlargement; however, a mass in the uterine body was appreciated with a high signal on T1 and T2 images and signal dropout in the fat suppression images, a finding most consistent with a uterine lipoma. A total hysterectomy and bilateral salpingo-oophorectomy was performed, and histopathological examination confirmed the preliminary diagnosis. No complications were observed during the postoperative period. A pure uterine lipoma is an extremely rare tumor with only a few cases reported worldwide. It is a benign tumor; however, it can sometimes be misdiagnosed as a malignant neoplasm. Pelvic MRI appears to be a useful tool in order to make the correct diagnosis preoperatively. Lipomatous tumors of the uterus are very rare and have an estimated incidence of approximately 0.03 to 0.2% . Mixed-tThe affected patient population consists of mostly postmenopausal women . UterineHere, we report the case of a large pure uterine lipoma preliminary diagnosed via pelvic MRI and confirmed by histopathological examination.A 74-year-old female was transferred to our hospital with a presumptive diagnosis of a left ovarian teratoma. She was diagnosed with an ovarian tumor at age 55 and was followed-up at another hospital with no apparent changes. However, she stopped showing for consult after one year. Eighteen years later, she presented to a local clinic with diffuse abdominal and flank pain. She had a past history of pneumonia and her family history was noncontributory.An abdominal and pelvic ultrasound and CT showed a fatty pelvic tumor of 12 × 10 cm in size. No lymphadenopathies were observed. Gynecological examination and vaginal ultrasound confirmed the previous characteristics. Serum tumor markers  were within normal levels. Although there were no calcifications nor hairball-like lesions inside the tumor, a left ovarian teratoma was suspected. Per the patient's and family's wishes, she was transferred to our hospital for further evaluation and treatment. A pelvic MRI showed no ovarian lesions, but the uterus was noted to be enlarged to 13 × 11 cm due to a tumor localized in the uterine body. High signal was observed in T1 and T2 images and signal dropout was noted in fat suppression images . As a reAfter discussion with the patient and her family, an abdominal laparotomy was performed and a 11 × 10 cm tumor originating from the body of the uterus was noted . Both ovThe postoperative course was uneventful, and the patient left the hospital 10 days after surgery. No complications were observed after 9 months of follow-up.Uterine fatty tumors constitute a range of benign tumors that may be composed entirely of adipocytes (pure lipomas) or intermixed with connective tissue or smooth muscle (lipoleiomyomas and lipofibromas) . They arAlthough uterine lipomas are difficult to diagnose by imaging, pelvic MRI can be useful in identifying the fatty nature of these lesions . PreviouThis type of tumors can present with vaginal bleeding or pelvic discomfort resembling symptoms of leiomyomas . Our patThe diagnosis of a pure lipoma of the uterus should only be made by histopathology when smooth muscle cells, if present, are confined to the periphery of the adipocyte lobules . VariousIn conclusion, a pure uterine lipoma is a very uncommon benign tumor that can sometimes be misdiagnosed as other neoplasms. We recommend the use of pelvic MRI as a reliable tool in order to make the correct preoperative diagnosis.


Surgical resection of tumors invading the aorta is a challenging procedure. More recently, the use of thoracic aortic endografts has been reported to facilitate en bloc resection of tumors invading the aortic wall. The best treatment option is to keep the procedure separated before lung resection to reduce the risks of bleeding, therefore avoiding adverse consequences for the patient. However, an aortic stent placement before surgery is not mandatory with no clear signs of tumor or atherosclerotic plaque infiltrating the entire aortic wall.d-glucose integrated with computed tomography (PET/CT with 18F-FDG) was positive for hypermetabolic mass with negative lymph node stations bilaterally. Patient was undergone surgery for major lung resection by left thoracotomy. For an unexpected intraoperative bleeding due to the rupture of a calcified plaque, a stent was placed before proceeding with lung surgery. Patient was persistently stable, discharged after six days from surgery with no morbidities.A 72-year-old man came to our Department for a persistent cough. Computed tomography (CT) scan with enhancement showed a mass located in the left upper lobe of the lung with no clear sign of infiltration or calcified plaques along the entire vascular wall. A positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-In our case, no signs of the atherosclerotic plaque infiltration as well as no tumor infiltration were shown. In these situations, the aortic stent placement is possible in emergency, even during another operation. Nevertheless, surgeon experience and the good coordination among specialists is mandatory to yield a satisfying solution. Preoperative endovascular stent graft placement has been normally used to facilitate sectioning of tumors infiltrating the aorta . However218F-FDG was positive  for hypermetabolic mass with negative lymph node stations bilaterally. The patient had a smoking history (one pack/50 pack-years), with no other previous malignancies, and 20 years of comorbidities, including diabetes mellitus type 2, hypertension and hypercholesterolemia treated with medical therapy. Pulmonary function tests before surgery showed a forced expiratory volume in the 1st second (FEV1) of 1.7, equal to 80% predicted, and a forced volume vital capacity (FVC) of 2.4, equal to 82% predicted. The endobronchial ultrasound (EBUS) showed no N2 lymph node infiltration, although the percutaneous lung mass biopsy was highly suspect for adenocarcinoma of the lung. After signing the consent, the patient underwent a double-sleeve left upper lobectomy plus en bloc resection of the aortic wall adventitia for 4 × 2 cm2 through a left posterior thoracotomy. At the beginning of the operation, during the mobilization of the mass, a 5-mm aortic rupture occurred in the adventitia due to the presence of an atherosclerotic calcified plaque at this level  for 48 h after surgery for optimal stabilization of his clinical condition. Chest tubes were removed on the third postoperative day, and the patient was discharged after six days from surgery with no morbidities A. No ste3The resection of the invaded adventitia of the aorta is a common procedure in thoracic surgery and the presence of atherosclerotic plaques is fairly common. In our case, after mobilization of the tumor mass, a calcified plaque lost the support inducing rupture of the adventitia of the aorta with consequent bleeding. In summary, even if it is possible to control and solve the aortic bleeding with an intraoperative stent placement and a good coordination among specialists, whenever it is possible to study and define accurately before the operation the characteristics of an atherosclerotic aortic plaque , especiaThe Authors have no financial and personal relationships to disclose.No funding.For single case report NO ethical approval needs. Patient signed a consent for publishing the case report.Patient signed a consent for the publication of this case report.W.H. and B.A. wrote the case report. J.F. revised the case report.Ethical Board approval is not required for case reports in our Center.Prof. Jiang Fan is the Guarantor of this case report.Not commissioned, externally peer-reviewed.


Angiomyxoma-related intussusception in adults is extremely rare. Herein, we report an adult man who presented with mechanical small bowel obstruction caused by ileo-colic intussusception triggered by an angiomyxoma of the terminal ileum and review the literature on this topic.A-40-year-old man was referred to Al-Ain Hospital with a clinical picture of small bowel obstruction. He has no previous abdominal surgery. Clinical examination showed a distended soft abdomen, and hyperactive bowel sounds. Abdominal ultrasound and computed tomography scan showed a doughnut sign confirming the presence of ileo-colic intussusception as the cause for small bowel obstruction. At laparotomy, a mass was found in the right iliac fossa. Right hemi colectomy was performed with ileo-colic anastomosis. An ileal pedunculated mass triggered the intussusception. Histopathology of the mass was diagnostic of an angiomyxoma of small bowel. Echocardiogram showed no atrial synchronous myxoma. The patient was discharged home with good general condition. At three years follow up, the patient remained asymptomatic without evidence of recurrence.Myxoma of small bowel should be included in the differential diagnosis of small bowel obstruction in the young age group particularly if the diagnosis of intussusception was made preoperatively. They 29 /L, his CRP was 6.51 mg/L. Erect abdominal X-Ray showed multiple air fluid levels in the small bowel. Abdominal ultrasound revealed distended small bowel loops and a doughnut sign in the ileo-cecal area  but needs a specific consent form that should be directly signed by the each patient approving publishing their data and clinical images. Any case series of five patients and more needs an approval of our Committee. We have obtained this written consent from our patient abiding with the regulations of our Committee. The senior and corresponding author of this manuscript is the Chair of the Human Research Ethics Committee of UAE University and confirms this fact.This is a case report and an exempt from a full Ethical Committee review. The patient gave his written consent to report his case and publish his clinical images. This has been explained in detail above.Hussam Mousa was the treating surgeon, had the idea, read the literature, wrote the first version and approved the final version of the paper. Suhail Al-Salam was the pathologist who reviewed the slides, prepared the pathology figure, and approved the final version of the paper. Fikri Abu-Zidan participated in the idea, edited the first version and approved the final version of the paper.NA.Fikri M. Abu-Zidan, Chair, Human Research Ethics Committe, UAE University, Professor; Acute Care Surgeon, Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.Not commissioned, externally peer-reviewed.


Soft tissue sarcomas represent an extremely rare cause of esophageal masses, and undifferentiated sarcomas are rarer. The proportion of dedifferentiated liposarcomas (DDL) is even lower. The case of a 58-year-old male who complained of dysphagia and was found to have an 18-centimeter long esophageal mass/polyp on esophagogastroduodenoscopy is presented. The lesion was resected endoscopically and a diagnosis of DDL was confirmed by fluorescence in situ hybridization. Due to its rarity, the treatment experience with esophageal DDLs is limited. However, based on our experience, endoscopic resection of the lesion can be considered as the treatment of choice when feasible. We performed a review of the literature to identify and analyze similar reported cases. Tumors of mesenchymal origin are rare in the gastrointestinal tract, with liposarcoma having an incidence of 0.1% to 5.8 % at autopsy -3. An evA 58-year-old male was evaluated at an outpatient clinic for difficulty in swallowing for the last few months. He complained of dysphagia with solid food but faced no problem with a liquid diet. The patient denied any odynophagia, vomiting, symptoms of gastroesophageal reflux, or weight loss. He did not have any significant past medical history and did not smoke or drink alcohol. Upper esophagogastroduodenoscopy (EGD) was performed for further assessment, which showed, a giant, pedunculated mass arising from the esophageal wall at 18 centimeters (cms) from the incisors, near the cricopharyngeus and extended up to 36 cms from the incisors  scan of the chest, which showed severe esophageal dilation, measuring up to 5.4 cms at mid-mediastinal level, with retained food debris. After a multidisciplinary discussion between gastroenterology and the thoracic surgery team, a decision was made to endoscopically resect the mass.During endoscopy, the mid-portion of the lesion was noted to have a large multi-lobulated mass Figure .At this point, a snare was used to attempt to resect the base; however, due to the presence of the mid lesional, multi-lobulated mass, we were unable to get around it; therefore, electrocautery was used in combination with an IT knife  to transect the lesion at the base Figure .At the completion of this, there was adequate hemostasis at the base and an endo clinch was used to further reinforce it. The entire mass was attempted to be pulled out of the esophagus but could not be moved out past the upper esophageal sphincter. Therefore, it was pushed back into the stomach, cut into smaller pieces using a hot snare, and removed in a piecemeal fashion Figure .The specimen was sent for routine pathological evaluation. A barium esophagram performed on the first postoperative day showed no evidence of a leak, and the patient tolerated a clear liquid diet without any complications. The pathology report revealed a diagnosis of DDL. The patient was advised about further imaging with positron emission tomography (PET)-CT scan and referral to a radiation oncologist, but he refused additional treatment.Dedifferentiated liposarcoma (DDL) is an extremely rare cause of an esophageal mass, with only eight reported cases so far. We did a literature review to identify the demographic details, clinical presentation, histology, treatment, and follow-up of esophageal DDLs Table .All patients were males, with an average age of 75 years (50-81 years) and the most common symptom was dysphagia followed by weight loss. Successful endoscopic resection was done in three of five (60%) and surgical resection in two of five (40%) of the cases.Five pathologic subtypes of liposarcoma are described in the literature, including well-differentiated, dedifferentiated, myxoid, pleomorphic, and round. DDL is defined as a tumor containing an atypical lipomatous tumor or a well-differentiated liposarcoma admixed to a component of high-grade non-lipogenic sarcoma. The genetic hallmark of these tumors is supernumerary ring chromosomes that contain amplification of chromosome 12q13-15. The MDM2 (mouse double minute 2 homolog) gene is present in this region of chromosome 12 . The CPMIn our case, the histology of the resected specimen showed both well-differentiated and dedifferentiated components. The well-differentiated part was characterized by adipocytes, myxoid change, and scattered atypical cells Figure .The DDL component consisted of fascicles of hyper-cellular spindle cells without lipogenic differentiation Figure . Immunohistochemical stain was performed to further explore the presence of DDL. The majority of the tumor cells displayed at least one centromeric chromosome 12 signal and many MDM2 signals, with an MDM2/CEP12 ratio >/= 2.0, consistent with the amplification of MDM2. The interphase fluorescence in situ hybridization (FISH) technique was used to confirm the amplification of the MDM2 gene locus and it was positive. The overall histologic and molecular findings supported the diagnosis of esophageal DDL.Due to its rarity, the treatment experience with esophageal DDLs is limited. A study by Wu et al. from the SEER registry demonstrated that patients with esophageal sarcomas were more likely to have localized disease, to be treated with surgery, and to have better overall survival  than patients with esophageal carcinoma. The authors also proposed that surgery should be the primary treatment for patients with esophageal sarcoma due to the survival benefit . A reviePreviously esophageal liposarcomas were treated by surgical methods, including simple enucleation and partial or total esophagectomy. However, this approach is more invasive with a longer postoperative recovery period, hospital stay, and cost as compared to endoscopic resection. This case demonstrates that even giant esophageal DDLs can be successfully resected by the endoscopic technique. Even though there are no guidelines on the duration of follow-up, esophageal liposarcomas can recur with a latency period of up to 25 years after resection . Most soRecommendations for surveillance include annual upper endoscopy with biopsies and rigorous clinical follow-up with history and physical examinations performed every three months to identify those with new-onset dysphagia . A chestEsophageal DDLs are rare tumors but should be considered as a differential diagnosis when evaluating esophageal masses/polyps. FISH showing the amplification of the MDM2 gene locus is diagnostic. Resection of the esophageal DDL can be considered as the treatment of choice and with recent advances in technology, endoscopic resection of such tumors is achievable, offering several potential benefits over surgical resection.


Solitary calcified nodule-related carpal tunnel syndrome (CTS) is rare and easy to be misdiagnosed owing to the high incidence of primary CTS. Release of the transverse carpal ligament without removal of the mass leads to persistence of the symptoms and subsequent complications like wasting of the thenar muscles. Here, we report two cases of solitary calcified nodule-related CTS and discuss the role of ultrasound in preventing misdiagnosis. Both patients reported persistent numbness over the lateral side of their palm and weakness of the right wrist with thenar muscle atrophy. One patient had undergone transverse carpal ligament release 2 years previously, and the other had received a local injection of lidocaine at the clinic. Neither patient experienced symptom relief. X-ray revealed a similar finding of nodule lesions in front of the capitate–hamate region. Solitary calcified nodule-related CTS was diagnosed, and the patients underwent nodule removal with/without transverse ligament release. The first patient was a typical case of misdiagnosed solitary calcified nodule-related CTS. The second patient had a definitive clinical sonographic diagnosis before surgery. The accurate diagnosis of secondary CTS is paramount for performing effective surgery. Thus, ultrasonography is an easy, convenient, safe, and effective method in screening for secondary CTS. Secondary carpal tunnel syndrome (CTS) is less common than primary CTS wherein the median nerve is entrapped within the transverse carpal ligament. The pathological causes of secondary CTS may include trauma, dialysis-related amyloidosis, pregnancy, or space-occupying lesions . Space-o3 at the volar side of the capitate–hamate region  after reviewing 324 cases of CTS . SimilarA careful physical examination should be initially performed for establishing an accurate diagnosis. Identification of a space-occupying lesion becomes easy when the nodule is palpable and presents as swelling and local tenderness over the flexion crease of the wrist . The inc3 in front of the capitate. Owing to the accurate diagnosis of space-occupying lesion-related CTS, the patient underwent surgery that included nodule excision and transverse carpal ligament release and achieved satisfying outcomes. All of the above-mentioned studies concluded that the possibility of space-occupying lesions should be considered when treating patients with typical symptoms of CTS at the initial presentation.Our second patient responded poorly to a local injection of lidocaine and exhibited typical symptoms of CTS during physical examination of the unilateral wrist. Due to obscure local tenderness and the small size, the lesion was difficult to locate via only physical examination. A hyperechoic ovoid lesion occupying the carpal tunnel and directly compressing the median nerve was detected using sonography. A subsequent X-ray also revealed a radiopaque nodule sized 0.6 × 0.6 × 1.3 cmIn both patients, the final pathological findings indicated a calcified nodule. Namba et al. inferred that the pathogenesis of calcified nodules in the carpal tunnel and calcifying tendinitis of the rotator cuff may be the same . They coWith respect to the examination, electrodiagnosis, which can help evaluate the severity of mononeuropathy of the median nerve as well as establish a differential diagnosis, is the gold standard for diagnosis. Several drawbacks of the NCV/EMG tests have been noted, for example, it is an invasive and uncomfortable procedure and is associated with increasing costs and relatively low sensitivity . For theAs the initial imaging modality for secondary CTS, ultrasound is convenient, inexpensive, and non-invasive; further, it does not require additional radiation exposure and helps establish initial differential diagnoses in the outpatient department. When compared pre- and postoperatively, ultrasound can also be used to examine the decompression of the median nerve. Most importantly, ultrasound could prevent the misdiagnosis of space-occupying lesion-related CTS, thereby facilitating the performance of effective surgery.Written informed consent was obtained from the patient for the publication of this case report.T-FC, C-YC, and S-WY contributed to the operation and writing. P-TL performed the ultrasound. All authors contributed to the manuscript revision and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A seven-year-old spayed female Labrador retriever presented for necropsy following an acute history of thrombocytopenia, anemia, leukocytosis and abdominal effusion. A 2 × 3 × 10 cm, cylindrical to tubular, mottled red-to-tan mass extended from the caudal pelvic cavity caudally and ventrally under the dermis along the caudal aspect of the left pelvic limb adjacent to the semimembranosus and semitendinosus musculature. Histologic examination of the mass revealed a singular central lumen lined by urothelium that multifocally transitioned into non-keratinizing, stratified squamous epithelium associated with few hair follicles and sweat glands. The lumen was surrounded by a dense collagenous stroma containing numerous, variably sized blood vessels. The combination of lesions was consistent with a diagnosis of incomplete urethral duplication associated with a dermoid cyst and vascular hamartoma. To the authors’ knowledge, this is the first report of an incomplete urethral duplication associated with a dermoid cyst within a vascular hamartoma. Urethral duplication is a rare congenital anomaly infrequently diagnosed in domestic animal species. A total of five cases of urethral duplication have been reported in veterinary medicine, with four cases reported in dogs ,2,3,4. UA seven-year-old spayed female Labrador retriever presented to the Utah State Veterinary Diagnostic Laboratory for necropsy following an acute onset of thrombocytopenia and anemia coupled with a peripheral neutrophilia, lymphocytosis and monocytosis. The history indicated a previous diagnosis of coccidioidomycoses that was being treated at the time of death. Abdominal ultrasound revealed an enlarged, granular liver with irregular liver margins. The urogenital tract showed no significant ultrasonographic abnormalities. In addition to fluconazole and amphotericin B treatment for coccidioidomycoses, the patient was receiving prednisone and myocophenolate for a presumptive immune mediated anemia and thrombocytopenia, and S-adenosyl-L-methionine (SAMe) for elevated hepatic enzymes prior to presentation for necropsy. The patient died naturally at home seven days after initial presentation.Gross necropsy revealed a hemoabdomen with approximately 1 L of serosanguineous fluid within the abdominal cavity, petechiation along the ventral abdomen and dark-red-to-purple viscous material within the entirety of the gastrointestinal tract. Originating within the pelvic fat lateral to the pelvic urethra and coursing caudally and dorsally within the subcutaneous fat overlying the left semimembranosus and semitendinosus muscles was a 2 × 3 × 10 cm, cylindrical to tubular, mottled tan-to-red mass that ended abruptly approximately one quarter to one third of the way down the pelvic limb. It was not determined at the time of necropsy if the mass directly communicated with the urinary bladder or urethra. The mass was grossly soft to spongy with a central slit-like lumen measuring up to 25 mm in diameter on cross section. The lumen continued down the entire length of the mass ending approximately 1 cm proximal to the blinded end within the pelvic limb.Microscopic evaluation of the mass revealed an unencapsulated, moderately cellular, well-demarcated expansile mass . The masAdditional gross and histologic diagnoses included cirrhosis, multiple adenohypophyseal cysts, meningioangiomatosis, splenic and bone marrow myeloid dysplasia, adrenal cortical hyperplasia and hypertrophy, lymphoplasmacytic gastritis and hemomelasma ilei. The cause of death in this dog was attributed to sequela associated with cirrhosis. Presumptive myeloid dysplasia was diagnosed on histopathologic examination of the bone marrow and splenic tissue. A complete blood count in the ante-mortem period was unavailable to confirm a concurrent diagnosis of myeloid leukemia.Urethral duplication is a rare lesion in veterinary medicine. This report outlines the first case of urethral duplication in a female dog. All cases of urethral duplication reported in veterinary medicine have been described in male dogs. In humans, urethral duplication is also rare, and is usually diagnosed at a young age, primarily in male patients. When diagnosed in female patients, urethral duplication is often coupled with additional urogenital abnormalities such as a prepubic sinus formation, abnormal urethral location within the vagina, duplication of the urinary bladder or renal abnormalities ,7. None Unlike previous reports of urethral duplication in dogs, the clinical history and medical record provided with this case did not indicate the presence of any previous urogenital abnormalities. Recurrent urinary tract infections have been previously reported with urethral duplication in a dog . There wAs with other cases of urethral duplication, multiple unrelated congenital anomalies were present in this dog. The mass ended blindly with a dermoid cyst. Dermoid cysts are rare lesions in domestic animals characterized by reduplication of haired skin including follicles and associated adnexa . DermoidThe association of a vascular hamartoma in conjunction with a duplicated urethra resembles the corpus cavernosum of a penis. The external genitalia of this female dog were grossly unremarkable. Specifically, the clitoris did not appear abnormally large or prominent. However, the gonads were unavailable for histopathologic evaluation due to a previous ovariohysterectomy. A singular case report in human literature of accessory female phallic urethral diverticulum formation described similar histopathologic findings that manifested clinically as an enlarged clitoris with urinary retention . The hisUrethral duplication remains a rarely diagnosed and poorly studied condition in veterinary medicine. While this condition is uncommon, urethral duplication should remain a differential diagnosis for cases of recurrent cystitis and should be evaluated in patients that present with disorders of sexual development.