Uterine leiomyomas are common benign neoplasms. While generally easily diagnosed, variations in size and type of degeneration can drastically alter the imaging findings and result in diagnostic uncertainty. We present the case of a 34-year-old female with a large, cystic, pelvi-abdominal mass that was discovered in advanced pregnancy and misdiagnosed as an ovarian tumour. Intra-uterine demise of a viable foetus during an induction of labour and clinical deterioration necessitated further imaging and emergent surgical intervention. Further imaging, intra-operative findings and histopathological correlation revealed a pedunculated uterine leiomyoma with hyaline degeneration and areas of necrosis, complicated by left ovarian vein thrombosis. In addition to the intra-uterine demise, the unfortunate outcome included a total abdominal hysterectomy and unilateral salpingo-oophorectomy in a young patient. Typical leiomyomas are easily detected with imaging, however the varied clinical presentation and imaging findings in degenerating leiomyomas can prove a diagnostic challenge. This case describes a rare manifestation of a common condition and its subsequent diagnostic dilemma resulting in dire foeto-maternal outcomes.Leiomyoma; Hypercalcaemia; Ovarian Vein Thrombosis; Pregnancy; Intra-Uterine Foetal Demise. Simultaneous heterogeneity amongst the patient profile  further complicates accurate analysis.3 As a result, the relationship between leiomyomas and adverse obstetric outcomes is incompletely understood.The current literature suggests that the majority of women with uterine fibroids will have normal pregnancy outcomes.3 Local advances in reproductive health, as well as the current trend of delaying childbearing, further increase the relevance to the South African population, as treating clinicians can expect to see more women with leiomyomas presenting for antenatal and obstetric care.5Accurate diagnosis of leiomyomas in pregnancy is particularly important in a South African context as an increased prevalence of leiomyomas in the African population was described by Stewart et al.Typical leiomyomas are readily diagnosed radiologically; however, the appearance of uterine leiomyomas is commonly altered by degenerative changes including cystic, hyaline, myxoid and red degeneration. This can make differentiation between leiomyomas and other adnexal or other intra-abdominal pathology challenging.Ultrasound is used to diagnose and monitor the growth of leiomyomas, and typically shows a well-defined hypoechoic mass. Intra-lesional cystic areas or calcification depends on the presence of complication or degeneration. Computed tomography (CT) generally depicts a soft tissue mass with variable enhancement, which distorts the uterine contour and may exhibit coarse peripheral or central calcification.2Typical magnetic resonance imaging (MRI) features of non-degenerated leiomyomas include a well-circumscribed mass of homogeneously low to intermediate signal intensity (as compared to myometrium) on T1-weighted images, decreased signal intensity on T2-weighted images with surrounding flow voids and variable contrast enhancement. Degenerated leiomyomas have variable but characteristic appearances depending on the type of degeneration. Defining features include high T1 signal intensity or an irregular, T1-hyperintense rim around a centrally located leiomyoma in red degeneration; high T2 signal intensity in cystic degeneration; low T2 signal intensity with poor enhancement in hyaline degeneration; and very high T2 signal intensity with gradual enhancement on T1-contrasted sequences in myxoid degeneration.7 but they are rarely reported in pregnancy.In this case, a subserosal leiomyoma was misdiagnosed as an ovarian tumour antenatally. There are multiple reported cases of ovarian tumour-like leiomyomasA 34-year-old gravid female was referred to a tertiary hospital at 38+ weeks with a large cystic pelvi-abdominal (PA) mass detected on ultrasound. She had no known medical co-morbidities and one previous uneventful pregnancy culminating in a normal vaginal delivery (NVD) at full term. On presentation, the patient was asymptomatic and examination revealed only an increased symphysis-pubis fundal height (SFH) for expected gestation. Urine analysis showed proteinuria and blood tests revealed a minimally elevated cancer antigen-125 of 48 kU/L  and a normal carcinoembryonic antigen level of 0.7 ng/mL .Transabdominal ultrasound showed a thick-walled cystic mass measuring approximately 25 cm × 14 cm × 15 cm with no internal vascularity. The mass was assumed to be ovarian in origin. A singleton intra-uterine pregnancy with foetal heartbeat was confirmed. A transvaginal ultrasound scan was not performed.The decision was made to induce labour based on the unclassified proteinuria and the clinical suspicion of possible underlying pre-eclampsia. During the induction of labour, foetal monitoring showed subtle signs of foetal distress, which warranted continuous monitoring, but despite in-patient care and continuous foetal monitoring, there was subsequent intra-uterine foetal demise and the patient delivered a stillborn baby via NVD. Following delivery, the patient’s condition deteriorated in the ward, developing a persistent unexplained tachycardia of approximately 150 bpm, a blood pressure of 156/119 mmHg and a serum calcium level well above normal limits . Emergent cross-sectional imaging in the form of contrasted CT abdomen showed a large cystic mass with a thick, irregular enhancing wall and septations , which wExploratory laparotomy revealed a large, friable, thick-walled, pedunculated fundal mass, left ovarian vein thrombosis, necrosis of the left ovary and broad ligament and offensive intra-uterine contents. The decision to proceed to total abdominal hysterectomy and left salpingo-oophorectomy was taken based on significant intra-operative bleeding, friable necrotic tissue and haemodynamic instability. Histopathological evaluation revealed a subserosal uterine leiomyoma with extensive hyaline degeneration and necrosis, left ovarian vein thrombosis, haemorrhagic infarction of the left ovary and endometrial and myometrial necrosis.No patient identifiable information has been presented. Informed verbal consent was obtained from the patient prior to publication.2 Although usually asymptomatic, some pedunculated subserosal leiomyomas may undergo torsion, resulting in infarction. Rare but recognised complications linked to uterine leiomyomas in pregnancy include an increased risk of spontaneous abortion, foetal malpresentation, placenta previa, preterm birth, caesarean section and peripartum haemorrhage.6 Placental abruption is a rare but potentially devastating outcome that has been inconsistently associated with uterine leiomyomas.6 The strongest correlation with placental abruption has been documented in patients with submucosal or retroplacental leiomyomas.5Leiomyomas are characterised by location, whether submucosal, intramural (within the myometrium) or subserosal. The latter are a subtype that may become pedunculated, projecting out of the uterine contour and mimicking an adnexal mass.Ultrasound is employed as the primary diagnostic imaging modality because of its accessibility, safety and bedside application. Ultrasound gives information on leiomyoma size, characteristics and complications. Cross-sectional imaging is usually not required for initial diagnosis in typical cases and is reserved for patients with diagnostic uncertainty or suspected complications.8 Difficulties in detection can occur with smaller tumours, those that extend into the uterine cavity, those that occur only in the lower segment and in the absence of intra-lesional calcification. Internal heterogeneity depends on the type and degree of degeneration. A cystic appearance occurs with various forms of degeneration and is generally attributed to tumour growth beyond its vascular supply.9 Because of the varied imaging patterns, degenerating leiomyomas often pose a diagnostic challenge, as in the case of our patient. Hyaline degeneration is the most common type of degeneration, accounting for 60% of cases. Cystic degeneration is observed in 4% of leiomyomas and is the terminal sequelae of oedema.10Coarse intra-lesional calcification, although an uncommon finding, remains the most specific sign for leiomyomas.11Confirming the diagnosis of ovarian vein thrombosis with ultrasound is highly operator dependent and may be confounded by patient factors such as overlying bowel gas and poor patient cooperation. Contrasted abdominal CT is sensitive and specific for ovarian vein thrombosis and should be considered as the initial investigation of choice in the absence of pregnancy. Computed tomography features include visualisation of a tubular retroperitoneal mass with central low attenuation extending cephalic to the inferior vena cava or left renal vein.14 The presumed pathophysiology is leiomyoma-induced elevated serum parathyroid hormone-releasing protein (PTHrP), with a likely causal relationship proven in all but one case.13 In our patient’s case, serum PTHrP was not tested and the role of hypercalcaemia in the eventual outcome cannot be accurately extrapolated because of many concurrent variables. However, it should certainly encourage further research into PTHrP-secreting leiomyomas.Leiomyoma-associated hypercalcaemia is a rarely described entity, with seven reported cases to date.2This case highlights the importance of employing multiple imaging modalities when confronted with a PA mass of uncertain origin in a pregnant patient. It also underscores the importance of a thorough search for the ovaries when imaging a PA mass, although this search may be hampered by distortion and displacement by large masses. Magnetic resonance imaging is the most accurate modality to evaluate tumour characteristics and may be utilised in the pregnant patient when ultrasonography is inconclusive.Leiomyomas in pregnancy are common and are usually easily diagnosed, with no expected adverse obstetric complications. However, in rare cases, they may present in unpredictable ways with variable imaging findings that delay diagnosis and result in potentially harmful outcomes. Pedunculated uterine leiomyomas should be considered in the differential diagnosis of any PA mass. As degenerating leiomyomas are great mimics of other gynaecological and non-gynaecological medical conditions, familiarity with the different types of degeneration and their sonographic appearance is imperative to aid accurate diagnosis.Ultrasound should be employed as the initial imaging modality of choice for PA masses in pregnancy. However, its limitations should be carefully considered and cross-sectional imaging should be used where appropriate.


Background: Acinar cell cystadenoma is a rare pancreatic cyst that has been described in several case reports. This lesion may be incidental or asymptomatic, occurs predominately in females, and has a mean age of onset in the fourth decade.Case Presentation: A previously healthy 14-year-old male presented with abdominal pain. He was found to have a pancreatic cystic lesion on ultrasound and cross-sectional imaging. His diagnosis remained uncertain despite additional analysis, including endoscopic ultrasound with fine-needle aspiration. The patient underwent successful laparoscopic excision for definitive diagnosis and management with an unremarkable postoperative course. He was diagnosed with a multilocular acinar cell cystadenoma.Conclusion: Acinar cell cystadenoma is a rare pancreatic cyst whose true malignant potential is unknown. Although there are no formal recommendations for post-operative monitoring and the true risk of recurrence is unknown, we recommended every other year magnetic resonance imaging/magnetic resonance cholangiopancreatography for postresection surveillance for this patient due to the theoretical risk of recurrence with malignant transformation. ACA may be unilocular or multilocular, with larger locules harboring internal septations. Unilocular ACA are predominately lined by well-differentiated acinar epithelium without atypia and scattered ductal cells, whereas patches of ductal epithelium within a background of acinar epithelium are more typical of multilocular ACA.2Incidental pancreatic cystic lesions are becoming increasingly common with more widespread use of cross-sectional imaging. Pancreatic acinar cell cystadenocarcinoma and acinar cell cystadenoma (ACA) account for <5% of these lesions. Acinar cell cystadenoma is a rare pancreatic cyst that has been described in several case reports.4 Cysts may be incidental or symptomatic. When symptomatic, the most common presentation is pain. We describe a case of this rare cystic lesion occurring in a healthy adolescent male presenting with abdominal pain.Acinar cell cystadenoma occurs predominantly in females , with the age of diagnosis ranging from 9 to 66 years old and mean age of onset in the fourth decade.A previously healthy 14-year-old male presented to an emergency room with 3–4 days of diarrhea and abdominal pain in November 2014. Abdominal X-ray demonstrated dilated loops of bowel consistent with gastroenteritis. His serum aspartate transaminase was slightly elevated at 65 U/L (ULN 37); however, his remaining hepatic function panel, complete blood count, lipase, and amylase were normal. An abdominal ultrasound suggested a cystic structure medial to the left kidney with thickened internal septations. Despite repeating the abdominal ultrasound in multiple planes, it remained unclear whether the structure represented a distended fluid-filled loop of colon or a unique cystic lesion. Subsequent computerized axial tomography  revealed™ BSCI needle. One milliliter of pink tinged nonviscous fluid was aspirated. Cyst fluid analysis revealed carcinoembryonic antigen 7.1 ng/mL and amylase 633 U/L. Aspirate cytology was nondiagnostic with rare small groups of mildly atypical epithelial cells, benign acinar cells, ductal cells, and fragments of fibrous tissue and debris. RedPath PathFinderTG® integrated diagnosis was also indeterminate, due to lack of polymerase chain reaction amplifiability from low DNA quantity and poor DNA quality.The patient's symptoms resolved shortly following his emergency room visit, with normalization of his stools and resolution of his abdominal pain. After careful review of his images, his pancreatic lesion was felt to represent a cystic pancreatic mass and less likely a pseudocyst or a solid pseudopapillary tumor with cystic components. He was referred for an endoscopic ultrasound (EUS) to further characterize his lesion. An EUS  performeThe patient felt generally well and remained active in several sports, but continued to have episodes of recurrent abdominal pain. Repeat contrast-enhanced abdominal computed tomography in July 2015 demonstrated a persistent pancreatic cystic lesion measuring 2.6 × 3.1 × 1.8 cm, with prior imaging not available for comparison at that time. Although a definitive diagnosis had not been established, due to his recurrent pain and persistent lesion, the patient underwent laparoscopic excision in July 2015. The patient tolerated the procedure well. The lesion was easily dissected from the pancreas. Macroscopically, it was noted to have four cystic components, ranging in size from 0.8 × 0.7 × 0.4 to 2.6 × 1.6 × 1 cm. Each cyst contained a white smooth wall filled with white cloudy watery fluid. Microscopically, the cysts were lined by a single layer of cuboidal to columnar epithelium with focal acini, with one cyst demonstrating internal concretions . No cyto5 In addition, although nearly all previously reported cases of ACA resulted in extensive pancreatic resections, including pancreaticoduodenectomy, lateral pancreatectomy, and total pancreatectomy, we have described a case with successful cyst excision without pancreas resection. Postoperatively, we have recommended every other year magnetic resonance imaging/magnetic resonance cholangiopancreatography surveillance for this patient. Whether or not this is warranted or beneficial, especially given this patient's young age at diagnosis, is unclear.We have described a case of a young adolescent male with a multilocular acinar cell cystadenoma who underwent successful cyst excision. To our knowledge, he is the second youngest patient to have been reported with this lesion.1 More recently, however, pancreatic acinar cell cystadenoma has been described as an adenoma.1 Although it has been suggested that this lesion is a precursor to acinar cell cystadenocarcinoma, the true malignant potential of this lesion remains unclear.1 To our knowledge, no case report or case series has reported evidence of malignant transformation of ACA with up to 7.8-year follow-up, regardless of whether or not the lesion was completely resected.2 Although ACA lack atypia and mitotic activity that seems to favor a nonneoplastic lesion, the discovery of multiple chromosomal gains on comparative genomic hybridization that contain a few cancer-associated genes and genomic instability suggests the lesion is preneoplastic.1 In addition, a case of ACA with low-grade dysplasia was recently reported.4It has been proposed that ACA originate from nonneoplastic acinar dilatation that expand into and incorporate ducts and ductules, eventually forming large cystic lesions as secretions accumulate. Ductal-to-acinar metaplasia has also been a theoretical explanation.3 No postoperative recurrences have been reported.3 Until the course of ACA is better established, however, we believe these lesions should be aggressively monitored, with strong consideration for surgical resection to reduce the theoretical risk of malignant transformation. Given the rarity of these cysts, future studies to support this will likely be limited.We know from previous studies that ACA are likely to grow over time. In a case series of 10 patients, 4 of whom underwent sequential imaging, all four cysts showed interval enlargement over time with a mean increase of 1.5 cm for more than 2.9 years.


Hydrocele of the canal of Nuck is a rare developmental disorder and represents of a homolog of hydrocele of spermatic cord in males. Hydrocele of the canal of Nuck is a very rare cause of inguinal swelling in female infants and children. It results from the failure of obliteration of the distal portion of evaginated parietal peritoneum within the inguinal canal, which forms a sac containing fluid.We describe a case of hydrocele of the canal of Nuck in an 11-month-old girl with a past medical history of duodenal atresia and Arnold-Chiari malformation.Physical examination and ultrasound revealed a soft, cystic, noncompressible, and non-fluctuant labial mass measuring approximately 5 cm.The patient underwent surgical exploration through a right skin crease incision. The cystic lesion was histologically confirmed to be a non-communicated hydrocele of canal of Nuck.The child is doing well at 1-year follow-up with no swelling or recurrence on the operated side.Hydrocele of the canal of Nuck is a rare developmental disorder but should be considered in a differential diagnosis in young girls with an inguino-labial swelling. In most cases, the canal of Nuck disappears without a trace in the first year of life, but sometimes it does not disappear completely causing the formation of an indirect inguinal hernia or hydrocele of the canal of Nuck. The accumulation of fluid in this anatomical structure is called hydrocele/cyst of the canal of Nuck or female hydrocele.The inguinal canal in the female transmits the round ligament .,4,5 A hydrocele of the canal of Nuck is a very rare cause of an inguino-labial mass in females, especially in female infants and children and sometimes is overlooked in differential diagnosis for an inguinal mass.A hydrocele of the canal of Nuck is a rare developmental disorder and represents the female equivalent of the processus vaginalis in males. The canal of Nuck usually obliterates within the first 8 months of gestation although its patency may persist postnatally. The canal of Nuck was first described in 1691 by a Dutch anatomist Anton Nuck. There are three types of hydrocele of the canal of Nuck. The most common presentation of hydrocele is type 1, characterized by a unilocular encysted hydrocele, without communication with the peritoneal cavity. A type 2 hydrocele is characterized by a persistent communication between hydrocele and the peritoneal cavity. A type 3 is the rarest form of hydrocele and manifests itself in the form of an hourglass, whereby the internal inguinal ring is compressed by a large hydrocele. In our case, the girl had ventriculo-peritoneal (VP) shunt due to hydrocephalus before the development of hydrocele of the canal of Nuck. The association between VP shunt and hydroceles or inguinal hernias in male is well recognized, but in females, this association has been rarely reported in the literature. Yuksel et al reported a case of female infant with the appearance of left-side swelling at her left labium majus and groin 5 months after implantation of VP shunt due to lissencephaly and congenital hydrocephalus. They emphasized that VP shunts may clinically present with inguinal manifestations in female infants and may be an important sign of shunt malfunction. In our case, hydrocele of the canal of Nuck occurred 6 months after VP shunt implantation due to hydrocephalus associated with Arnold-Chiari malformation type 1. In contrast to the above-mentioned case where a palpable peritoneal catheter was detected within the cystic mass with shunt malfunction, VP shunt in our patient was functional and the peritoneal catheter did not have any contact with hydrocele of the canal of Nuck. Therefore, it is difficult for us to determine whether the VP shunt could cause a hydrocele of the canal of Nuck or not.The exact cause of cystic formation is unknown, but it is hypothesized that it is caused by the lack of balance of secretion and liquid absorption in the secretory membrane lining.Hydrocele of the canal of Nuck typically presents as a painless, translucent, fluctuating, and non-reducible swelling in the inguinal area and labia majora. Knowing and understanding the clinical presentation of this clinical entity can contribute to the prevention of unnecessary diagnostic tests and enable timely and adequate surgical treatment. In our case, ultrasonography, along with a physical examination finding, was sufficient for a proper preoperative diagnosis of the hydrocele of the canal of Nuck. Open surgical excision of the cyst and ligation of the neck of processus vaginalis proved to be adequate options for the surgical treatment. In addition to the predominant open excision of the hydrocele of the canal of Nuck, laparoscopic excision has been reported in the literature.In conclusion, hydrocele of the canal of Nuck is a rare developmental disorder but should be considered in a differential diagnosis in young girls with an inguino-labial swelling. Ultrasound and physical examination are sufficient diagnostic procedures for the proper clinical diagnosis. However, a surgical exploration and histopathologic confirmation are necessary for the definitive diagnosis.Conceptualization: Zlatan Zvizdic, Semir Vranic.Data curation: Adisa Chikha, Irmina Sefic, Amra Dzananovic.Formal analysis: Zlatan Zvizdic, Adisa Chikha, Irmina Sefic, Amra Dzananovic, Semir Vranic.Investigation: Zlatan Zvizdic, Emir Milisic.Resources: Semir Vranic.Writing – original draft: Zlatan Zvizdic, Emir Milisic, Adisa Chikha, Irmina Sefic, Amra Dzananovic, Semir Vranic.Semir Vranic ORCID: 0000-0001-9743-7265.


Mesenteric panniculitis (MP), also known as sclerosing mesenteritis (SM), retractile mesenteritis or mesenteric lipodystrophy, is a rarely diagnosed inflammatory condition of unknown etiology that involves the mesenteric adipose tissue. We are presenting a case of sclerosing mesenteritis which presented us with features suggestive of malignant lesion and turned out to be benign one. An elderly gentleman of 68 years male presented to us with history of nonprogressive pain abdomen since 2 months associated with low grade fever and on and off constipation. On evaluation with CECT he was found to have mesenteric mass probably malignant. PET/CT showed an FDG avid lesion suggestive of malignancy, requiring surgery. He underwent radical excision of mesentery with resection of corresponding bowel. Final histopathology report showed poorly defined lesion comprised of nodular, poorly defined proliferation of bland looking fibroblast like cells, which at places are lying in fascicles, in a background of dense fibrosis and mature fat cells, with prominent focal lymphocytic infiltrate, at place forming reactive follicles, suggestive of sclerosing mesenteritis. Now patient is on follow up for further therapy. Gives history of constipation on and off. No history of loss of appetite or loss of significant weight. Abdominal examination reveals a large slightly mobile, nontender mass in the left hypochondrial region. USG guided biopsy showed spindle cell mesenteric lesion with suspicion for GIST. Patient was evaluated with PET/CT abdomen which showed FDG avid lesion in mesentery measuring 5*6.4*8.7 cm, metabolically active perilesional and right supraclavicular lymph nodes suspicious of metastasis , Fig. 2.Intraoperatively there was a large mesenteric tumor measuring about 10*8 cm abutting SMA and SMV extending till the root of duodenojejunal flexure (DJF). Middle colic artery was completely encased by the tumor. Bowel and peritoneum was healthy. Minimal chylous ascites was noted. Few enlarged right supraclavicular lymph nodes were excised for biopsy , Fig. 4.3The prevalence of MP in one of the cohort is 0.58%, which is similar to data from Daskalogiannaki and Kipfer et al, but in contrast to Canyigit et al. and Coulier who reported a higher prevalence of 2.43% and 7.83%, respectively.  SM mostlWhen it comes to the diagnosis of SM imaging studies may not help us in a great way. But imaging helps in getting the tissue biopsy for diagnosis. SM is most commonly diagnosed incidentally by CT scan MRI and USG being alternatives. Mass lesion, absence of infiltration of neighboring structures, inhomogeneity, hypodense fatty halo surrounding blood vessels and nodes and hyperdense pseudocapsules are the criteria given by Coulier, may help to differentiate SM from lymphoma, carcinoid tumor, carcinomatosis, primary mesenteric mesothelioma, and mesenteric edema.  PET-CT cSpontaneous resolution can occur. Corticosteroids and other anti-inflammatory and immunosuppressive agents are adjuncts. Operative indications are diagnosis dilemma as in our case and acute intestinal obstruction. Rarity of this condition also makes intraoperative findings confusing during the laparotomy for most of the surgeons who would directly take it as neoplastic and do a radical resection.The treatment of this condition is controversial. One study reported the successful use of one and half year course of tapering azathioprine (1 mg/kg/day) and a three-year tapering course of prednisone (0.5 mg/kg/day) after initial surgery.  Tamoxife4Patients with intractable bowel obstruction or uncertainty in diagnosis may require surgery without having a diagnosis in hand. However, long-term follow-up studies are needed to substantiate any approach.No conflicts of interest.No.Ethical exemption is done by hospital. If any details required later on will furnish it.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.1, Vachan Hukkeri2, Satya Prakash3, Vivek Tandon4, Deepak Govil5 1,2,3 Resident in Dept of GI surgery, Apollo Hospital Delhi, India  5, 4 Senior consultant, Dept of GI surgery, Apollo Hospital Delhi, India .Adithya G. KNot a research article.Adithya G K.Not commissioned, externally peer reviewed.


Thoracic hernias are characterised by either protrusion of the thoracic contents outside their normal anatomical confines or extension of the abdominal contents within the thorax. Thoracic hernias can be either congenital or acquired in aetiology. They can occur at the level of the thoracic inlet, chest wall or diaphragm. Thoracic hernias can be symptomatic or fortuitously discovered on imaging obtained for other indications. Complications of thoracic hernias include incarceration, trauma and strangulation with necrosis. Multiple imaging modalities are available to evaluate thoracic hernias. Radiographs usually offer the first clue to the diagnosis. Upper gastrointestinal radiography can identify bowel herniation and associated complications. CT and occasionally MR can be useful for further evaluation of these abnormalities, accurately identifying the type of hernia, its contents, associated complications, and provide a roadmap for surgical planning. In this article, we review the different types of thoracic hernias and the role of imaging in the evaluation of these hernias.• Protrusion of lung contents beyond the anatomic confines of the thorax constitutes a hernia.• Complications of thoracic hernias include incarceration, trauma and strangulation with necrosis.• Multiple imaging modalities are available to evaluate thoracic hernias.• CT is the imaging modality of choice for identifying thoracic hernias and their complications.• Imaging can provide a roadmap for surgical planning.The online version of this article (10.1007/s13244-018-0670-x) contains supplementary material, which is available to authorized users. Thoracic hernias are characterised by either protrusion of the thoracic contents outside their normal anatomical confines or extension of the abdominal contents into the thorax. Thoracic hernias can be congenital or acquired in aetiology. When acquired, these are usually post-traumatic or post-surgical Fig. . They caDifferent imaging modalities can be useful in identification of thoracic hernias, with their advantages and disadvantages Table , includiChest radiographs (CXR) are usually the first imaging modality used in adults with any suspected thoracic pathology and may offer the first clue to a thoracic hernia.Gastrointestinal contrast radiography under fluoroscopy is a useful modality in identifying bowel herniation into the thorax. Upper gastrointestinal imaging with oral contrast (UGI) is useful in identification and classification of the hiatal hernias. Lower gastrointestinal radiography (contrast enema) is useful in identifying herniation of the large bowel into the thorax and complications of large bowel conduits. In patients with suspected bowel perforation, water-soluble contrast is initially used for both UGI and enema examinations. At our institution, low osmolar non-ionic contrast such as iohexol 350 mgI/ml  in adults and Optiray 240  in children < 17 years is used. We limit the use of oral barium to assessing any leaks in patients with large body habitus or overlying metal hardware when images with water-soluble or low-osmolar agents are suboptimal. Some radiologists prefer not to use barium sulfate in young or debilitated older patients who may be at risk for aspiration or may need additional imaging 39].Fig. Abdominal wall hernias can extend above the level of the diaphragm through the superficial or deep layers of the thorax and present as a superficial chest wall hernia. These hernias can originate from either the ventral or the lateral abdominal wall. Lumbar hernias occur through defects between the 12th rib and iliac crest and are usually sequelae of prior trauma or surgery Fig. a. IncisiComplications of thoracic hernias include trauma, obstruction, incarceration and strangulation. The herniated contents in a chest wall hernia are also at increased risk of injury from minor trauma. Obstruction can be seen in herniated bowel loops or stomach. Incarcerated hernia is characterised by an irreducible hernia because of a narrow neck and indicates that the contents of the hernia sac are irreducible , 41.Incarceration predisposes to strangulation and obstruction in cases with bowel herniation. Initially there is angulation and distortion of the lymphatics followed by veins and arteries at the level of the neck of the hernia, which can cause lymphatic and venous obstruction. On CT, the herniated viscera can appear enlarged, oedematous, hypodense and with decreased contrast enhancement. If left untreated, this can lead to complete arterial occlusion and strangulation. A strangulated hernia with arterial occlusion needs to be treated emergently; otherwise it will lead to ischaemia and necrosis .The complications of thoracic hernias can be best described in terms of the hernia contents.Incarcerated lung hernia presents as a non-reducible, well-circumscribed bulge. On CT, change in the calibre of the airways Fig. a or abruComplications of a herniated stomach include incarceration, strangulation and volvulus. Gastric volvulus can be either organoaxial or mesentroaxial. In organoaxial volvulus, the rotation occurs along the long axis of the stomach, whereas in mesentroaxial volvulus the rotation is perpendicular to the long axis of the stomach with the displaced antrum being superior to the GE junction. Gastric rotation or a twist > 180° can lead to strangulation and obstruction . OrganoaOn CXR, two retrocardiac air fluid levels can be seen. On UGI, findings diagnostic of an organoaxial volvulus include an intrathoracic stomach with an inferior position of the GE junction and inferiorly directed pylorus with a reverse position of the greater and lesser curvatures. In addition, inability to pass the orogastric tube or failure in the passage of oral contrast beyond the stomach indicates rotation > 180° and gastric obstruction. Often CT is obtained before UGI and can identify the herniated intrathoracic stomach and pneumatosis and locate the transition point of the gastric obstruction. Contrast-enhanced CT can also identify decreased enhancement in the gastric wall due to hypoperfusion and strangulation Fig. a, b.Fig.The herniated bowel can undergo a closed loop obstruction. In such cases, CT can identify bowel wall thickening, abnormal wall enhancement, engorgement of vessels and pneumatosis. Presence of free fluid, bowel wall thickening and distention represents impeding strangulation. In patients with chronic hernia, adhesions can form in the hernia sac with fibrosis. This can lead to slowly progressive obstruction of the herniated stomach or bowel loops, which can present as acute-on-chronic obstruction Fig. a, b.Fig.Herniation of lung, kidney, spleen, bowel, etc., through small defects can lead to obstruction, vascular compromise, strangulation and ischaemia. Acute herniation through a narrow neck increases the risk for vascular compression and strangulation of herniated abdominal organs and bowel. In cases of visceral herniation of solid organs such as kidney or spleen, venous compression and obstruction may occur before arterial obstruction Fig. . There cThoracic hernias can occur at the thoracic inlet, chest wall or diaphragm. Imaging, particularly CT, plays an important role in establishing the diagnosis, characterising the type, delineating the extent, identifying the content, detecting complications and providing a roadmap for interventions.Movie 1Lung hernia. Axial CT in a patient with previous right upper lobe wedge resection for a stage I lung cancer identifies focal intercostal herniation of the right upper lobe. (MP4 4032 kb)Movie 2Hiatal hernia. Axial contrast-enhanced CT identifies a large hiatal hernia containing stomach, large bowel, splenic vessels and pancreas in the hernia sac. This is a type IV hiatal hernia. (MP4 5772 kb)Movie 3Gastric volvulus. Contrast-enhanced CT of the thorax demonstrates intrathoracic stomach with organoaxial volvulus and gastric pneumatosis. (MP4 10600 kb)Movie 4Gastric outlet obstruction. Contrast-enhanced CT demonstrates herniation of the stomach into a Morgagni hernia with severe dilation of the stomach with gastric outlet obstruction (MP4 4021 kb)Movie 5Traumatic diaphragmatic hernia. Contrast-enhanced CT demonstrates a large left diaphragmatic hernia with left kidney, stomach and omentum present within the left thorax. Note the decreased enhancement of the left kidney. (AVI 5472 kb)


Acute promyelocytic leukemia and primary central nervous system lymphoma are uncommon hematological malignancies. The co-occurrence of acute myeloid leukemia with various lymphoproliferative diseases is an extremely rare condition, especially in the absence of previous chemotherapy or radiotherapy. Herein, we provide a comprehensive characterization of a patient with concomitant diagnosis of extranodal high-grade non-Hodgkin B-cell neoplasm confined to the central nervous system and acute promyelocytic leukemia. We describe the efficacy and feasibility of the consecutive use of all-trans retinoic acid and arsenic trioxide-containing regimen for the treatment of promyelocytic leukemia and high-dose methotrexate plus cytarabine to treat lymphoproliferative involvement of the central nervous system. Acute promyelocytic leukemia (APL) is a rare variant of acute myeloid leukemia (AML) with an age-adjusted annual incidence of 0.23 per 100,000 persons and a median age at diagnosis of 44 years /46, XY, t , del(9) (q21q23) [11]/46, XY [2]] and molecular biology tests (PML-RARA/bcr3 fusion transcript). The patient was then transferred to our Hematology Department for the treatment of APL.The morphological examination of peripheral blood showed promyelocytes with Auer bodies; flow cytometric analysis demonstrated CD11b + CD11c + CD15 + CD33 + CD38 + CD64 + CD13 + CD2 + CD117 + blast cells, while HLA-DR, CD34, or CD56 were not expressed. Diagnosis of high-risk classic APL was confirmed by cytogenetic [46, XY, 2 and intravenous arsenic trioxide (ATO) 0.15 mg/kg daily were administered through an off-label use. The therapy was conducted for four weeks plus prednisone (40 mg daily) to prevent ATRA-ATO-mediated differentiation syndrome, obtaining normalization of blood counts. A neurological improvement was also reported. A bone marrow aspirate performed after a month of ATRA-ATO treatment confirmed molecular remission of APL.In October 2014, in consideration of the APL diagnosis with a suspected CNS involvement, all-trans retinoic acid (ATRA) 45 mg/mNevertheless, at the time of interruption of steroid therapy, hyposthenia of the right side of the body and dysarthria reappeared and worsened. We repeated a CT scan and an MRI with gadolinium contrast medium that revealed a new hyperdense circular lesion in the white matter of the left frontal lobe.The PET scan of the brain confirmed hypermetabolism in the left paraventricular region of the frontal lobe that was presumed to be more likely a glial tumor than a lymphoproliferative lesion.μL; the viral research on cerebrospinal fluid was negative.A magnetic resonance spectroscopy (MRS) was performed with the aim of improving the differentiation of locally infiltrative brain tumor from other types of well-circumscribed intracranial lesions by analyzing the chemical composition in a selected area. The MRS revealed an increase of spectroscopic signals of lactate and a reduction in N-acetylaspartate and choline. These data supported the hypothesis of cerebral localization of APL, but the presence of contrast enhancement and the increase of lactate signal might also support the possibility of an immune reconstitution inflammatory syndrome (IRIS). The lumbar puncture showed normal pressure of cerebrospinal fluid, normal values of glucose and proteins, and only 2 white cells/In agreement with neurologists, neuroradiologists, and neurosurgeons, we decided to perform a stereotactic biopsy of the cerebral lesion.2 on day 1 and cytarabine 2 g/m2 every 12 hours on days 2-3) and continued high-dose steroidal therapy (dexamethasone 8 mg b.i.d.).The histological sample was diagnostic for primary central nervous system large B-cell lymphoma. Immunohistochemistry identified large cells that were CD20 + BCL-6 ± PAX5 + CD10-MUM1 + CD5-CD3-TdT-MPO- with a Ki-67 index of 80–90%, confirming the presence of B-cell lymphoma. Therefore, on 21 November 2014, we started the first cycle of chemotherapy with high-dose methotrexate and cytarabine , a stereotactic biopsy brain parenchyma was mandatory .t , leading to the resulting PML-RARA hybrid oncoprotein which is responsible for the block of differentiation of leukemic promyelocytes [APL is a subtype of AML with specific clinical and biologic features; its genetic hallmark is the balanced reciprocal translocation elocytes .κB and JAK/STAT signaling pathway [Pathogenesis of PNCSL is not as clear; different molecular and genetic alterations may contribute to malignant transformation, including aberrant somatic hypermutations of proto-oncogenes, DNA methylation of tumor suppressor genes, gains and losses of genetic material, as well as activation of the NF- pathway . In our Treatment regimens for concomitant hematological malignancies are not fully established.Because of the extreme particularity of our clinical case and the documented ability of ATO to cross the blood-brain barrier and penetrate into the cerebrospinal fluid, we decided to treat APL with an off-label ATO-ATRA combination –10. ATO We identified PCNSL after APL diagnosis, so firstly, treatment with ATO-ATRA was started, followed by a classical first-line therapy for PCNSL based on combination chemotherapy with high-dose methotrexate and cytarabine . ConsecuInterestingly, the specific therapies used for the two oncohematological diseases might influence the course of each other. Steroid therapy used to prevent ATRA-ATO-mediated differentiation syndrome led to a neurological improvement; corticosteroids are a well-known component of PCNSL treatment protocols because of their direct apoptotic effect on lymphoma cells . On the We suggest that if clinicians had to treat two synchronous oncohematological diseases, they should firstly privilege treatment of the pathology associated with major immediate life risks.In conclusion, we described the rare concomitance of APL and PCNSL in a patient who was not previously exposed to genotoxic agents. Furthermore, we showed the feasibility of consecutive use of ATO-ATRA regimen for the cure of APL and high-dose methotrexate plus cytarabine to treat PCNSL.


A 60-year-old woman with a history of a ruptured ectopic pregnancy and subsequent salpingo-oophorectomy presented with clinical signs. Pre-operative imaging and intra-operative observations were highly suggestive of acute on chronic cholecystitis. A laparoscopic cholecystectomy was performed. In addition to confirming calculous cholecystitis, final pathology revealed endosalpingiosis on the serosal surface of the gallbladder. Endosalpingiosis is a rare, benign presence of glands lined by tubal-like epithelium, and the few case reports describe it on the surface of the female reproductive organs or seeded on the pelvic peritoneum. We hypothesize that, in this unique case, the endosalpingiosis is due to patient’s ruptured ectopic pregnancy, which allowed tubal epithelial cells to spread to the gallbladder. The only documented cases of endosalpingiosis outside the pelvic and lower abdominal organs have been congenital choristomas. To our knowledge, this is the first documented case of acquired endosalpingiosis of the gallbladder. Endosalpingiosis is the benign presence of glands lined by tubal-like epithelium, which contains ciliated columnar cells, nonciliated columnar secretory mucus cells and intercalary peg cells in tissues outside the fallopian tubes. The condition usually manifests in organs contained by the pelvic and lower abdominal peritoneum and is often asymptomatic . There aA 60-year-old caucasian woman with a past medical history significant for obesity, hypertriglyceridemia, hypertension, gallstones, and gastroesophageal reflux disease was evaluated for worsening postprandial right upper abdominal discomfort, bloating, nausea, and mild to moderate pain radiating to the back. Her surgical history was significant for an emergency right salpingo-oophorectomy for a ruptured ectopic pregnancy roughly 30 years. The vital signs and physical exam were unremarkable.Abdominal ultrasonography showed gallstones without cholecystitis, confirmed by a hepatobiliary iminodiacetic acid (HIDA) scan. The preoperative diagnosis was acute on chronic calculous cholecystitis. A detailed discussion of the natural history, possible causes, and management of gallstone disease, including operative versus nonoperative management, was carried out, and the decision was made to proceed with surgery. Informed consent was obtained, and a laparoscopic cholecystectomy was performed without complications. During surgery, multiple adhesions of the transverse colon and omentum to the anterior and right lateral abdominal wall were noted, and lysis of adhesions was performed. The post-operative diagnosis remained acute on chronic calculous cholecystitis Figure  A. SurgiThe patient tolerated and recovered from surgery well and was discharged to home on the same day of surgery.The incidence and prevalence of endosalpingiosis are poorly studied. This could be in part due to its asymptomatic nature or coexistence with endometriosis. It is possible that tubal epithelial cells are lost during the surgical ablation of endometriosis prior to histological examination . In a stThere are several proposed theories of the pathogenesis of endosalpingiosis, and these theories fall into two categories: embryological origin and acquired origin. It was proposed that endosalpingiosis and the other three Mullerian diseases - endometriosis, endocervicosis, and adenomyosis - arise as choristomas, normal Mullerian tissues, singly or in combination, incorporated within other normal organs during organogenesis. Embryonic endosalpingiosis most often results in cystic, often painful lesions in the affected areas .The ability of tubal endometrial cells to proliferate outside the fallopian tube was first postulated by Sampson in 1930, who observed the invasion of fallopian tube epithelium through the walls of post-salpingectomy tubal stumps . KistnerWe believe the gallbladder endosalpingiosis presented in this case is likely due to the patient’s ruptured ectopic pregnancy 30 years ago, and her subsequent salpingo-oophorectomy. Although embryonic relationship between tubal epithelium and the gallbladder serosa in this case is not completely impossible, it is highly unlikely. The endosalpingiosis did not produce symptoms, and its presence was not evident on intra-operative or post-operative gross examination of the gallbladder. These indications, and the history of ruptured ectopic pregnancy, all point to an acquired route of pathogenesis.It is our hypothesis that our patient’s ruptured ectopic pregnancy resulted in hemorrhagic dissemination of the tubal epithelial cells through the abdominal cavity, where they seeded the gallbladder. This hypothesis is also supported by the evidence of extensive adhesions found localized in the right flank and right upper abdominal quadrant during surgery. The vast distance the cells traveled to seed the gallbladder is the main limitation of this hypothesis. To our knowledge, this is the first case of endosalpingiosis of the gallbladder documented in the literature.Given this hypothesis, it is plausible that there are other areas of endosalpingiosis present within the patient’s abdominal cavity. However, due to the asymptomatic nature of these lesions, it would go against the laws of beneficence and non-maleficence to search for them. Although this diagnosis bore a little impact on the patient, this incidental finding demonstrated the resilience and the potential of differentiated human cells to thrive outside their native tissue niche. This unique case may stimulate the establishment of novel cellular models guiding the development of new testable hypotheses for better understanding of the global principles and programs of the epithelial-to-mesenchymal transition and associated cellular invasion-migration programs.As the first documented case of endosalpingiosis of the gallbladder, this case increases awareness of human cells’ propensity to survive and thrive, even in the most foreign of conditions. Endosalpingiosis remains difficult to study because of its traditionally asymptomatic nature. However, since the different forms of mullerianosis, including endometriosis and endocervicosis, often occur together, it is imperative that clinicians use every case of as an opportunity to develop a greater understanding about this group of diseases as a whole.


A 52-year-old woman presented with abdominal pain and vomiting. Computed tomography (CT) scan of the abdomen revealed a huge exophytic gallbladder mass displacing or invading the surrounding structures. The patient underwent radical cholecystectomy, transverse colectomy, distal gastrectomy, and liver bed resection. Histologically, the tumor showed both carcinomatous and sarcomatous components, with prominent chondrosarcomatous differentiation. In addition, several malignant cells showed intracytoplasmic eosinophilic hyaline globules (Thanatosomes). The tumor showed metastatic deposits to the omentum, the liver, and the peripancreatic lymph nodes. We report this unusual case and present a review of all cases of carcinosarcoma of the gallbladder with chondrosarcomatous differentiation. Carcinosarcoma of the gallbladder, also referred to by some authors as malignant mixed tumors and sarcomatoid carcinoma, is a rare malignant neoplasm representing less than 1% of all gallbladder malignant tumors .Herein, we report a 52-year-old woman with carcinosarcoma of the gallbladder featuring an anaplastic sarcomatous component associated with prominent chondrosarcomatous differentiation and extensive metastases. In addition, sarcomatous tumor cells contained hyaline eosinophilic globules, a novel finding in these tumors. We present a review of all cases of carcinosarcoma of the gallbladder with chondrosarcomatous differentiation.A 52-year-old Saudi Arab woman presented to the Emergency Department of a local hospital complaining of right upper quadrant pain accompanied by vomiting of 5 day-duration. The patient had a progressive right upper quadrant abdominal pain for the last five months that increased in severity with fatty meals radiating to the back. She had no history of jaundice, change of urine color, or weight loss. On physical examination, there was a palpable abdominal mass in the right upper quadrant that is 8 cm below the costal margin. Abdominal ultrasound showed the gallbladder to have thick wall with large irregular shaped soft tissue mass arising from the fundus, measuring 8 x 6 cm. This was seen infiltrating the surrounding sub-hepatic fat planes and inseparable from the transverse colon. There were no focal hepatic lesions; dilated intrahepatic biliary radicals or significant enlarged lymph nodes were noted.α-fetoprotein (AFP) were normal, but carbohydrate antigen 19-9 (CA 19-9) was elevated (154.33 IU/ml). CT scan of the abdomen showed a gallbladder mass with huge exophytic component, displacing the surrounding structures with few small portal lymph nodes , low albumin (32 g/L) and unremarkable total bilirubin, alkaline phosphatase, ALT, and AST. Renal function tests were within normal limits. Serum carcinoembryonic antigen (CEA) and ph nodes . No hepaThe gross pathological specimen consisted of portion of liver with attached gallbladder, portion of stomach, segment of large bowel and attached omentum. The gallbladder measured 13.0 cm in length and 6.0 cm in diameter. On opening the gallbladder, a large polypoid tumor mass was seen filling the lumen measuring 11.0 cm in length and 6.0 cm in diameter. The tip of the mass was friable reddish brown in color. The root which was mainly present in the body is soft reddish tan in color. No gallstones were identified in the lumen of the gallbladder. On cut section, fleshy tumor was seen arising within the gallbladder extending to surrounding tissue, forming rubbery soft tan and hemorrhagic nodules the largest measured 11.0 cm in diameter, reaching to the wall of the stomach and colon surrounded by omental tissue. A large nodule measuring 8.0 cm beneath the omentum adherent to the liver was noted. Another hemorrhagic nodule measuring 7.8 cm was present between the liver and the stomach. On opening the stomach and the large bowel, the mucosal linings of both were unremarkable.Histological examination of the intraluminal large polyp of the gallbladder showed a biphasic highly malignant tumor featuring both solid epithelial nests within highly malignant sarcomatous stroma Figures  with scaInfiltrating highly sarcomatous component was seen in the pericolic fat, perigastric fat, hepatic parenchyma, and perihepatic fibrous tissue. Foci of malignant solid epithelial nests and malignant glandular formation surrounded by sarcomatous stroma with scattered islands of malignant cartilage were identified in the omental mass. Peripancreatic lymph nodes revealed metastatic deposits of sheets and clusters of malignant cells with epithelioid features in half of the lymph nodes which were identified.Immunohistochemical stains revealed the malignant epithelial cells to be positive for cytokeratin  and negaIn view of these findings, the diagnosis of gallbladder carcinosarcoma with anaplastic sarcomatous and chondrosarcomatous components was confirmed. This neoplasm was staged as stage III (pT4 pN2 pMx).2 and cisplatin 25 mg/m2). Upon the patient's request, she continued her chemotherapy treatment near her home and no further follow-up information was obtained afterwards.The postoperative course was uneventful. The patient was referred to the Medical Oncology team 7 weeks following the surgical procedure. A management plan was set and included six cycles of adjuvant chemotherapy  are quite rare. Okabayashi et al. in a review of surgical outcome of 131 cases of carcinosarcoma of the hepatobiliary tract reported that, between 1970 and 2012, there were 59 cases CSGB documented in the world literature . They seThere had been some controversy regarding the pathogenesis of this tumor, reflected by the multitude of names designated for it, including malignant mixed tumor –7, sarcoTo add to this controversy regarding its pathogenesis, CSGB had been categorized as a “true” carcinosarcoma if the mesenchymal elements showed differentiation into neoplastic bone, cartilage or skeletal muscle , 40, or We collected all cases of CSGB that exhibited chondrosarcomatous differentiation . There wIn a review of 59 cases of CSGB that underwent surgical resection, there were 18 males and 39 females, with male to female ratio of 1:2.2. Two-thirds of the patients (38 patients) were 65 years or older. The survival rate by the end of one year was 42.8%, and the 5-year survival rate was 37.6%. The median survival in months was 7.0 ± 2.0 [Comparing the data from these studies to ours, the dominance of CSGB in the females is apparent. The mean age is very close in all four studies, ranging from 65 to 68.8 years. Survival data were similar There are some variations in the mean of survival in months following surgical intervention, but is not greatly significant. One of the interesting points made in the meta-analysis study was correlation of the race of the patients with survival. They found that Japanese patients (27 cases) had longer survival time than non-Japanese 24 cases), with mean survival of 19.9 months for the Japanese vs 11.5 months for the non-Japanese, with a median of 6 vs 4 months. In our review, 11 out of 29 patients (38%) were Japanese, with average survival of 16.9 months, compared with nine non-Japanese, with available data on their survival, who had average survival of 6.2 months. Three of the Japanese patients had prolonged survival of 24, 48, and 54 months, respectively . Japanes cases, wAbdominal mass, fever, nausea, vomiting, abdominal pain, anorexia, loss of weight, and painless jaundice are some of the nonspecific presentations of this tumor , 31. OurGallstones were observed in 8 out of 9 cases (88%) of CSGB in one review , in 14 oHistorically, the concept of “carcinosarcoma” was introduced by Rudolf Virchow in 1865 . Karl LaTo the best of our knowledge, none of the cases of CSGB on record had demonstrated the presence of eosinophilic hyaline globules (EHG). The present case showed the presence of several EHG within the cytoplasm of the mesenchymal sarcomatous spindly and pleomorphic cells, as well as free within the surrounding extracellular tissue. They were variable in size and were highlighted by Periodic Acid Schiff (PAS) stain. Such EHG had been labelled as “Thanatosomes,” a term proposed by Papadimitriou et al. denoting a degenerative phenomenon related to apoptosis, common to all cell types, benign or malignant, resulting from cytoplasmic blebbing and nuclear fragmentation followed by phagocytosis by neighboring cells or auto-phagocytosis, accompanied by increased membrane permeability to plasma proteins . In theiIn another study related to Thanatosomes in gastrointestinal epithelium, Dikov et al. examined 2230 biopsies of normal and pathological epithelium. EHGs were very rarely found in normal epithelium (1.1%), but their number increased significantly in specimens with ischemic injury 47%) and benign regenerative proliferation (70%). They concluded that Thanatosomes represented a relatively constant and useful histologic marker of enhanced cell turnover and ischemic injury % and ben. Our cas


Intrahepatic cholangiocarcinoma (ICC) originates from the epithelial cells of the secondary branches that are distant from the intrahepatic bile duct. ICC is a rare pathological type of primary liver cancer, with a high malignancy rate and poor prognosis. However, patients with ICC metastasis to the skull are extremely rarely encountered. Herein, we present a case of a metastatic skull tumor from ICC, along with a literature review.A 50-year-old right-handed man who did not smoke was diagnosed with a poorly differentiated ICC (T2aN0M0) in segment VI of the liver in February 2017. Hepatectomy was performed. The patient then presented with a painful mass in the posterior occipital region with dizziness experienced since 1 month, for which he underwent posterior occipital craniotomy. Postoperative specimens were sent for pathological examination.We diagnosed the patient with a metastatic skull tumor from ICC.The patient underwent posterior occipital craniotomy and total resection of the tumor.The patient received chemotherapy 1 month after surgery, and after 6 months of follow-up, the patient was alive.ICC often shows metastases to the vertebrae. Therefore, physicians should consider the possibility of metastasis in patients with ICC, especially in those who show a painful skull mass of unknown origin; moreover, among patients with vertebral metastasis, physicians should be very vigilant about an occipital mass. We believe that the craniospinal venous system may be the pathway for occipital metastasis in patients with ICC. ICC has a high malignancy rate and poor prognosis. Advanced stage ICC can metastasize to multiple organs, including the lungs, kidneys, and bones. However, patients with ICC metastasis to the skull are extremely rare. Only 4 cases have been reported till date. Therefore, herein, we present a case of a metastatic skull tumor from ICC, along with a literature review. We believe that this summary will be helpful for the diagnosis and treatment of patients with ICC in the future.Intrahepatic cholangiocarcinoma (ICC) originates from the epithelial cells of secondary branches that are distant from the intrahepatic bile duct. ICC is a rare pathological type of primary liver cancer, with an incidence of 10% to 15%.21 (TTF-1). The Ki-67 labeling index was 70%  in segment VI of the liver in February 2017. Hepatectomy was performed. The patient had clear resection margins and was treated postoperatively with transcatheter arterial chemoembolization. After perfusion, the patient showed good recovery; after discharge, he had a normal life without any discomfort. However, the patient did not undergo regular follow-up computed tomography (CT) per the doctor's advice, and 1 month later presented with presented with a painful mass. He did not complain of nausea, vomiting, or other neurological deficit symptoms. On physical examination, the tumor was hard, showed poor mobility, was not tender, and had no surface skin ulceration. Brain CT revealed a single mass within the central part of the occipital bone. T1-enhanced brain magnetic resonance imaging (MRI) revealed a heterogeneous enhanced mass, measuring approximately 3 cm × 3 cm × 2 cm. The tumor had clear boundaries along the bone tissue, had invaded the dura mater, compressed the brain tissue, and showed osteolytic changes in the bone. Three-dimensional CT of the skull showed a defect in the bone window of approximately 2.5 cm × 2.5 cm, with invasion to the entire skull layer . The CSVS has 2 main systems: 1) the intracranial veins, which include the cortical veins, dural sinuses, cavernous sinuses, and ophthalmic veins; and 2) the vertebral venous system, which includes the vertebral venous plexus (the Batson plexus).Extrahepatic metastases of ICC are often observed in the vertebrae. Therefore, physicians should consider the possibility of metastasis in patients with ICC who show a painful skull mass of unknown origin; in particular, among patients with vertebral metastasis, an occipital mass should be considered a possibility. In fact, the CSVS may be the pathway of occipital metastasis from ICC.The authors thank all the staff of the Neurosurgery Department and General Surgery Department of The Second Affiliated Hospital of Bengbu Medical College for their support.Conceptualization: Dawei Wang, Shiwei He, Qiujian Zhang, Hansheng Shu.Data curation: Liang Chu, Qiujian Zhang.Formal analysis: Liang Chu.Funding acquisition: Dawei Wang, Shiwei He.Software: Qing Chao.Supervision: Qing Chao.Writing – original draft: Dawei Wang, Shiwei He.Writing – review & editing: Liang Chu.


Due to the growing use of cross-sectional imaging in emergency departments, acute gynaecologic disorders are increasingly diagnosed on urgent multidetector computed tomography (CT) studies, often requested under alternative presumptive diagnoses in reproductive-age women. If clinical conditions and state-of-the-art scanner availability permit, magnetic resonance imaging (MRI) is superior to CT due to its more in-depth characterisationof abnormal or inconclusive gynaecological findings, owing to excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.This pictorial review aims to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their CT and MRI appearances, in order to provide a timely and correct imaging diagnosis. Specifically, this second instalment reviews with examples and emphasis on differential diagnosis the main non-pregnancy-related uterine emergencies  and the spectrum of pelvic inflammatory disease. The main uterine emergencies include bleeding endometrial lesions, degenerated leiomyomas and uterine inversionIdentification of central fibrous core and intratumoural cysts suggest endometrial polyp over carcinomaThe rare uterine inversion appears at MRI as U-shaped uterus with a depressed fundus and “bulls-eye” transverse configuration.The PID spectrum encompasses cervicitis, endometritis, salpingitis, pyosalpinx and tubo-ovarian abscess (TOA)Identification of fallopian tube dilatation allows differentiation of TOA from complex adnexal tumourAlthough transabdominal and transvaginal ultrasound (US) is the ideal technique for initial investigation of women with suspected genital disorders, in the emergency department (ED), the use of cross-sectional imaging is steadily growing. As a result, nowadays radiologists increasingly encounter unsuspected female genital diseases on urgent CT studies requested under alternative presumptive diagnoses. Therefore, familiarity with these conditions and their imaging appearances is required to avoid missing or misinterpreting clinically important abnormalities –4.Compared to CT, on state-of-the-art scanners, MRI provides a superior characterisation of abnormal or inconclusive gynaecological findings. If scanner availability and patient’s conditions permit, the use of MRI is attractive for further investigation of acute female genital disorders without ionising radiation –7.This pictorial essay aims to provide radiologists with an increased familiarity in recognition and characterisation of acute gynaecologic disorders on CT and MRI, in order to allow timely diagnosis and appropriate treatment. The previous first instalment reviewed the cross-sectional imaging appearances of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum from either ruptured corpus luteum and ectopic pregnancy and adnexal torsion. The present second instalment will discuss and present (with imaging examples) the main non-pregnancy-related uterine emergencies  and the spectrum of pelvic inflammatory disease (PID) , 9.Abnormal genital bleeding represents the characteristic and most common manifestation of acute uterine disorders and is one of the most common presentations in the emergency gynaecology unit as it accounts for approximately one-third of urgent gynaecologic visits. Causes encompass a wide spectrum of systemic and endocrine disorders, benign conditions  and malignancies .In reproductive-age women, when pregnancy is ruled out, clinical examination is required to search for vaginal and cervical abnormalities underlying acute bleeding. Additional imaging is required to detect or exclude abnormalities such as endometrial polyps or submucosal fibroids. Endometrial cancer is rarely encountered in pre-menopausal women, very exceptionally under 40 years of age. Dysfunctional uterine bleeding (idiopathic menorrhagia) represents a diagnosis of exclusion, in the absence of a recognizable pelvic pathology .Transvaginal US remains the initial modality of choice in the evaluation of endometrial diseases, but the use of MRI to clarify abnormal or suspicious US findings before hysteroscopy is increasing, as it provides superior detection and characterisation of abnormalities in the uterine cavity .Endometrial polyps (EP) represent a localised overgrowth of endometrial glands with a central stroma composed of fibrous tissue or smooth muscle. Sometimes asymptomatic, EP easily cause either menometrorrhagia in pre-menopausal women or post-menopausal bleeding. The prevalence ranges from 7.8% to 34.9% and increases with age; tamoxifen is a well-established risk factor , 14.On T2-weighted MR images, EP appear as low signal intensity sessile or pedunculated masses projecting into the endometrial cavity, surrounded by high signal intensity fluid and endometrium. Furthermore, a fibrous core  and intratumoural cysts  may be identified within the mass. Cystic spaces correspond to dilated glands but are nonspecific as they may be present within EP, hyperplasia or cancer. On T1-weighted images, EP generally have isointense signal compared to the endometrium, and may become haemorrhagic after ulceration or infarction leading to the appearance of hyperintense region best appreciated using precontrast fat saturation. After gadolinium contrast, EP may show either early persistent or gradually increasing enhancement, equal to or greater than that of outer myometrium  on T2-weighted images . IdentifIn post-menopausal women, the normal endometrium measures a mean 4 mm (range 1–12 mm) thickness , and endIn reproductive age, the normal endometrial thickness varies according to the menstrual cycle phases. Shitano et al. prospectively investigated the MRI appearance of normal endometrium in 32 healthy pre-menopausal women in follicular phase (FP) and luteal phase (LP). The maximum thickness of the normal endometrium, measured on sagittal T2-weighted images, in FP  was significantly lower than that in LP . Furthermore, on T2-weighted sequences, the signal intensity of the normal endometrium in FP was significantly higher than that in LP [The most common gynaecological mass, fibroids (leiomyomas) are benign tumours composed of smooth muscle cells and fibrous connective tissues that develop in almost 20–30% of reproductive-age women. In non-complicated fibroids, CT findings include uterine enlargement with lobulated contours, deformity of the endometrial cavity, and presence of focal masses that vary from exophytic or subserosal to intramural to submucosal. When present, coarse calcification is quite specific. Contrast enhancement is variable, so that fibroids may appear isodense, hypodense or hyperdense relative to the myometrium. MRI is the most accurate modality to detect, localise and characterise leiomyomas, which are typically T2-hypointense compared to the surrounding myometrium and of intermediate signal intensity on T1-weighted images .Acute pain develops in up to 30% of patients, secondary to either acute degeneration or torsion of an exophytic or submucosal pedunculated leiomyoma; in the latter case, vaginal bleeding coexists. Degeneration of leiomyomas results from the volumetric increase that outgrows vascular supply and may take different forms  according to the rapidity of development. The most common form is the hyaline one, with a deposit of collagen fibres. Among the different types of degeneration, the haemorrhagic one is most likely to cause acute pelvic pain. Haemorrhagic (“red”) degeneration often occurs during pregnancy or in association with the use of oral contraceptives and consists of haemorrhagic infarction of the leiomyoma secondary to venous thrombosis at the periphery of the lesion .At CT, haemorrhage and loss of contrast enhancement within a pedunculated, subserosal or intramural fibroid with a development of a cystic-like appearance may suggest the possibility of degeneration or infarction Fig. . At MRI,The most challenging differential diagnosis of benign degenerating leiomyomas is from uterine leiomyosarcomas that may exhibit different MR imaging patterns: (a) lobulated mass with high signal intensity on T2-weighted sequences, (b) well-marginated mass with low signal (similar to that of a leiomyoma), or (c) mass with extensive invasion and infiltrative margins. The suspicion of leiomyosarcoma may also be raised by the identification of haemorrhage and coagulative necrosis. The latter can present as areas of slightly high signal intensity on T1-weighted sequences and heterogeneous signal intensity on T2-weighted sequences . In the As for the role of DWI, restricted diffusion may represent a pitfall since it is observable in benign cellular leiomyomas as well as in leiomyosarcomas, although some authors demonstrated significantly lower mean ADCs in leiomyosarcomas than in degenerated leiomyomas . AlthougIn patients with symptomatic uterine leiomyomas, embolisation is recognised as a minimally invasive uterine-sparing treatment option. Although embolisation is generally safe, post-procedural pain may occur: pain may range from mild to severe, is more frequent during the first week after embolisation and forms the “post-embolisation syndrome” along with fever, loss of appetite, nausea and malaise. Post-procedural readmission is needed in about 10% of cases , 27. SevContrast-enhanced MRI is the imaging method of choice to evaluate post-embolisation appearances of fibroids. At follow-up, treated leiomyomas may show increased signal intensity on T1-weighted images, due to the shortening effect of methaemoglobin, and variable signal intensity on T2-weighted images, a finding consistent with haemorrhagic infarction induced by the procedure Fig. . On contUterine inversion (UI) refers to inside-out overturning and protrusion of the uterine fundus downwards up to or through the cervix that may occur either as an acute (within 24 h) life-threatening obstetric complication of mismanaged labour or in multiparous post-menopausal women from pulling effect of submucosal or pedunculated leiomyomas attached to the fundus; in the latter case, symptoms include pelvic tenderness or pain, vaginal discharge and irregular uterine bleeding. Physically, the vagina is occupied by the inverted uterus, but the clinical diagnosis is challenging without a high index of suspicion. Imaging is crucial to avoid misinterpretation as cervical tumour and to obviate biopsy which may cause profuse bleeding , 32.Whereas the nature of the “mass” protruding into the vagina is difficult to identify at US, MRI generally clinches the diagnosis. The hallmark of UI on sagittal viewing is a U-shaped uterus with indentation and depression of the fundus, and a “bulls-eye” transverse configuration reflecting the zonal anatomy Fig. d, f. AddTreatment of UI should consider the fertility and reproductive wishes of the patient, stage of inversion and underlying  pathology. Whereas in puerperium manual repositioning is possible, post-menopausal UI requires abdominal or vaginal hysterectomy .Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and gram-negative bacteria; mixed aerobic and anaerobic infections represent 30–40% of cases. Causative agents spread from the vagina to the cervix and uterine cavity, followed by the fallopian tubes and ovaries and even to the peritoneal cavity. Therefore, PID represents a spectrum of abnormalities encompassing cervicitis, endometritis, salpingitis, pyosalpinx and tubo-ovarian abscess (TOA) [Acute PID currently affects nearly one million reproductive-age women in the USA, represents the single most common  cause of ED gynaecological visits and is increasingly encountered due to changing sexual habits. Risk factors include multiple sexual partners, high coital frequency and the presence of intrauterine contraceptive devices (IUCD). PID results from untreated ascending microbial infection from the vagina by sexually transmitted microorganisms such as ss (TOA) .PID is often diagnosed clinically on the basis of fever, dull aching pelvic pain and cervical tenderness, vaginal mucopurulent discharge, leukocytosis and elevated C-reactive protein (CRP) levels. Most patients meeting these diagnostic criteria are treated empirically with broad-spectrum antibiotics. However, clinical manifestations are often unspecific. Therefore, cross-sectional imaging may be useful in patients with nonspecific presentation or inconclusive US, in those unresponsive to conventional therapy or with suspected complications such as abscesses requiring drainage. Furthermore, CT imaging is often requested in the ED to provide a differential diagnosis from other acute conditions such as urinary infection, appendicitis and diverticulitis , 38.Tables Cervicitis and endometritis represent early manifestations of PID and are often subclinical; when present, symptoms include pelvic pain, fever, vaginal discharge and menstrual abnormalities. In the former, MRI may demonstrate an enlarged uterine cervix with a prominent enhancement of the endocervical canal reflecting inflammation and hyperaemia Fig. . Free peOn the other hand, endometritis may be encountered during pregnancy, during the postpartum period, following invasive gynaecologic procedures or in the setting of PID. CT Fig.  and MRI Salpingitis corresponds to a swollen fallopian tube with mural inflammation and thickening Fig. . ConversThe strength of MRI relies on its ability to identify the ovary, to demonstrate the tubular nature of a mass, and to differentiate pyosalpinx from haematosalpinx on the basis of signal intensity of the tubal fluid. Tukeva et al. found MRI  to be more accurate than transvaginal US in the diagnosis of PID  and to be useful in decreasing the need for diagnostic laparoscopy . CompareAnother differential diagnosis is haematosalpinx Fig. , correspPosterior extension of the inflammatory process may cause thickening of the uterosacral ligaments, a common finding of PID, easily recognizable at both CT and MR . AdditioTOA develops in up to 15% of patients and represents the full-blown manifestation of untreated PID, in which further progression of infection leads to complete destruction of the normal adnexal structure and formation of an inflammatory mass that encompasses both the fallopian tube and ovary. Making the diagnosis of TOA is important since it requires hospitalisation and sometimes image-guided or surgical drainage.Sometimes bilateral, TOA shows up at CT Figs.  and 19 aAt MRI, TOA Fig.  is usualThe differential diagnosis from an adnexal tumour may prove very challenging. The cross-sectional appearance of a TOA may closely resemble those of ovarian epithelial malignancies, but it should be remembered that ovarian cancer is generally not associated with tubal dilation . The excActinomyces israelii infection of the female genital tract characteristically spreads across soft-tissue planes, resulting in heterogeneous adnexal masses with small rim-enhancing hypoattenuating abscesses, complex masses in the peritoneal cul-de-sac and perirectal region, that commonly appear more solid, mass-like compared with usual TOA [Occasionally, PID may spread even further in the pelvis forming peritoneal cavity abscesses Fig.  or involsual TOA .Fig. 21Finally, in Western countries, genitourinary tuberculosis is increasingly encountered because of the spread of HIV infection and increasing immigration; the fallopian tubes are the commonest site of tuberculous involvement, which appears as bilateral pyosalpinx or TOA. Calcifications are uncommon, particularly in the acute phase. Coexistent endometritis appears as distended pus-filled uterine cavity and prominent endometrial enhancement Fig. . PeritonChlamydia, N. gonorrheae or polymicrobial infection of the Bartholin gland  and may require surgical incision (Fig. Vaginal abscesses appear as hypodense, thick-walled rim-enhancing lesions, which may arise from ion Fig. . AlternaAlthough discouraged in childbearing-age women, CT often provides the first diagnosis of an unsuspected acute gynaecological disorder; therefore, familiarity with their imaging appearances is crucial to avoid missing or misinterpreting clinically important entities which may require surgical treatment. If clinical conditions and scanner availability permit, MRI is superior to CT for further characterisation of uterine abnormalities causing acute pain and genital bleeding. Additionally, cross-sectional imaging is helpful to elucidate the varied imaging appearances of PID and atypical genital infections.


Formation of an internal hernia beneath a skeletonized pelvic vessel after pelvic lymph node dissection is extremely rare. We report a case of an internal hernia formation beneath the left external iliac artery after a robotic-assisted laparoscopic prostatectomy with extended pelvic lymph node dissection.A 72-year-old man visited our hospital complaining of severe lower abdominal pain. On physical examinations, his abdomen was distended and tympanitic with rebound tenderness and muscular defense. Abdominal non-enhanced computed tomography showed a small bowel obstruction with marked ascites. A coronal non-enhanced computed tomography image revealed thickened loops of small bowel with surrounding mesenteric edema in the left lower quadrant. Enhanced computed tomography was not performed because we decided to perform urgent surgery with a diagnosis of strangulated small bowel obstruction based on physical examination and the computed tomography findings. The patient underwent urgent laparotomy at which time bloody ascites was seen in the peritoneal cavity. The ileum, which was approximately 60 cm proximal to the ileocecal junction, formed a closed loop beneath the left external iliac artery. The incarcerated ileum, 120 cm in length, appeared non-viable with a color change of the ileum to black. We therefore resected the strangulated ileum for a length of 120 cm and performed a functional end-to-end anastomosis. The orifice beneath the left external iliac artery was about 4 cm in diameter. We did not close the orifice because of the risk of injuring the left iliac artery. The postoperative course was uneventful, and the patient was discharged from our hospital 10 days after surgery. Presently, the patient is doing well 5 months after surgery without recurrent disease.We report an extremely rare case of internal hernia formation beneath the left external iliac artery after a robotic-assisted laparoscopic prostatectomy with extended pelvic lymphadenectomy. Awareness of such complication and early surgical treatment are important when treating patients with this rare occurrence. Pelvic lymph node dissection is a standard procedure in many operative treatments in cancer, such as prostate cancer , bladder3 μL) and no elevation of his C-reactive protein level (0.01 mg/dL). Abdominal non-enhanced computed tomography (CT) showed a small bowel obstruction (SBO) with marked ascites. Also, a coronal non-contrast CT image revealed thickened loops of small bowel with surrounding mesenteric edema in the left lower quadrant (Fig. A 72-year-old man visited our hospital with a 1-day history of severe lower abdominal pain, vomiting, and the inability to pass gas or stools. Two months prior to presentation, the patient underwent a robotic-assisted laparoscopic prostatectomy with ePLND for prostate cancer. The patient had no history of previous illness except for prostate cancer and was not taking any regular medications. On physical examination, he showed a pulse of 97 beats/min and blood pressure of 122/64 mmHg. His abdomen was distended and tympanitic with rebound tenderness and muscular defense. Bowel sounds were absent. His groin examination was normal with no signs of herniation through the femoral or inguinal canals. Laboratory data showed only a marked elevation of the white blood cell count 15.0 × 10 μL and nThe incidence of SBO after abdominal operations is about 3–5% in a previous report . Also, oIn our case, the internal hernia beneath the external iliac artery occurred 2 months after a robotic-assisted laparoscopic prostatectomy. As shown in Table Our patient had severe, agonizing abdominal pain. The suspicion of strangulated SBO was our first differential diagnosis according to the physical examination, and it was confirmed with abdominal non-contrast CT. We decided to perform urgent surgery as soon as possible as strangulated SBO is a life-threating disease. Therefore, enhanced CT was not performed. Viktorin-Baier et al.  and DumoSeveral treatment options for internal hernia beneath the external iliac artery have been discussed in the previous reports to prevent its recurrence. Guba et al.  closed tWith the advances in laparoscopic surgery, Dumont and Wexels  reportedIn conclusion, internal hernia beneath the external iliac artery is a rare but serious complication after ePLND. Awareness of such complication and early surgical treatment are important in treating patients with this rare occurrence.


We report the case of a 77-year-old female patient with the diagnosis of pancreatic head insulinoma, in whom we used near infrared light (NIR) to detect synchronous pancreatic tumors and potential secondary lymph node or liver involvement. The patient presented with hypoglycemia manifesting by lipothymia. With the diagnosis of secretory neuroendocrine tumor (insulinoma) of the pancreatic head, cephalic pancreatoduodenectomy with the preservation of the pylorus was performed after NIR visualization of the pancreatic tumor mass. At 6, 12, 18 months postoperatively, the patient no longer had hypoglycemia and her general state was good.NIR with indocyanine green (ICG) evidences pancreatic neuroendocrine tumors, as well as possible synchronous tumors and secondary lymph node or liver involvement. Sporadic insulinoma occurs in the pancreas in 98% of cases and is usually small (0.5 cm–3 cm), but may have malignant characteristics if its size exceeds 2.5 or 3 cm. Surgery is the only curative treatment. The examinations used to evidence the location of these neuroendocrine tumors preoperatively are somatostatin receptor scintigraphy, echoendoscopy, F dihydroxyphenylalanine (F-DOPA) PET CT. Somatostatin receptor scintigraphy (SRS) has a sensitivity of about 50–60% in detecting benign insulinomas. Echoendoscopy (EES) has an 86% 57–100%) rate of detection, while intraoperative ultrasound identifies 92% (84–100%) of all insulinomas. If the preoperative location of insulinoma is difficult, F dihydroxyphenylalanine (F-DOPA) PET CT is indicated. Another examination to detect secretory pancreatic neuroendocrine tumors (PanNET) is glucagon-like peptide-1 PET CT, which is useful particularly in MEN-1 (1). Intraoperatively, PanNET can be examined by palpation, intraoperative ultrasound (IOUS) or near infrared (NIR) light [00% rate A 77-year-old female patient was treated in the Surgical Department of the Cluj-Napoca Clinical Emergency Hospital.The aim of this case report is to demonstrate whether ICG administration and NIR examination in pancreatic insulinoma are beneficial for patients.The work in this case has been reported in line with the SCARE criteria .Surgical Clinic II, “Iuliu Hatieganu” UMF Cluj-Napoca, Romania.22, dark circles under eyes, moderately altered general status, hot, dehydrated skin, murmur in the aortic focus, diminished vesicular murmur bilaterally and left basal crackles, kyphotic chest, painless abdomen on superficial and deep palpation.Caucasian, female patient NM aged 77 years, from an urban area, retired, was admitted to the Surgical Clinic II by transfer from the Clinic of Diabetes Mellitus and Nutrition Diseases for repeated lipothymia, symptomatic hypoglycemia. The patient’s personal pathological history included antral gastritis, Helicobacter pylori infection and hypertriglyceridemia. She was on hypolipidemic medication and she had never smoked. Objective examination showed an overweight patient with a BMI of 28.3 kg/mThe diagnosis of pancreatic insulinoma was confirmed by Whipple’s triad: low glycemia, hypoglycemia-associated symptoms and disappearance of symptomatology when glycemia returns to normal (ingestion of sugar).Laboratory examinations showed glycemia 110 mg/dl under 20% glucose 3 vials 500 ml/day, glycosylated hemoglobin 4.37%, hypertriglyceridemia, hepatic and renal tests within normal limits, serum cortisol within normal limits, thyroid hormones within normal limits, parathormone within normal limits. Insulinemia in the hypoglycemic crisis was 28.7 μg/l (NV 2.6–24.9 μg/l). Imaging explorations  detected a hypoechogenic tumor mass in the pancreatic uncinate process, with gross calcification and peripheral vascularization 3.4/2 cm in diameter, without causing a mass effect in the pancreatic duct , Fig. 2.The near infrared (NIR) detection device in the reported case was NIRF-800 probe, ArteMIS Handheld System, Quest Medical Imaging BV, Wieringerwerf, the Netherlands, which detects NIR between 790 nm and 805 nm, and indocyanine green (ICG) (25 mg/20 ml VERDYE). Five boluses of 2 ml from the 2.5 mg/ml ICG solution were administered.The exclusion criteria (contraindications) for ICG administration in the current case were allergy to ICG and shellfish; hepatic or renal failure, hyperthyroidism, criteria that the patient denied. The patient’s informed consent for this procedure was obtained.which entered into contact with the pancreatic duct without having a mass effect on it. No other pancreatic or hepatic tumor masses were ultrasonographically detected.With the diagnosis of insulinoma of the pancreatic uncinate process, surgery was performed under general anesthesia. Intraoperative ultrasound evidenced a pancreatic uncinate process tumor of 3.3/2 cm, Intraoperatively, after Kocher procedure, a tumor mass in the uncinate process was detected. To explore a possible multicentric insulinoma or secondary lymph node involvement in the hepatic hilum or liver metastases, ICG injection and examination with a NIR camera were carried out. No other tumor masses were found in the tail of the pancreas and no secondary hepatic or lymph node involvement was detected , the patient did not require 20% glucose intake, and discharge was on the 12th postoperative day. The histopathological result was G2 neuroendocrine tumor consistent in the clinical context with a pT2N0M0L0V0R0 insulinoma with a 3% Ki67 index .Fig. 5HEEvolution at 30 days was favorable, without ultrasonographically detected recurrences, and computed tomography with iv contrast detected no tumor recurrences and no secondary lymph node or liver involvement.3The incidence of PanNET has increased over the last two decades .Given the size of the tumor and its relationship with the pancreatic duct (the tumor was in direct connection with the main pancreatic duct), limited tumor resection could not be performed. The appropriateness of extended pancreatic resection was also supported by the high mitotic index (Ki67 3%).3.1insulinomas, surgery is the only curative treatment [In cases of reatment ,5. Becaugastrinoma because, while long-term recovery is possible after R0 surgery for sporadic gastrinoma (20–45%), complete cure is very rare when gastrinoma is a component of MEN 1 (<10% when PD is not performed).Multiple endocrine neoplasia (MEN) should be excluded in the case of other functional PanNET  are even rarer. These tumors are usually voluminous, malignant, with locoregional or liver extension [The xtension .3.2The type of surgery depends essentially on the size of the tumor and its location, but also on the relationship with nearby structures, the existence of synchronous lymph node metastases (LNM) or liver metastases (LM), patient co-morbidities, and possible hormonal secretion.Pancreatoduodenectomy with tumor-free margins and lymphadenectomy is the carcinological operation for PanNET of the pancreatic head. The expected risk/benefit ratio has to be measured with extreme caution, particularly if the lesion is benign or of borderline malignancy . This opDistal pancreatectomy is the carcinological operation for lesions in the body or tail of the pancreas. This procedure, especially when performed for proximal lesions, removes the major part of the gland with a risk of pancreatic insufficiency (mainly endocrine) leading to de novo postoperative diabetes in about 15% of patients . AccordiIn patients with a low carcinological risk, it is appropriate to preserve as much pancreatic parenchyma as possible, to avoid the risks of endocrine and/or exocrine insufficiency, particularly when the tumor is small, benign or of low-grade malignancy ,11. EnucIn the absence of liver metastases, PanNET and metastatic lymph node resection is the only accepted curative treatment . In a liShirata et al. demonstrated that 100% of PanNET were visualized using fluorescence imaging .Guarantying free resection margins and oncological radical resections, laparoscopy is becoming widely preferred over open surgery for the treatment of small benign or indeterminate pancreatic lesions, such as PanNET, the body–tail of the gland ,14.One of the most challenging aspects of the surgical plan is the exact localization of the tumors. Considering small PanNET, the reported preoperative and intraoperative detection rate is up to 92% , even whFluorescence-guided surgery has emerged as a novel intraoperative modality to assist surgeons to visualize tumors, sentinel lymph nodes, and vital structures in real time ,12. A viDetection of PanNET with NIR prolongs surgery by approximately 8 min, but brings important benefits for visualizing the tumor .Paiella et al. report a 0% reintervention and mortality rate in 10 cases operated by laparoscopy with a mean size of 2.4 cm (1–4 cm) and a Ki-67 index of 6% (2–12%). Nine patients underwent corporeo-caudal pancreatectomy and for one patient, tumor enucleation was performed. Eight PanNETs were non-secretory and two were insulinomas .4NIR by ICG administration is a method with almost 100% sensitivity and specificity for the intraoperative exploration of secretory PanNET and for the identification of other synchronous lesions, secondary lymph node involvement or liver metastases, which does not significantly prolong surgery.No founding received.Not applicable. The study is exempt from ethical approval in our institution.Consent has been obtained from the patient. No identifying details have been used in the article.V. Muntean: study concept, and final approval. V. Muntean, D. Constantinescu, R. Ciocan, D. Pintea treated the patient. D. Constantinescu, M. Constantinescu, S. Chiorescu wrote the first draft of the manuscript and the final draft of the manuscript, M. Pop photoediting, in editing manuscript. All authors read and approved the final manuscript.Not available.Valentin Muntean.Not commissioned, externally peer-reviewed.None of the authors have any conflict of interest.


Acute esophageal necrosis is an uncommon clinical disorder diagnosed on endoscopy as a black esophagus. It has a multifactorial etiology that probably represents a combination of poor nutritional status, gastric outlet obstruction, and ischemia secondary to hypoperfusion of the distal esophagus. It typically occurs in older males with comorbidities. A 37-year-old woman presented with diabetic ketoacidosis and hematemesis. At esophagogastroduodenoscopy acute esophageal necrosis was diagnosed. The treatment included fluid and electrolyte management, insulin, and a proton pump inhibitor. She improved and left the hospital on day 3. Diabetic ketoacidosis can result in a profound osmotic diuresis, fluid loss, and hypoperfusion of the distal esophagus. This condition can then lead to ischemic injury and acute esophageal necrosis. Awareness of the possibility of its presence in young women with hematemesis and poorly controlled diabetes is important since early identification with esophagogastroduodenoscopy is necessary to prevent serious postnecrotic complications. Acute esophageal necrosis (AEN) is also known as black esophagus or Gurvits Syndrome. It was first described in the medical literature in 1990 by Goldenberg and colleagues but became a distinct clinical syndrome in 2007 by Gurvits , 4. Trea Clostridium difficile colitis and completed a full course of antibiotics with resolution of symptoms; however over a week prior to the current admission her diarrhea had recurred. She denied any history of tobacco or alcohol use but did describe daily marijuana use. She was taking hydrocortisone 20 milligrams (mg) twice daily (bid) for Addison disease, insulin lispro 5 units (u) with meals, and insulin glargine 10 u at night. On admission her vital signs were temperature 97.1° F, blood pressure 130/102 mmHg, heart rate 140 beats/minute, and respiratory rate 26 breaths/minute. Her physical exam was only significant for abdominal guarding. The remainder of the physical exam was unremarkable. Metabolic panel demonstrated a blood glucose of 763 mg/dL, CO2 of 8 mmol/L, and β-hydroxybutyrate of 15.3 mmol/L with an anion gap of 36 mmol/L. Arterial blood gas (ABG) was significant for a metabolic acidosis with a pH of 7.11 and HCO3 of 4.1 mmol/L. Additional laboratory values were significant for urinary ketones of 80 mg/dL, urine glucose of ≥ 500 mg/dL, and a hemoglobin A1C of 15.3%. The findings were consistent with diabetic ketoacidosis (DKA) and she was started on an insulin drip with aggressive intravenous fluid resuscitation. Due to her significant abdominal pain, a computed tomography (CT) of the abdomen and pelvis was done which revealed extensive low-attenuation surrounding the distal esophagus with esophageal wall thickening (A 37-year-old female with a past medical history significant for type I diabetes mellitus for > 20 years, Addison disease, and systemic lupus erythematosus presented to the emergency department with increasing abdominal pain over a six-day period. She also described poor oral intake and several episodes of nausea with blood-tinged emesis. She was treated 6 weeks earlier forickening . Gastroeickening . A diagnThere are two unique elements to this case. First, AEN is a rare disorder, , 6 and, The second unique element of this case is that this disorder is rare in the younger female population; thus it would be easy to overlook the possibility of AEN in that demographic. A timely diagnosis is fundamental to preventing long term consequences. Consequently, EGD should be considered early in the course of management even in the young female population if there is a suspicion based on history, exam, or imaging. Our case clearly demonstrated an abnormality in the distal esophagus on abdominal CT scan, but EGD is necessary for confirmation.With the exception of cases resulting from caustic substance ingestion, AEN has not been reported in the pediatric group, even in type I diabetics, suggesting this disorder is the result of recurrent local ischemic and chemical insults to the distal esophagus.Our patient presented with hematemesis, abdominal pain, and diarrhea. Hematemesis occurs in approximately 70% of cases. Other presenting features include vomiting, retrosternal chest discomfort, and dysphagia , 6. Her The correlation between hyperglycemia and AEN has been well described in the literature. Up to 90% of patients with AEN are found to be at least moderately hyperglycemic at the time of presentation . Though As a rare, understudied clinical entity, no standardized therapies for acute esophageal necrosis currently exist. Treatment should be directed at correcting the underlying medical condition with hemodynamic resuscitation and glycemic control , 4, 5. A