To describe the clinicopathological and imaging features of mixed endometrial stromal and smooth muscle tumors with intracardiac extension and to explore the diagnostic value of dual-energy computed tomography (DECT) for this rare entity.This retrospective study analyzed the clinicopathological data and images of a 41-year-old female patient with pathologically documented mixed endometrial stromal and smooth muscle tumors with intracardiac extension who had undergone DECT examination. Seven virtual monoenergetic images (VMIs) in 10-kiloelectron volt (keV) intervals (range = 40–100 keV), iodine density (ID) maps, and Z effective (Zeff) maps were reconstructed, and lesion conspicuity was assessed. Tumor homology was analyzed using quantitative DECT parameters and energy spectrum attenuation curve.The patient complained of a 10-day history of bilateral lower extremity edema. Computed tomography showed a hypoattenuating filling defect located within the paracervical vein that extended into the right atrium to the ventricle through the right iliac veins and inferior vena cava (IVC). Intracardiac and intravenous lesions mainly demonstrated moderate progressive enhancement, with localized non-enhancing necrotic areas on contrast-enhanced CT. Multiple nodules showing progressive enhancement  were observed at the fundus of the uterus on dynamic contrast-enhanced magnetic resonance imaging (MRI), which were deemed the primary lesions of the tumor. Overall, the tumor was characterized by a small primary lesion with extensive vascular extension. In addition, the 40 keV VMIs reconstructions were found to provide best visualization for the early detection of tumors.Although a definitive diagnosis of MESSMT with intracardiac extension requires confirmation by histopathological examination, imaging examination can be used to characterize the extent of the lesion. The dual-energy dataset facilitates tumor visualization and homology evaluation. Mixed endometrial stromal and smooth muscle tumor (MESSMT) is an uncommon mesenchymal uterine tumor characterized by the presence of both endometrial stromal and smooth muscle tissue . Such tuThis retrospective study was approved by an ethical committee, and the requirement for informed consent was waived.The clinicopathological features and imaging findings  of a case of mixed endometrial stromal and smooth muscle tumor with intracardiac extension in a 40-year-old woman are analyzed. We searched the literature using medical terms  in PubMed; previously reported cases are summarized and explored .The virtual monochromatic images (VMIs) , iodine density (ID) maps, and Z effective (Zeff) maps were reconstructed from the dual-energy dataset using dedicated workstations . Notably, 70 keV VMI is equivalent to 120 kV conventional single energy CT acquisition  .2 were placed on the involved paracervical vein, gluteal muscle, and subcutaneous fat of hip across three adjacent levels, avoiding large vessels and any area with obviously gross necrosis, or calcification. The mean CT attenuation values and standard deviation (SD) in VMIs were obtained within the ROIs, and averaged across the consecutive sections. The SNR and CNR were calculated by the following formula:Furthermore, VMI has been confirmed to improve the signal-to-noise ratio (SNR) and the contrast-to-noise ratio (CNR) in tumor imaging –11. To dHU) was calculated as follows: λHU = (HU40 keV − HU70 keV)/(70 − 40), where HU40 keV and HU70 keV refers to the CT values at each energy level  as the abscissa and the CT value as the ordinate. The slope of the energy spectrum curve , carcinoembryonic antigen (CEA), cancer antigen 19-9 (CA19-9), cancer antigen 125 (CA125), and cancer antigen 15-3 (CA15-3) levels were all within the normal range.A 40-year-old woman presented to the intervention department complaining of edema in both lower limbs for 10 days. Physical examination revealed a depression in the lower limb edema after finger pressure was applied to the area. Additionally, she complained of a 1-year history of menorrhagia. Laboratory blood tests revealed a Tumor Abnormal Protein (TAP) level of 203.375 μmCardiac US imaging demonstrated a 74 mm × 34 mm solid mass within the right atrium that moved back and forth between the right atrium and right ventricle with the cardiac cycle. The mass extended down to the inferior vena cava in a long strip that floated slightly in the bloodstream. Pelvic US revealed a hypoechoic mass measuring 47 mm × 22 mm in the right posterior part of the uterus, which was closely connected with the right lateral wall of the uterus; a mixed mass measuring 52 mm × 41 mm was observed in the right rear of the uterus, which had an irregular shape, unclear boundaries, and a tortuous distal end. The two masses were partially connected. Color doppler flow imaging (CDFI) showed a blood flow signal in these two masses.Computed tomography of the chest, abdomen, and pelvis depicted a filling defect within the tortuous and enlarged paracervical vein that extended superiorly through the right common iliac vein into the right atrium and right ventricle. The filling defect showed heterogeneous hypoattenuation, mainly progressive enhancement, accompanied by a non-enhanced low attenuation area. In addition, a circular enhanced thick-walled cystic lesion could be seen on the right of the uterine body , 2.To further clarify the condition of the uterus, pelvic MR imaging was performed and revealed the following: ➀ Multiple nodules of varying sizes were observed at the fundus of the uterus, which showed low signals on T1-weighted images, high signals on T2-weighted images and a low signal intensity in DWI images. The nodules demonstrated progressive enhancement following intravenous administration of gadolinium-based contrast material. ➁ Multiple tortuous and dilated vascular structures with heterogeneous signal intensity were observed at the fundus and the parametrium. The vascular structure demonstrated mixed equal or high signals on T1-weighted images and mixed low or high signals on T2-weighted images. After the injection of gadolinium-based contrast material, there were progressively enhanced lesions in the lumen, which were the invaded vein. No evidence of lymph node metastasis was detected in the pelvic cavity .All reconstructed dual-energy datasets are presented in The objective quantitative SNR and CNR values are displayed in Single-stage operation was performed, including total hysterectomy, and resection of intracardiac, IVC, and right common iliac vein tumor. During surgical exploration, space-occupying lesions originating from the inferior vena cava could be seen in the right atrium, and the head of this entity was found to enter the right ventricle through the tricuspid valve. In addition, a long and continuous mass was observed in the inferior vena cava, blocking it and extending down to the level of the right common iliac vein. Uterine enlargement was found, which was similar to that commonly observed in women after more than 40 days of pregnancy; and there was an enlarged mass on the right side of the cervix, compressing the cervix toward the left, and tumor thrombus could be palpated in the parametrial vein. No obvious abnormality was found in the bilateral adnexa.The tumor was predominantly composed of spindle cells that were intertwined with each other. These cells had relatively abundant eosinophilic cytoplasm and oval or elongated nuclei with coarse-grained chromatin structure. Mitotic figures were rarely seen. Focal necrosis of the tumor cells located in the heart was observed, whereas no definite necrosis was observed in the uterus. Regarding immunohistochemistry, the tumor cells of the uterine mass were positively immunolabeled with smooth muscle actin (SMA), desmin, and CD10. The labeling index of Ki-67 index was less than 10%. The immunostaining results of the tumor cells in the venoatrial mass were the same as those of the cells in the uterine mass. In addition, estrogen receptor (ER) and progesterone receptor (PR) staining were performed to determine whether the venoatrial mass originated from the uterus, and the results showed that the labeling index of ER and PR was more than 80 and 90%, respectively , 7.The final pathological diagnosis was mixed endometrial stromal and smooth muscle tumor of the uterus with inferior vena cava metastasis into the right atrium.The patient recovered uneventfully and was followed up by CT for 8 years without any complications or recurrence.Mixed endometrial stromal and smooth muscle tumor is a rare and miscellaneous mesenchymal uterine tumor characterized by the presence of endometrial stromal and smooth muscle tissues (each component > 30%) . The bioCompared with that of uterine stromal tumors and smooth muscle uterine tumors, the incidence of MESSMT is very low, especially with intracardiac extension. MESSMT was first reported by Tang under the name of endometrial stromal tumor in 1979 . IncrediCareful preoperative imaging examination is of great clinical significance for planning the treatment of pelvic tumors with intravenous extension . Since tFrom a clinical point of view, it is difficult to differentiate MESSMT with intracardiac extension from IVL. Moreover, tomographic differential diagnosis of the two is even more challenging. On CT imaging, IVL usually manifests as hypoattenuating intravascular filling defects and associated uterine leiomyomas, with heterogeneous enhancement and, occasionally, blood vessels in the lesion . MeanwhiDual-energy computed tomography is a landmark CT acquisition method that collects two different energy spectra as input for material decomposition algorithms, and it can offer clinically informative image sets . VirtualThe most effective treatment is dependent on complete surgical resection, and multidisciplinary combined surgery is necessary due to the complexity of the tumor . Staged Although MESSMT with intracardiac extension is exceedingly unusual, it is a lesion with malignant biological behavior that can be lethal and is prone to recurrence. Imaging examination can characterize the primary lesion of the uterus and provide clarity regarding the range of the intravascular extension of the tumor, which is closely related to the formulation of the surgical scheme. Nevertheless, the imaging appearance of MESSMT with intracardiac extension overlaps highly with IVL, so the final diagnosis requires further pathological and immunohistochemical evidence. Complete surgical resection and close long-term follow-up are necessary for these patients. Concurrently, this study also shows that 40 keV VMIs are most helpful to improve the visualization of paracervical abnormal vascular changes for the early detection of MESSMT with intravascular extension. Quantitative DECT parameters and energy spectrum curves can provide support for the determination of the extensive lesion homology.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.This study was reviewed and approved by the Medical Ethical Committee of Zhengzhou University. The requirement for informed consent was waived.Y-yL: manuscript preparation, literature research, and data analysis. ZY: manuscript preparation and literature research. RW: manuscript review and data collection. K-sC: guidance of pathological knowledge. S-wY, JL, and X-mG: guidance of imaging knowledge. C-mD: imaging data collection and analysis. Z-xW: language editing. XZ: dual-energy knowledge guidance. J-bG: study conception and design, manuscript review, and guarantor of integrity of the entire study. All authors contributed to the article and approved the submitted version.


The retroperitoneum is the anatomical compartment positioned behind the peritoneal cavity. It is separated into three primary spaces: the anterior pararenal, perirenal, and posterior pararenal spaces. Retroperitoneal cystic mass is a rare surgical problem that is often wrongly identified before surgery.We report a case of a 27-year-old female presenting with abdominal swelling and pain starting from 9 months. An abdominal computed tomography scan showed a right adnexal mass with a high probability of a serous ovarian. The patient was diagnosed with ovarian tumors before surgery, but it was identified with a retroperitoneal cyst during surgery.A retroperitoneal cyst's clinical signs and symptoms vary, and the diagnosis can often be challenging. Computed tomography scans are appropriate for assessing retroperitoneal pathology because they produce separate sectional images and couldn't find the correct diagnosis in previous cases.This paper shows the rare case of primary retroperitoneal lesions, which can be hard to diagnose before surgery, even though medical imaging has come a long way. •A retroperitoneal cystic tumor is a very uncommon medical condition that is often misdiagnosed prior to surgery.•The diagnosis is made based on the patient's medical history as well as imaging using a computed tomography (CT) scan, which shows unilocular or multilocular thin-walled cyst lesions with watery liquids.•Although a CT scan can aid in the detection of these lesions, surgery is still the essential factor in identifying the diagnosis.•Clinical doctors should be aware in conducting early accurate diagnosis when facing like these lesions to avoid severe complications. It consists of three primary divisions, the anterior pararenal space, perirenal space, and posterior pararenal space. It contains the abdominal organs such as the kidneys, adrenal glands, ureters, ascending colon, descending colon, the duodenum, pancreas, and the abdominal aorta Here we reported a case of a 27-year-old female with a huge retroperitoneal cyst masquerading as an ovarian tumor. We recommended that clinical doctors be aware of retroperitoneal mass when there are imaging features of ovarian tumors.The case was written by following the scare checklist guidelines 2020 for writing case reports 2A 27-year-old female presented to the University Hospital complaining of abdominal swelling and abdominal pain starting from 9 months and five months, respectively, with heaviness in the abdomen. Her medical history was clear, and the physical examination revealed a right flank abdominal pain extending to the right iliac fossa, with a palpable mass in the right side of the abdomen extending to the pelvis, with no hepatosplenomegaly or palpable lymph nodes. Complete blood tests were within normal range, and there were no tumor markers tests due to insufficient financial capabilities. Abdominal ultrasound revealed a multiloculated cyst with an incomplete thick septum across the right side of the abdomen, with no solid component. Abdominal computed tomography showed a mass extended to the right side of the abdomen, so we suggested it may be a right adnexal mass with a high probability of a serous ovarian tumor measuring approximately (13 × 10 × 15 cm) , althoug3A retroperitoneal cyst's clinical signs and symptoms vary, and the diagnosis can often be challenging Computed tomography scan showed left adnexal mass with a possibility of ovarian serous cystadenoma measuring 14.5 × 14.6 × 18.2 cm with local mass effect to the ureter causing mild left hydronephrosis. Intraoperatively, a vast mass arose from the retroperitoneal space attaching to the psoas muscle, spine, and encasing the internal iliac and left ureter. Rafique U Harvitkar et al. Because they continue to recur following simple aspiration, retroperitoneal cysts should be surgically removed. In this article, we showed a rare case that caused a diagnostic challenge due to overlapping imaging findings, where only by surgery we discovered the correct diagnosis.4Cysts originating outside the major organs of the retroperitoneum are incredibly uncommon. Although a CT scan can aid in the detection of these lesions, surgery is still the essential factor in identifying the diagnosis. This article aims to raise awareness among doctors about retroperitoneal cysts, especially when they are masquerading as ovarian tumors.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.Not commissioned, externally peer reviewed.This case report didn't require review by Ethics committee, Aleppo university hospital, Aleppo University, Aleppo-Syria.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Hidar Alibrahim.Not applicable.Hidar Alibrahim: contributed in writing manuscript and data collecting, Amany Al Ali: contributed in writing manuscript, Haidara Bohsas: contributed in writing manuscript, Safaa Mohamed Alsharief Ahmed: contributed in writing manuscript, Eman Mohammed Sharif Ahmed: contributed in writing manuscript, Sarya Swed: contributed in reviewing the paper.All authors declared no conflict of interest.


Vasitis is a rare condition that may be challenging for the clinical practitioner. Sometimes it is misdiagnosed as incarcerated inguinal hernia; thus, patients end up receiving unnecessary surgery. Compared with the traditional approach with only sonography, the more recent introduction of computed tomography in the diagnostic process has provided higher quality imaging and more detailed anatomy. Consequently, some urologists advocate the efficacy of computed tomography in the differential diagnosis of difficult cases.We present the case of a 23-year-old male who suffered from right inguinal pain and swelling. His scrotum ultrasound showed multiple tubular structure dilatation within the subinguinal area and no testis torsion. The initial diagnosis was a right inguinal hernia. Computed tomography supported that initial diagnosis, and we presumed the lesion represented a herniation of the omentum with mesenteric vessels. Since there was a suspicion of hernia incarceration, the patient underwent diagnostic laparoscopy, which did not reveal herniation, but only erythematous reaction and swelling over the right spermatic cord. Following a final diagnosis of vasitis, he received empirical antibiotic treatment and his symptoms entirely resolved.Even though computed tomography can provide thorough imaging of the urogenital system, the contrast enhancement within vessels and inflammatory organs can still be misleading in the diagnostic process. Vasitis is an infection or inflammatory condition of the vas deferens . Vasitis3/μL; reference range, 4–10 × 103/μL) and elevated C-reactive protein levels ; however, beta-human chorionic gonadotropin  and alpha-fetoprotein  levels were within the normal limits. Urine analysis revealed microscopic hematuria without pyuria. CT showed a segmental ileal loop within the right inguinal area and multiple hyperdense tubular organs incarcerated into the right scrotum  pain score remained below 4. Moreover, the patient denied any history of systemic disease or previous surgery. His history was also negative regarding weight-bearing, chronic cough, trauma, or strenuous exercises before symptoms onset. Notably, the patient had no family history of testicular torsion. Physical examination showed right subinguinal erythema and tenderness. However, Prehn’s sign was negative, and there was no swelling of the testis and epididymis bilaterally Fig. A. InguinVasitis can be classified as either an acute infection/inflammation or a chronic disease. The chronic condition, also known as vasitis nodosa, was first described in 1943 by Benjamin . VasitisThe pathophysiology is associated with obstruction or injury to the vas deferens, which is a complication of vasectomies. Indeed, post-vasectomy pain syndrome is associated with chronic vasitis . In a reEscherichia coli and Haemophilus influenzae [Chlamydia trachomatis [Mycobacterium tuberculosis and Brucella have also been isolated [Infectious vasitis is associated with retrograde spread from cystitis, epididymitis, or prostatitis. Possible pathogens include fluenzae . Sexuallfluenzae  and infechomatis  have alsisolated . Even thSonography was the gold standard for diagnosis before the widespread use of high-resolution CT images. Yang et al.  reportedSome differential diagnoses should be considered before a definitive diagnosis of vasitis is made. First, an incarcerated inguinal hernia can present similar features in the acute setting. However, diameters of dilated bowel loops can be significant great in an inguinal hernia, with or without bowel gas (hyperechoic spots) . A ValsaAlthough the diagnosis of vasitis entails differential diagnosis with a wide range of other clinical conditions, clinicians usually focus on ruling out only the acute ones, such as incarcerated inguinal hernia and testicular torsion. The initial diagnostic approach is with ultrasound. However, some studies revealed equivocal ultrasound results, thus advocating the use of further imaging modalities. Lin et al.  reportedUnfortunately, few published papers have reported on the diagnosis of vasitis using CT scans since the previous approach to diagnosis was based only on ultrasound assessment. In a typical CT scan of vasitis , 15–18, Compared with the typical clinical picture of vasitis reported in previous studies, our patient had enlargement and hyperattenuation over the spermatic cord and its adjacent vessels, with peripheral fat stranding on a CT scan. There was no intratubular content. The tubular structure could be traced back to the small bowel without interruption. Thus, the patient was misdiagnosed with omental or mesenteric incarceration in the inguinal area. That was the reason why we resolved to perform a diagnostic laparoscopy.To the best of our knowledge, this is the first case report of a patient with vasitis with a detailed medical record from physical examination to the definitive diagnosis through laparoscopy. Since vasitis is a rare disease, first and foremost, it is essential to differentiate it from acute severe conditions, such as testicular torsion and incarcerated inguinal hernia. Contrary to testicular torsion, there has been no formal report on decreased or absent blood flow on colour Doppler sonography in the case of incarcerated inguinal hernia. Both conditions share the same clinical features from the initial presentation to sonography. Our patient presented with omental adhesion in the inguinal region and swelling of the vas deferens, which mimicked omental incarceration on a CT scan due to contrast enhancement. Therefore, we performed diagnostic laparoscopy and only then could we formulate the correct diagnosis and treat the patient with appropriate antibiotics.The present article purports to share the case of a patient with vasitis and atypical imaging findings on CT that did not help clarify the diagnosis.


The tumor was resected using the translabyrinthine approach and was pathologically confirmed as schwannoma based on the surgical specimen.Preoperative audiogram and vestibular test findings and MRI images.Preoperatively, pure-tone audiogram showed progressive sensorineural hearing loss only on the affected side. The video head impulse test and vestibular evoked myogenic potential test showed vestibular dysfunction on the affected ear. Immediate gadolinium-enhanced T1-weighted MRI revealed an enhanced region in the vestibule. Meanwhile, magnetic resonance cisternography showed a filling defect. Delayed 3D-FLAIR MRI revealed a signal void in the scala media of the cochlea indicative of cochlear hydrops, and a strong signal in the perilymph at the basal cochlea suggestive of impaired blood–labyrinthine barrier.Delayed 3D-FLAIR MRI is useful in diagnosing concurrent ILSs and endolymphatic hydrops. Intralabyrinthine schwannomas (ILSs) are a rare clinical entity, and they arise from the distal branches of the vestibular and cochlear nerves within the membranous labyrinth , 2. The A woman in her 30's visited our department due to hyperacusis in the right ear. Audiogram showed almost normal hearing level . The patvia 3D-FLAIR MRI and ILS diagnosed via pathological examination of surgical specimen. To the best of our knowledge, there are only two studies describing endolymphatic hydrops diagnosed via delayed 3D-FLAIR MRI in patients with ILS   of patients  for the publication of any potentially identifiable images or data included in this article.KN conceived the idea of the study and drafted the original manuscript. All authors reviewed the manuscript draft, revised its intellectual content critically and approved the final version of the manuscript for publication.The study was supported by JSPS KAKENHI Grant Number 22H03239.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Choroidal sarcoid granulomas are often diagnosed in patients without a prior history of sarcoidosis. They are often mistaken for choroidal metastasis, choroidal nevi, amelanotic choroidal melanomas, and uveal lymphomas; however, are easily treatable when accurately identified.We searched PubMed, Medline, and Scopus for English-Language case reports published before September 2021. Additionally, we presented a case of a 45-year-old woman with a right-sided amelanotic choroidal mass whose diagnosis was delayed by a COVID-19 infection. Of the 26 cases reported in the literature, 46% were female, 38% were African American, and 19% had bilateral involvement. There was a mean age of 42.15 years and a mean follow-up period of 27 months. The most common complaint was of a progressive, painless blurring of vision, and only five patients had been previously diagnosed with sarcoidosis. The choroidal granulomas were typically described as yellow lesions, single or multiple, found temporal to or at the macula. Most patients were administered steroids, with 69% receiving them systemically, 5% topically, and 8% locally with a triamcinolone injection. All patients reported symptomatic improvement at their final follow-up with resolution of the mass in 65% of patients and improved visual acuity in 76%.Primary testing including fundoscopy, fluorescein angiography, fundus autofluorescence, A/B-scan, and OCT are useful for diagnosis, differentiation from other choroidal lesions, and monitoring treatment response. Steroids are a mainstay of treatment for sarcoidosis and are effective at treating choroidal granulomas. Therefore, early recognition and diagnosis of choroidal granulomas is imperative as treatment can be curative and sight-sparing. Sarcoidosis is a chronic inflammatory granulomatous disease that can affect multiple major organ systems including the eye and its surrounding structures . The widUveitis is an inflammatory process that affects the uveal tissues - iris, ciliary body, choroid – and surrounding structures – anterior chamber, retina, vitreous humor . It is oThis article summarizes all published case reports documenting choroidal sarcoid granulomas in the English language from December 1982 to July 2021 and presents a unique case of a choroidal granuloma in a patient with previously undiagnosed sarcoidosis that was initially mistaken for malignancy.A literature review accessing PubMed, Medline, and Scopus databases was performed in September 2021. The keywords “choroid,” “sarcoid,” “sarcoidosis” and “granuloma” were used to gather all peer-reviewed case reports published in the literature. Non-English case reports were excluded from the review. We used the PRISMA and CARE checklists when writing our report , 14.A 45-year-old previously healthy female presented to the Ophthalmology Specialty Clinics at the American University of Beirut Medical Center with a referral diagnosis of a suspicious choroidal lesion associated with subretinal fluid in the right eye. The patient had no personal or family history of cancer. The patient was a current everyday hubble-bubble smoker but did not consume alcohol or use recreational drugs. scan, and brain and orbit magnetic resonance imaging (MRI). All were non-revealing with no evidence of malignancy except for the chest CT scan showing few scattered subcentimetric lymph nodes in prevascular and bilateral hilar spaces. The decision was made for close follow-up considering the difficulty, low yield potential and vision threatening risk of a biopsy of the lesion. After an increase in subretinal fluid (SRF) and slight increase in diameter was noted on the 3-month follow-up Fig. B, an onc.A repeat PET-CT scan at 3 months showed persistent lymphadenopathy. Clinically, the patient’s vision had worsened to 20/200 and the choroidal lesion had continued to increase in size with a largest basal diameter of 6.81 mm and a maximal thickness of 3.01 mm. An endobronchial ultrasound guided biopsy revealed a non-necrotizing granuloma suggestive of sarcoidosis. Systemic steroid therapy was initiated resulting in an improvement in vision to 20/60 and complete regression of the choroidal lesion with residual chorioretinal atrophy Fig. .Fig. 4RiA summary of the 26 published cases of sarcoid granulomas is presented in Table Five patients had been diagnosed with sarcoidosis before developing choroidal granulomas , 27, 34,A summary of all the examination and imaging findings of the 26 cases is presented in Table Fluorescein angiography (FA) was used in 12 cases (46%) and demonstrated hyperfluorescence in 5 cases , 28, 36,Fundus autofluorescence (AF) was used in 2 cases (8%) and showed hypoautofluorescence in areas of hemorrhage , speckleUltrasonography (A/B scan) was used in 9 cases 35%) and identified the presence of elevation in 4 cases , 35, 36 % and ideOcular coherence tomography (OCT) was used in 10 (38%) cases and was notable for a homogenous hyporeflective lesion in 1 case , a homogIndocyanine green (ICG) was used in 3 cases (12%) and showed hypocyanescence through the late phase of the angiogram in 1 case , low hypAdditional systemic investigations revealed lymphadenopathy on imaging in 54% of cases 14/26) , 33–36,  , 33–36,Of the 26 cases, 18 (69%) received systemic steroids , 32–36, In our case, the choroidal granuloma was the only clinical manifestation of sarcoidosis, which was discovered after systemic screening for neoplasms was performed. Diagnosis was delayed by a COVID-19 infection which confused the clinical presentation. Of the cases reviewed, only 5 patients had a sarcoidosis diagnosis prior to the identification of the choroidal granuloma , 27, 34.Due to its rich vascular supply, the choroid is the most common ocular structure affected by metastasis and the reported mean survival time following a diagnosis of ocular metastasis is 21 months , 38. TheIt is also important to consider choroidal nevi and amelanotic choroidal melanomas (ACM) in the differential for a choroidal granuloma. Choroidal nevi are benign tumors of the posterior pole with a reported incidence of 6.5–33% , 54. Of Uveal lymphoma may present similarly to choroidal granulomas with many patients being asymptomatic or having a slow progression of symptoms –65. TheyAlthough extensive research is being conducted, the etiology of sarcoidosis remains unclear . The curIt is imperative to consider the full differential diagnosis when evaluating a choroidal lesion as the treatment plan will differ significantly depending on the final diagnosis. If there is ever a time where inconsistency between symptoms, fundoscopy, and imaging arises, or there is doubt, a choroidal sarcoid granuloma should be considered. A choroidal granuloma has a wide variety of clinical presentations and can affect both sexes, several racial groups, and a broad age range. It is not always preceded by a diagnosis of sarcoidosis and treatment with corticosteroids is often curative. Therefore, regardless of the characteristics of the patient, it should always be included when considering a differential for a choroidal lesion.This review summarizes the 26 cases of choroidal sarcoid granuloma in the English language and presents a unique case of a sarcoid granuloma initially mistaken for a choroidal neoplasm. Choroidal granulomas are a rare presentation of ocular sarcoidosis that can impede vision. They are typically yellow lesions, single or multiple, found temporal to or at the macula. Primary testing including fundoscopy, fluorescein angiography, fundus autofluorescence, A/B-scan, and OCT are useful for diagnosing and monitoring response to treatment in patients with a choroidal granuloma. Systemic work-up and ACE levels are helpful in diagnosing atypical choroidal lesions in the absence of a confirmed sarcoidosis diagnosis. Steroids are a mainstay of treatment for sarcoidosis and are effective at treating choroidal granulomas. Early recognition and diagnosis of choroidal granulomas is imperative as treatment can be curative and sight-sparing.


Owing to the complexity of their blood supply, renal tumors in horseshoe kidneys are sometimes technically challenging to resect through laparoscopic procedures.A 75‐year‐old man presented with a 3‐cm lower‐pole mass in the right moiety of the horseshoe kidney. Indocyanine green administration allowed for the identification of the tumor's feeding artery, which was selectively clamped to perform laparoscopic partial nephrectomy. During the procedure, the patient was positioned in the modified supine position , which enabled us to approach the branch of the left renal artery. Postoperative pathologic examination of the resected mass confirmed the diagnosis of pT1a clear cell renal cell carcinoma with negative surgical margins.Our novel laparoscopic approach with indocyanine green fluorescence in the modified supine position facilitates the identification of and access to the tumor's feeding artery. This technique is advantageous for laparoscopic partial nephrectomy in patients with horseshoe kidney. CECTcontrast‐enhanced computed tomographyCTcomputed tomographyHSKhorseshoe kidneyICGindocyanine greenNIRFnear‐infrared fluorescenceLPNlaparoscopic partial nephrectomyRAPNrobot‐assisted partial nephrectomyRCCrenal cell carcinomaWITwarm ischemia timeWe performed laparoscopic partial nephrectomy with guidance from indocyanine green fluorescence in a modified supine position for a renal mass in a horseshoe kidney.HSK is the most common congenital fusion anomaly of kidney, and its prevalence within the world population ranges approximately from 0.15% to 0.25%.A 75‐year‐old man with HSK was referred to our department due to a 3‐cm lower‐pole tumor, which was incidentally discovered by CECT in the posterior part of the right side of the kidney Fig. . The patWe performed retroperitoneal LPN in the modified supine position  with five ports (5–12 mm) Fig. . During A NIRF system with was employed to identify the tumor's feeding artery. One minute after intravenous administration of 1 mL of 2.5 mg/mL ICG, strong fluorescence was observed in the right part of the kidney except in the tumor Fig. . When thThe tumor was resected following a standard protocol, and the resected site was closed by a running suture using 2–0 V‐Loc™ . The operation time was 225 min, and the WIT was 18 min. The patient was discharged without any intraoperative or postoperative complications. The pathological diagnosis of the resected specimen was pT1a clear cell RCC  with negative surgical margins. No local recurrence or metastasis was observed with follow‐up CT, and there was no change in renal function at 3 months.One of the unique anatomical features of HSK tumors is aberrant blood vessels in the isthmus that can bifurcate from the aorta, the common, internal or external iliac artery, or from the inferior mesenteric or sacral arteries.One novel aspect of our study is the employment of the modified supine position, which was deemed as the optimal surgical placement of the patient because it allowed to visualize the anterior aspects of the isthmus for the exact identification of the vessel supplying the tumor and its surroundings. In fact, reaching the anterior aspects of the isthmus is likely to be challenging with the conventional retroperitoneal approach in the lateral position.Another innovative aspect of this report is the use of ICG‐guided NIRF. This technique has been applied in various clinical settings. Especially, the NIRF imaging technology, which offer real‐time fluorescing information, has been applied to a variety of surgical procedures, such as for evaluation of vessel blood flow, identification of sentinel lymph nodes, and detection of cancerous masses.Injection of ICG, which binds to serum proteins, enables surgeons to visualize the vascular network with fluorescence.To date, the usefulness of ICG fluorescence in laparoscopic and robotic urologic procedures has been reported.ICG guidance LPN for HSK was a very effective technique for assessing blood flow and identifying the area of blockage. In addition, the semi‐lateral positioning and modified port placement provided an excellent operative field. It is considered to be an effective method not only for LPN but also for RAPN Fig. .The authors declare no conflict of interest.Not applicable.Consent to participate and for publication were acquired from the patient.Not applicable.Yu Imai: Conceptualization; data curation; writing – original draft. Fumihiko Urabe: Conceptualization; data curation; writing – original draft; writing – review and editing. Wataru Fukuokaya: Writing – review and editing. Akihiro Matsukawa: Conceptualization; writing – review and editing. Kosuke Iwatani: Conceptualization; visualization; writing – review and editing. Koichi Aikawa: Conceptualization; visualization. Koki Obayashi: Writing – review and editing. Takafumi Yanagisawa: Supervision; writing – review and editing. Shunsuke Tsuzuki: Supervision; writing – review and editing. Hiroshi Nakajo: Supervision; writing – review and editing. Takahiro Kimura: Conceptualization; supervision; writing – review and editing. Shin EGAWA: Supervision; writing – review and editing. Jun Miki: Conceptualization; data curation; investigation; methodology; supervision; visualization; writing – original draft; writing – review and editing.


The diagnostic capabilities of ultrasound extend far beyond the evaluation of the pleural space and lungs. Sonographic evaluation of the chest wall is a classic extension of the clinical examination of visible, palpable, or dolent findings. Unclear mass lesions of the chest wall can be differentiated accurately and with low risk by additional techniques such as color Doppler imaging, contrast-enhanced ultrasound, and, in particular, ultrasound-guided biopsy. For imaging of mediastinal pathologies, ultrasound has only a complementary function but is valuable for guidance of percutaneous biopsies of malignant masses. In emergency medicine, ultrasound can verify and support correct positioning of endotracheal tubes. Diaphragmatic ultrasound benefits from the real-time nature of sonographic imaging and is becoming increasingly important for the assessment of diaphragmatic function in long-term ventilated patients. The clinical role of thoracic ultrasound is reviewed in a combination of narrative review and pictorial essay. For the ultrasound (US) evaluation of the chest wall, a distinction must be made between superficial and deep pathology. Due to their superficial location, pathology of the chest wall is usually examined with a small-part linear transducer with a frequency range of approximately 7–12 MHz. In this regard, the transducer can be considered to be an extension of the examination of a visible pathology, a palpation finding, and, in some cases, of localized pain. The ultrasound section planes should be selected according to the pathological findings. In the near-field region of the chest wall, pathology of the skin, subcutaneous adipose tissue, chest wall musculature, ribs, endothoracic fascia, and parietal pleura can be assigned. Knowledge of sonoanatomy of the chest wall with respect to the course of the vessels , bony ribs, and cartilaginous ribs is required. During the examination of ribs, it should be noted that they run primarily horizontally in the dorsal arch part, steeply caudally in the lateral arch part, and then mostly horizontally again near the sternum (ribs 1–6) or run steeply cranially (ribs 7–10). In the differentiation of pulmonary pathology, attention should be given to the respiratory motion of the lungs . Th. Th17]. US is of high importance in the detection of malignant lesions due to its location in the near-field region. In addition to imaging, US-guided biopsy is an essential pillar of diagnostics .The lymph node region along the parasternal mammary vessels must be explored conscientiously .Osteolytic metastases show an irregular interruption of the contour of the cortical bone on ultrasound, with varying degrees of inhomogeneously hypoechoic soft tissue. Destruction of the bone results in pathological sound transmission .US is of considerable clinical importance in the evaluation of unclear scintigraphic findings in patients with known malignancies because it can often clearly distinguish bone fractures from metastases . In unclUS examination of the chest wall has several diagnostic limitations. The US examination is generally characterized by high interobserver and interequipment variability. Furthermore, it is limited by technical difficulties, for example, in detecting the posterior location of fractures and the penetration of soft tissues in patients with excess adipose tissue or patients with large breasts .Compared with US, CT and MRI provide a better overview for the detection of pathologies in the chest wall. Furthermore, although pain during the examination may be helpful in detecting the focal pathology, patient-reported pain during the US examination may limit the examination . In addiNevertheless, due to advantages such as dynamic imaging capabilities and relative simplicity, US can be used especially as a point-of-care procedure in the detection of traumatic pathologies and has a good diagnostic accuracy compared with CT as the gold standard ,20 Tabl.In assessing the malignancy of chest wall neoplasia, the domain of US is in the evaluation of secondary infiltration of the chest wall by intrathoracic tumors. Here, US has a high diagnostic accuracy due to its high local resolution . AnotherThe chest wall is almost ideally suited for sonographic examination due to its localization close to the surface. Indications for sonography of the thoracic wall are primarily the clarification of swellings or palpable findings of the thoracic wall or the specific clarification of pain points in the area of the thoracic wall . In addiSonographic examination of the prevascular mediastinum is limited by the ribs and sternum. Sonographic access to the mediastinum is via the supra- and parasternal, and occasionally also via the infrasternal, routes. The great vessels serve as guide structures because of their positional relationship to the heart at various levels. Suprasternal examination is performed with the patient in the supine position. The view into the upper mediastinum is facilitated by reclining the head, preferably with the thoracic spine padded underneath. Right and left rotation of the head is also helpful. Right- and left-sided positioning results in a displacement of the mediastinum, with displacement of the lung space, which allows an improved view of the mediastinum. The assessment is most favorable in the expiratory position .Before the contrast examination, the best view should be determined using B-mode US, and the target lesion should be identified. Linear probes or curved probes should be selected depending on the depth of the lesion. The contrast agent is administered via avenous access as a bolus injection with a dose of usually 2.4 mL of SonoVue . The lesion should be observed continuously and recorded by a clip for at least the first 30 s after contrast administration. Thereafter, the perfusion pattern of the lesions should be examined continuously by several short examinations at 30 s intervals up to 3 min.The mediastinum has a systemic vascularization pattern. On CEUS, the presence of homogeneity, the extent of enhancement, and the decrease in the enhancement can be evaluated. The domains of CEUS are differentiation of cystic from solid lesions and avoidance of avital parts during biopsy.Transthoracic ultrasound (TUS) plays a minor role in the diagnosis and differentiation of mediastinal pathologies compared with other methods such as CT or magnetic resonance imaging . The domIn adults, the involved thymus is mostly replaced by adipose tissue and usually cannot be visualized. Cystic involvement is possible  31,32].,32.31,32Reactive thymus enlargement (thymus rebound) can be observed after stressful situations  . In chilThe spectrum of primary mediastinal masses includes a heterogeneous group of benign and malignant pathologies ,31,36. BThe last-mentioned entities are predominantly located in the paravertebral mediastinum. Primary malignant mediastinal masses of the prevascular mediastinum include malignant thymomas  or thymiMalignant tumors of the thymus may have irregular borders with infiltrative growth, chaotic vascularization, cystic areas, or necrotic components on B-mode US, CDS, and CEUS ,36,37. TCentral bronchial carcinomas can also be sonographically visualized by using the associated atelectasis as an “acoustic window” into the mediastinal processes  Figure .Mediastinal lymphadenopathy can be benign or malignant . In the In malignant lymphomas, lymph nodes present as hypoechoic in B-mode US and are often fused together forming bulky lesions ,37. The Enlarged lymph node metastases can be visualized on TUS if they are located in the prevascular superior mediastinum  and infeIn bronchial carcinoma, the detection and histologic diagnosis of cervical and retrosternal–mediastinal enlarged lymph nodes are of major importance because they influence the staging and treatment of the disease. Detection of cervical lymph node metastases corresponds to an N3 manifestation and qualifies the patient for a palliative therapeutic approach ,42. AccoUS has proven to be a helpful method for the rapid evaluation of the trachea in the operating room, intensive care unit, and emergency department . VariousThe use of transthoracic mediastinal sonography is limited by several factors. These include the extensive experience required of the examiner and the limited examination possibilities in the presence of mediastinal distortions (such as those resulting from surgery or after irradiation), the overlay of air-containing lung tissue , and the limited reclination of the mediastinum . TherefoThe diagnostic accuracy of TUS is dependent on the mediastinal compartment. In the evaluation of the supra-aortic, pericardial, prevascular, and paratracheal regions, sonography has a sensitivity of 89–100% and an accuracy nearly equal to that of computed tomography. However, in the aortopulmonary window and subcarinal regions, sonography has a sensitivity of only 69–81% ,47. TablIn the case of lesions visualizable on B-mode US, CEUS can also be used for the evaluation of the malignancy. In cases of suspected lung carcinoma, CT is recommended to evaluate mediastinal tumor formation, and, in an appropriate clinical context, complementary positron emission tomography (PET)-CT is recommended . PET-CT For sonographic evaluation of the diaphragm, the patient should be in the supine position with the head angled at 30°, as this position reduces examiner variability, increases reproducibility, and enhances excursion ,53. The Border shadow artifacts may indicate an apparent diaphragmatic gap, which disappears when the transducer position is changed .Clinical indications for diaphragmatic US include characterization of diaphragmatic morphology in terms of diaphragmatic thickness and focal pathology. Diaphragmatic function must be assessed for the diagnosis and follow-up of patients with diaphragmatic paresis or diaphragmatic dysfunction. In addition, US is used to assess diaphragmatic function and morphology in ventilated patients with difficult weaning ,54,55,56inspiration) and the thickness at the end of expiration  in relation to the thickness of expiration  [To measure diaphragmatic thickness, a linear transducer (≥7 MHz) should be positioned at the anterior axillary line between the 8th and 11th ribs. Visualization should be performed inferior to the costodiaphragmatic angle, where the diaphragm is attached to the inside of the chest wall  ,53. Bothiration)   in an anterior subcostal view through the liver window. The transducer should be positioned between the middle clavicular line and the anterior axillary line and directed medially, cranially, and dorsally to visualize the posterior third of the right diaphragm, approximately 5 cm lateral to the inferior vena cava foramen ,53. The The diaphragm presents as a three-layered structure with external bounding pleural and peritoneal membranes and a muscular layer . The diaThe benefits of US for the examination of diaphragmatic function and detection of diaphragmatic paresis or dysfunction have been described in several publications ,66,67,68Mechanical ventilation is associated with decreased muscle strength and a decrease in the contractile function of the diaphragm within 48 h of intubation . BedsideLung US is considered a reliable, cost-effective, and (due to the absence of radiation exposure) safe method for use at the bedside (point-of-care) in the neonatal unit ,73. The Point-of-care lung US can provide rapid diagnosis of congenital diaphragmatic hernias and is particularly helpful in cases of absent prenatal diagnosis . CongeniThe diagnostic relevance of diaphragmatic US in patients with chronic obstructive pulmonary disease, patients with diaphragmatic dysfunction due to neuromuscular diseases, and trauma or intensive care patients has already been described . For morThe diaphragm is not completely visible sonographically on the right and especially on the left side. Diaphragmatic US is dependent on the cooperation of the patient. Furthermore, the normal values for diaphragmatic pathologies that have been developed so far were established for the right hemidiaphragm only . HoweverIn the detection of acute diaphragmatic injuries, TUS is not a suitable diagnostic method due to its low sensitivity. The domains of diaphragmatic US are in the examination and assessment of diaphragmatic function in intensive care patients, patients with chronic obstructive pulmonary disease or neuromuscular disease, and neonates with congenital diaphragmatic hernias ,57,74. D


The fusion of gonadal structures with internal organs is very rare. The close proximity between the left gonad and spleen during embryogenesis may result in splenogonadal fusion (SGF). Moreover, the trapping of hepatocyte-destined mesenchyme cells in gonads is defined as hepatogonadal fusion (HGF). The fusion of gonads with intra-abdominal organs may be continuous and may impair testicular descent during the prenatal period. We herein report an 18-month-old boy presented with bilateral nonpalpable testis due to concomitant continuous HGF and SGF. To our knowledge, this is the first case of concomitant HGF and SGF in a boy with bilateral intra-abdominal testis. Laparoscopic excision of fibrous cords and orchidopexy can be achieved despite continuous fusions. In his medical history, he had partial anomalous pulmonary venous return and pulmonary hypertension. At the time of the presentation, his height was 74.5 cm (10–25 p), weight was 8.8 kg (3–10 p), and the head circumference was 45 cm (25–50 p). Other physical findings were unremarkable except for a grade 2 systolic murmur. The genitourinary examination revealed bilateral nonpalpable testis and a stretched penile length of 4.5 cm with no sign of undervirilization. Suprapubic and scrotal ultrasonography did also not show the presence of gonads. Karyotype was normal . The gonadotropin, anti-Mullerian hormone, and testosterone levels were also normal. The detectable anti-Mullerian hormone level  suggested existence of testicular tissue with functional Sertoli cells. A human chorionic gonadotrophin (HCG) stimulation test  was performed. HCG-stimulated testosterone level (562 ng/dL) suggested the presence of functional gonads. The patient underwent abdominal magnetic resonance imaging (MRI) with a presumptive diagnosis of bilateral intra-abdominal testis. Testes were not observed in the scrotum and both groins on ultrasound. Abdominal MRI revealed bilateral intra-abdominal tissue was observed adjacent to the psoas muscles below the kidneys. The fibrous cord like structure between spleen and left testicle was also demonstrated . After Several theories have been suggested in the etiology of SGF and HGF. SGF is thought to occur between the fifth and eighth weeks of gestation. The developing spleen comes into close proximity to the left urogenital fold during rotation of the embryonic gut. This spleen–gonadal relationship remains until the eighth week of development, when gonadal descent is initiated. At this period, the fusion started between the surface of the developing genital ridge and the splenic anlage.SGF occurs predominantly in males with a male-to-female ratio of 16:1, and only nine female cases have been reported.HGF is extremely rare, and only five cases have been reported.The treatment of SGF varies according to the type of gonadal fusion. In the past, some authors report unnecessary orchiectomy with a presumptive diagnosis of primary testicular tumor. SGF can be demonstrated by 99Tc sulfur colloid preoperatively.In conclusion, concomitant continuous HGF and SGF may cause bilateral undescended testis with intra-abdominal localization. Laparoscopic excision of continuous fibrous cords and orchidopexy can be achieved despite continuous fusions.


Jejunal diverticulitis is an uncommon and underdiagnosed condition. Due to the rarity of This disease, diagnosis is often difficult and delayed. Medical treatment is usually sufficient for jejunal diverticulitis without peritonitis. Surgery is required in case of generalized peritonitis or voluminous abscess complicating diverticulitis. We report the case of a 76-year-old woman who suffered from recent abdominal pain. Diagnosis of uncomplicated jejunal diverticulitis was based on computed tomography (CT) scan. The evolution was favorable after antibiotic treatment. Jejunal diverticulitis have to be evoked among the differential diagnosis of patients with abdominal pain especially in the elderly and it is important for clinicians and radiologists to have awareness about this disease. Although diverticula of the gastrointestinal tract are common in the colon, they are relatively rare in the small intestine and predominantly involve the proximal jejunum . The couPatient information: a 76-year-old woman with a history of high blood pressure presented to the hospital with abdominal pain that predominates in the left upper quadrant and vomiting. The pain was moderate without irradiation. The transit was normal.Clinical findings: her vital signs were normal with a temperature of 37.8°C, a heart rate of 65 beats per minute, blood pressure at 130/70 mm Hg, and saturation 98% on room air. Abdominal examination found a tenderness of the left hypochondrium with no distension. There were no palpable masses or organomegaly.Timeline of the current episode: this was the first episode, and have never presented such clinical manifestations. The episode began ten days before her admission.Diagnostic assessment: the white blood cell count, pancreatic enzymes and liver function tests were in the normal range. C-reactive protein was 14 mg/L (range 0-5 mg/l). Patient underwent oeso-gastro-duodenal endosopy and colonoscopy which were normal. We performed an abdominal ultrasound which revealed wall thickening of a small bowel segment in the mid left abdomen. We completed with abdominal computed tomography (CT) scan which showed two large diverticula arising from the mesenteric border of jejunum with wall thickening of the affected segment with a surrounding significant inflammatory reaction and the infiltration of the surrounding mesenteric fat. No abscess formation or fluid collection was seen  scan of the abdomen plays a crucial role in the diagnosis of jejunal diverticulitis as well as its complications. The CT scan of jejunal diverticulitis typically shows an inflammatory process, wall thickening of the affected segment, infiltration of the surrounding mesenteric fat or an abscess adjacent to a jejunal loop ,2. The iTherapeutic management of acute jejunal diverticulitis is not consensual and it is based on the experience of the different teams . The treJejunal diverticulitis is an uncommun cause of abdominal pain especially in the elderly. It is often overlooked by the clinician. The diagnosis must be early because the perforation is associated with a high morbidity and mortality. It is therefore important to recognize and include this entity in the differential diagnosis of patients with abdominal pain. Computed tomography imaging aids in diagnosis, excludes other causes of abdominal pain, assesses the extent of the disease and its complications. The therapeutic option depends on the terrain, the severity of the clinical and radiological signs and the evolution.


Cloacal Exstrophy (CE) is a rare congenital birth defect. A correct prenatal diagnosis of CE is rarely made, even when congenital abnormalities are suspected on prenatal ultrasound examination.We report a case of CE with an abdominal defect about 5.31 cm in diameter seen below the umbilicus covered by a membrane. It was difficult to identify the left kidney, the bladder, the genital, and the anal dimple in the early third trimester ultrasound. The diagnosis of CE was then confirmed postnatally.Omphalocele and persistent bladder nonvisualization despite normal amniotic fluid volume detected by prenatal ultrasound can be suggestive for CE.Accurate prenatal diagnosis of CE is important to carry out multidisciplinary management and prenatal counseling to parents. •Prenatal diagnosis of cloacal exstrophy can be done based on ultrasound findings.•Omphalocele with bladder nonvisualization can be suggestive for cloacal exstrophy.•Prenatal diagnosis is important to carry out prenatal counseling to parents. As one of the most severe birth defects involving multiple organ systems including neurological, gastrointestinal, musculoskeletal, renal and genitourinary, it requires a multidisciplinary approach [Here, we present a case of a 26-year-old primigravid woman whose fetus was diagnosed with cloacal exstrophy. This case has been reported in line with the SCARE 2020 guidelines .2A 26-year-old primigravid woman with 33–34 weeks of gestation came to the obstetrics emergency room with complaints of intermittent back pain that radiates to the placenta. During pregnancy, the patient had been treated for hyperemesis gravidarum (HEG). The patient also consumed multivitamins, ferrous sulphate, and folic acid tablet given by an obstetrician during the nine months of pregnancy, and the patient did not show any allergic and/or adverse reactions. There were no history of smoking, alcohol, and recreational drug use. There were no complaints of spotting or bleeding during pregnancy. There were no history of surgery before. Antenatal care (ANC) with an obstetrician in the early third trimester revealed a suspected abdominal wall defect in the form of an omphalocele. The patient denied having family history of congenital malformation. The patient was then referred to our facility.Physical examination revealed normal vital signs. The patient was diagnosed with G1P0A0 with preterm contractions and suspected congenital abnormalities  of the fetus. The patient was anemic with Hb level of 9,0 g/dL. The cardiotocography was reassuring. Five days before admission to our facility, the patient underwent a detailed ultrasound with the following findings: single intrauterine fetus, 33–34 weeks of gestation (based on biometry), estimated foetal weight (EFW) 2100 g, foetal heart rate (+), and normal thorax 4 chamber view (4CV). There was an abdominal defect about 5.31 cm in diameter , seen beThe patient entered labor on the third day of treatment and the baby was born with a birth weight of 2560 g, body length of 45 cm, ballad score in accordance with 35–36 weeks of gestational age, and multiple congenital abnormalities i.e. omphalocele, an open bladder in the lower abdomen with the mucosa visible through a triangular fascia defect, prominent ileum, genital malformations, and a shortened distance between umbilicus and anus . The pat3Cloacal exstrophy (CE) is a very complex anatomical anomaly and one of the most difficult congenital abnormalities to reconstruct. It is defined as ventral abdominal wall defect with omphalocele as well as bowel and bladder exstrophy. Omphalocele is located at the superior border, whereas the exposed ileocaecal area and bladder are located at the inferior border. A zone of intestinal mucosa separates the hemibladders at the midline, with a ureteral orifice at each hemibladder. The proximal intestinal opening often proliferates making an overall appearance resembling an elephant trunk. The distal bowel is a blind pouch. All babies born with CE have imperforate anus, and 85% of them have neural septal defects . Hence, Cloaca is divided into urogenital sinus anteriorly dan hindgut posteriorly at six weeks of pregnancy. The failure of lateral to medial mesoderm extension to form an infraumbilical abdominal wall causes cloacal membrane rupture. Cloacal exstrophy is caused by the rupture of the cloacal membrane before the complete descent of the urogenital septum, causing herniation of the bladder and bowel that can be detected using prenatal ultrasound .With current advances in neonatal care and surgical techniques, the survival rate for CE can reach 100%. Thus, early prenatal diagnosis and transfer to a tertiary medical center for further neonatal care are essential for newborns with CE. However, early prenatal diagnosis of CE remains a challenge because of the complicated anatomy of the associated anomalies . A correThe diagnosis of CE should be suspected in the second or third trimester if there is ventral wall defect associated with persistent bladder non visualization in a fetus with normal amniotic fluid volume; genitalia identification difficulty beyond 20 weeks of gestational age; hemivertebrae with kyphoscoliosis, or evidence of lumbosacral meningomyelocele. The fetal bladder usually begins to fill again within a few minutes of urination; thus, a prolonged period of non visualization will indicate abnormalities. The prolapsed terminal ileum has a characteristic “elephant trunk” appearance. In the first trimester, a cystic mass can sometimes be identified, before the rupture of the cloacal membrane. There also appears to be an association between increased nuchal translucency and CE . AccuratIn an attempt to establish criteria for the early prenatal diagnosis of cloacal exstrophy, Meizner et al. 1995) reviewed sonographic findings in six CE cases and compared them with sonographic features of other anterior abdominal wall defects. Of the six cases, specific sonographic signs were observed: (1) large defect in the anterior midline infraumbilical line with prominent omphalocele; (2) absent bladder; (3) narrowed thorax; (4) distorted spine; (5) sacral myelomeningocele; and (6) bilateral club feet. In all cases, the bowel was noted to be floating in a large amount of ascitic fluid. Polyhydramnios is present in four out of six cases . These s95 reviewIn our case, the prenatal ultrasound at 33–34 weeks of pregnancy showed a defect in the midline of the anterior abdominal wall with prominent omphalocele and persistent bladder non visualization despite the normal amniotic fluid volume. The finding is in line with previous studies of CE cases. However, the diagnosis was made in the third semester, so the amount of time for prenatal counseling was limited. In Indonesia, it is not legal to terminate a viable fetus with major congenital anomalies. Nonetheless, prenatal counseling is important to prepare the parents to raise a child with a special trait. Early prenatal diagnosis is crucial not only for early management but also for the long-term quality of life of CE patients.4Omphalocele and persistent bladder non visualization despite normal amniotic fluid volume detected by prenatal ultrasound can be suggestive of CE. Accurate prenatal diagnosis of CE is important to carry out multidisciplinary management and prenatal counseling to parents.Not commissioned, externally peer-reviewed.The authors have no funding support to report.Not applicable.F performed manuscript draft writing, conceptualization, and resources; F and MAA performed a critical review and editing of the manuscript. All authors have checked the final version of the manuscript.1.Name of the registry: N/A.2.Unique Identifying number or registration ID: N/A.3.Hyperlink to your specific registration (must be publicly accessible and will be checked): N/A.Febriani accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.Written informed consent was obtained from the patient's guardian 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.The authors declared no conflict of interest.


ST-segment elevation myocardial infarction (STEMI) is a known medical exigency that has seen considerable advances in medical treatment, dramatically boosting survival rates. Post myocardial infarction ventricular rupture is a major serious mechanical complication following myocardial infarction. We present a case of a 68-year-old male admitted to the emergency department with heaviness in the chest, for which electrocardiography was done and it was suggestive of anterior and lateral wall myocardial infarction. After six hours he experienced breathlessness, jugular venous pressure (JVP) was raised, and auscultation revealed early systolic murmur at apex suggestive of ventricular septal rupture. An urgent echocardiogram was done and it confirmed the diagnosis of ventricular septal rupture (VSR). To enhance the prognosis, early identification and appropriate care are required, which necessitate a thorough clinical evaluation that raises the possibility of mechanical problem, as late presentation is one of the major risk factors for developing VSR. VSR can manifest itself in numerous ways, based on the patient’s condition. Right clinical judgement and ECG are required to establish a quick diagnosis, as a result, to determine the most appropriate treatment at the appropriate time. Acute myocardial infarction (AMI) is a major cause of death in the world, affecting almost three million people globally and resulting in over one million deaths in the United States each year. Because of the absence of oxygen, myocardial infarction (MI) causes unrecoverable damage to cardiac muscles -3. MI inA 68-year-old male presented to the emergency department of this hospital in the morning at 8:30 am with a chief complain of chest pain radiating to his left arm and jaw with a history of chest discomfort, post-dinner on the previous night. He took an antacid and went to bed, considering it was due to gastritis. He had experienced a similar ache in the middle of the night associated with diaphoresis which lasted for 10-12 minutes, took the same medication, and went to sleep. In the morning when he got up he still had heaviness in the chest for which he presented to the hospital. There was no history of breathlessness, pre-syncope, cough, orthopnea, or vomiting. Clinical examination revealed pulse to be 100 beats per min and regular blood pressure of 110/70 mm Hg. JVP was normal. Oxygen saturation was 95% while breathing ambient air. A cardiovascular (CVS) examination revealed a soft S1, normal S2, no S3, and no murmurs. Respiratory system examination revealed minimal bi-basal scattered crept. The rest of the examination was unremarkable. An urgent ECG revealed an elevated ST segment in the anterior and lateral leads. ECG was suggestive of anterolateral wall MI ; urgent cardiothoracic surgery consultation was taken but the patient succumbed within the next hour. In the current era of percutaneous coronary intervention, ventricular septal rupture following an acute myocardial infarction is not common, although mortality is still high. The importance of early detection cannot be overstated, and definitive surgery, despite its difficulty and high mortality rate, remains the preferred therapeutic option. In both anterior and inferior/lateral infarctions, ventricular septal rupture appears to be equally common . Female ECG is crucial for determining the location of a VSR. It indicates that in many of the individuals having VSR, like in our instance, the anterior part is more commonly afflicted (60%) rather than the inferior area (40%) . It is cDespite recent advancements, post-MI VSD is a fatal consequence. The gold standard is early clinical diagnosis and immediate surgical intervention. Pre- and post-operative care provided, in addition to surgical treatment, is critical for improving survival rates.


Schwannomas of the head and neck are relatively rare benign tumors that derive from the Schwann cells. Schwannomas are usually asymptomatic; however, tumors of bigger size may produce unspecific symptoms due to compression of the adjacent anatomic structures. Vagus nerve schwannomas may present as solitary neck masses, produce hoarseness of voice, or induce paroxysmal cough on palpation, which is also pathognomonic. Preoperative diagnosis is challenging and imaging studies may play a vital role in the diagnosis. Surgical treatment with complete tumor removal is the treatment of choice. In this study, we present a case of vagus nerve schwannoma in an adult male patient. Schwannomas are slow-growing, benign, encapsulated nerve sheath tumors that derive from Schwann cells . EmbryolA 41-year-old male patient was referred to the outpatient clinic of the Oral and Maxillofacial Surgery Department with a history of a mass in the right lateral neck area. The mass had been present for the last eight years; however, the patient had begun to experience some nonspecific symptoms in the previous year. The main complaints were mild hoarseness of voice, episodes of bradycardia, and syncope. His physical examination revealed a non-tender, soft, mobile, smooth-surfaced mass on the right side of the neck. Notably, the palpation of the neck induced paroxysmal cough. No cervical lymph nodes were palpated.The patient underwent an MRI of the neck Figure , which dThe patient underwent complete tumor removal under general anesthesia. The incision was placed in an upper neck skin crease extending from the mastoid process toward the hyoid bone, overlying the mass. Then, the skin incision was deepened through the platysma to expose the anterior border of the sternocleidomastoid muscle. The fascia anterior to the sternocleidomastoid muscle was incised and the sternocleidomastoid muscle was retracted laterally to expose the mass. The carotid sheath was dissected and the internal jugular vein, the carotid artery, and the vagus nerve were exposed. The tumor was found to be arising from the vagus nerve and separated the internal jugular vein from the carotid artery. Notably, the internal jugular vein was compressed by the tumor. The entire tumor was safely separated from the nerve and totally excised while preserving the anatomic continuity and the functionality of the nerve Figure . HistoloThe postoperative period was uneventful, and the patient was discharged on the fourth postoperative day. Upon follow-up after 12 months, he remains asymptomatic with no signs of recurrence.Schwannomas of the head and neck are benign tumors with a slow growth rate. However, it is important to note that there is an incidence rate of 8-13.9% of malignant transformation, which should be taken into consideration in the management of schwannoma . They arPreoperative diagnosis of cervical vagus schwannoma is difficult since the clinical presentation tends to be nonspecific . PreoperImaging is useful in distinguishing between the entities included in the differential list as it can depict the relationship of the mass with the adjacent structures, and provide some insight into the mass composition. Differentiation between vagal schwannomas and cervical sympathetic chain schwannomas can be made by the displacement of the carotid sheath contents. The latter displace both the carotid artery and internal jugular vein laterally since they are not inside the carotid sheath, while vagal schwannomas tend to separate them. Lymph node involvement can be considered when both the carotid and the jugular vein are displaced medially, as cervical lymph nodes are lateral to the carotid sheath. Carotid body tumors separate the internal and external carotid arteries at the carotid bifurcation level . UltrasoThe role of FNAC is debatable because schwannomas are deep-seated and usually adjacent to the large vessels, and injury may occur . Hence, There are two histopathological patterns of schwannomas: Antoni A and B. Both types may coexist. In Antoni A pattern, there is high cellularity, with the cells being arranged in palisades, bundles, or whirls, around central acellular eosinophilic areas, called Verocay bodies ,4. AntonComplete surgical removal of the tumor is the mainstay of treatment. In the literature, there are two different methods of dealing with schwannomas. One involves the dissection of the nerve fascicle from which the schwannoma originates, removing the schwannoma with its capsule  with the occasional sacrifice of the vagus nerve, while the other, more conservative, method pertains to the enucleation of the schwannoma from inside its capsule with the preservation of the nerve ,6.A recent review by Sandler et al.  comparinRecently, vagus nerve monitoring has been proposed as an additional precautionary measure to ensure fewer incidences of postoperative nerve damage. However, it remains to be determined how useful nerve monitoring is as there have been a few cases that reported nerve monitoring during the procedure .Vagus nerve schwannomas are rarely occurring neck masses with unusual and atypical symptoms. Imaging is a very helpful modality for diagnosis and surgical planning. It seems that the enucleation method is associated with fewer complications, but this depends on the surgeon’s skills. Recurrence rates are estimated to be very low. In our case, the patient presented with a palpable neck mass and nonspecific symptoms, such as mild hoarseness of voice, episodes of bradycardia, and syncope. Preoperative imaging suggested cervical vagus nerve schwannoma as the most possible diagnosis. Complete tumor removal with dissection and preservation of the vital anatomic structures and the functionality of the vagus nerve under general anesthesia was performed. Upon follow-up after 12 months, the patient remains asymptomatic with no signs of recurrence.


Dermoid cyst also called Mature cystic teratoma is the most common ovarian germ cell tumor of pre-menopausal females, composed of skin, hair, teeth, and sebum covered by thick fibrous tissue. It can present with complications like torsion, rupture, infection, and autoimmune hemolytic anemia. The case highlights the role of imaging in the diagnosis of ruptured dermoid cyst which can have subtle clinical features.Herein we present a case of 53 years multiparous postmenopausal female who presented with lower abdominal pain. Examination findings at presentation were normal. 2 years back patient was evaluated for the abdominopelvic mass which was diagnosed radiologically as an ovarian dermoid cyst. This time, Ultrasonography (USG) of the abdomen and pelvis followed by Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis revealed the features consistent with a ruptured dermoid cyst. Exploratory laparotomy and histopathological examination of the specimen confirmed the diagnosis.. Following rupture patient may present with peritonitis which may be acute or chronic. Chronic peritonitis may not show any clinically distinguishable features such that the clinical diagnosis of the rupture dermoid cyst is difficult to make. The radiological assessment helps to make an accurate diagnosis so that appropriate surgical intervention can be instituted.Rupture of a dermoid cyst is a very infrequent complicationFollowing the rupture of the dermoid patients may progress to a stage of chronic peritoneal inflammation. At this stage, the radiological assessment may be crucial for appropriate diagnosis and thus further management. •Dermoid cyst is the most common ovarian germ cell tumor of pre-menopausal females.•Rupture of an ovarian dermoid cyst is a rare complication.•Rupture of the dermoid cyst may present with very subtle and marginal symptoms that are not clinically distinguishable.•The ruptured teratoma can be accurately diagnosed by the contrast CT and hence the appropriate management can be made. ThThough the tumor is usually asymptomatic and remains an incidental finding, a few times patients present with complications with their corresponding clinical and imaging features . 2]. Th. Th2]. THerein we present a case of 53 years female with a ruptured dermoid cyst diagnosed with contrast CT. This case report has been reported as per SCARE 2020 criteria .2History dates back around 2 years to a 53-year-old postmenopausal multiparous woman who presented to gynecological OPD with a complaint of lower abdominal pain. The pain was associated with abdominal heaviness and fullness. It was non-radiating with no known relieving and aggravating factors. Patient had no significant surgical or medical history in the past. There was no relevant family history.Abdominal examination revealed a cystic/solid globular mass in the lower abdomen with a size of approximately 24 weeks. The mass was smooth, freely mobile with getting below the swelling possible. It was non-tender and non-pulsatile. Examination of the other systems were insignificant., 2020, showed a large well defined, smoothly marginated thick-walled cystic lesion measuring approximately (14.0 × 12.0x10.0) cm in size in the abdominopelvic region with few foci of calcifications within suggestive of a dermoid cyst. It was followed by a Contrast-Enhanced Computed Tomography (CECT) abdomen and pelvis which revealed a large, well-defined, smoothly marginated, predominantly fat attenuating lesion with fat fluid level, few Rokitansky soft tissue nodules, and few calcifications in the abdominopelvic cavity abutting the bilateral adnexal region measuring about (9.7 × 14.5 × 13.7) cm-consistent with dermoid cyst most likely of ovarian origin . Th. Th5]. Txpansion .After the rupture of the dermoid cyst, the release of tumor contents can cause peritonitis. The presentation can be acute or chronic . 2]. Th. Th2]. THere in our case, it is likely that the dermoid got ruptured with a small rent when the patient traveled on a motorbike along the unlabeled off-road. The ruptured contents disseminated in the abdominal cavity causing peritonitis which was initially acute for the first three days that subsequently developed into chronic granulomatous inflammation of the peritoneum due to continuous leakage from the rent. By the time the patient developed chronic peritonitis the symptoms were very vague, subtle, and clinically indistinguishable from other causes of abdominal pain. In this situation, the USG and CECT were key to the diagnosis with their characteristic findings as mentioned above. It is also notable that the fat deposition in the right subdiaphragmatic region which was evident in the CECT caused the patient to have right shoulder pain which is explained by the diaphragmatic irritation by the fat. The rupture with the rent was later confirmed in the surgery which also showed chronic inflammatory changes along with fat deposition within the peritoneal cavity.4Dermoid can often present with an uncommon complication like a rupture. It might be a spontaneous rupture or due to any inciting trauma. Following the rupture, the patient can develop acute or chronic granulomatous peritonitis. Patients who develop chronic granulomatous peritonitis may not be clinically evident and imaging can be diagnostic with its characteristic finding. Specifically, contrast CT has very high sensitivity and specificity to diagnose such cases. It is therefore advisable to perform the imaging in the patients who present with vague abdominal pain inconsistent with acute peritonitis and have a well-known history of mature cystic teratoma to rule out possible rupture of the teratoma. The ruptured teratoma can be accurately diagnosed via the imaging modalities and hence the appropriate management can be intervened.None.Not applicable.Not commissioned, externally peer reviewed.N/A.None.Author 1: Led data collection, concept of study, contributed in writing the case information.Author 2: Literature review, writing initial draft, revising, and editing the manuscript.Author 3: Literature review and writing case information.Author 4: Literature review, revising and editing the manuscript.Author 5: Revised and edited the rough draft into final manuscript.Author 6: Revised and edited the rough draft into final manuscript.All authors were involved in manuscript drafting and revising and approved the final version.1.Name of the registry: N/A.2.Unique Identifying number or registration ID: N/A.3.Hyperlink to your specific registration (must be publicly accessible and will be checked): N/A.dhbinay@gmail.com Phone: +977–9849764844.Binaya Dhakal, Military Hospital Nepalgunj, Banke, Nepal. Email: 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.None.


Cancer patients need multimodal therapies to treat their disease increasingly. In particular, drug treatment, as chemotherapy, immunotherapy, or various associations between them are commonly used to increase efficacy. However, the use of drugs predisposes a percentage of patients to develop toxicity in multiple organs and systems. Principle chemotherapy drugs mechanism of action is cell replication inhibition, rapidly proliferating cells especially. Immunotherapy is another tumor therapy strategy based on antitumor immunity activation trough agents as CTLA4 inhibitors (ipilimumab) or PD-1/PD-L1 inhibitors as nivolumab. If, on the one hand, all these agents inhibit tumor growth, on the other, they can cause various degrees toxicity in several organs, due to their specific mechanism of action. Particularly interesting are bowel toxicity, which can be clinically heterogeneous , up to severe consequences, such as ischemia, a rare occurrence. However, this event can occur both in vessels that supply intestine and in submucosa microvessels. We report drug-related intestinal vascular damage main characteristics, showing the radiological aspect of these alterations. Interpretation of imaging in oncologic patients has become progressively more complicated in the context of “target therapy” and thanks to the increasing number and types of therapies provided. Radiologists should know this variety of antiangiogenic treatments and immunotherapy regimens first because they can determine atypical features of tumor response and then also because of their eventual bowel toxicity. Cancer patients need multimodal therapies to treat their disease increasingly. In particular, drug treatment, as chemotherapy, immunotherapy, or various associations between them are commonly used to increase efficacy. However, the use of drugs predisposes a percentage of patients to develop toxicity in multiple organs and systems . They caCommon side effects during chemotherapy are observed in gastrointestinal system and consists of mucosal damage mainly, which can manifest itself with various symptoms . At the Many anticancer drugs can induce vascular toxicity, venous, and more rarely arterial system. Great and microvessels may be affected by thrombosis and thromboembolism; if bowel vessels are involved, they can give rise to critical ischemic events, which lead to necrosis and perforation. Thrombotic and thromboembolism events pathogenesis is induced by drug-related endothelial damage, with consequent basement membrane exposure and abnormal coagulation cascade activation , 32. PlaClinical features of acute ischemic bowel is very changeable: acute abdominal pain could be determined by many different causes  and the ‘classic triad’ of chronic mesenteric ischemia  is rarely found in clinical practice .Radiological imaging is crucial in the emergency setting. It is very difficult to make differential diagnosis only through physical examination; as explained by Terlouw et al., at least upper gastrointestinal endoscopy and abdominal imaging (computed tomography/magnetic resonance imaging) must be executed if there is a suspicious of chronic mesenteric ischemia. Colonoscopy should be performed in patients with diarrhea.In the emergency setting the baseline of radiological examination in patient with acute abdominal pain include abdominal ultrasonography (US) and/or abdominal plain radiography. US allows to detect some differential diagnosis of acute abdominal pain such as cholecystitis, pancreatitis, hernias. Colour and Power Doppler imaging therefore could be useful to study bowel’s vascularity: an increase of vascularity of the bowel wall and adjacent mesentery is a sign of hyperemia and inflammatory bowel disease. On the contrary, a reduction of vascularity is a specific sign of ischemia . Duplex According to Mazzei et al., MRI could play an important role not only for follow up but also for the diagnosis of acute ischemic colitis without using contrast medium through combined T2-weighted steady state free procession sequences on coronal plane and T2W fast-recovery fast-spin echo sequences both in coronal and axial plane. For example, colonic wall thickening is typical both on CT and MR in case of severe colonic: especially when this sign has segmental distribution is quite specific for ischemic colitis compared to inflammatory colitis . MRI is Currently, computed tomography (CT) represents the primary imaging technique in imaging bowel injuries with numerous advantages in comparison with other diagnostic modalities . In partMainly, multidetector CT represents the gold standard for the intestinal study because, in few minutes, it can provide a complete study of the abdomen also in non-cooperating patients and can avoid angiography through a multiphase study using contrast agents.First, we know that oncologic patients are almost exclusively examined by CT to detect their “tumor burden” so it is possible to discover intestinal pathological features in asymptomatic patients during the planned follow-up; it is known that 70.8% of cancer patients with pneumatosis and/or bowel perforation are asymptomatic . If sympFree intraperitoneal gas means perforation of an infarcted bowel segment . In the Radiologists must take in count that bowel ischemia can also exist in malignant conditions, such as in proximity to a colonic carcinoma or a metastatic intestinal lesion .Moreover, some chemotherapy agents may determine spontaneous gastrointestinal necrosis and even perforation , 64. At Side effects from molecular target therapy include enterocolitis, pneumatosis, micro-perforations of the bowel, fistula formation, and wound dehiscence, especially in rectal carcinoma , 65, 66.These features, however, are not specific because they can also occur after radiation that induces small-vessel occlusions and could determine ischemia anywhere in the digestive tract, especially in patients with prior abdominal surgery with adhesive changes, previous peritonitis before radiation therapy and in patients that have cardiovascular factors or risk . ImmunotWe report the case of a 35 years old male patient diagnosed in February 2017 with squamous non-small-cell lung cancer (sqNSCLC). From June 2017, he received a second-line treatment with nivolumab for advanced disease achieving a major partial response. After 23 drug administrations, he presented with symptoms of moderate left lower quadrant pain without fever. Abdominal CT with IV iodinated contrast showed sigmoid diverticulitis with colonic wall thickening and pericolic fat stranding  –80. It iWe believe that CT is the primary imaging technique with a high temporal resolution that can provide a specific diagnosis of chemotherapy-induced bowel ischemia. CT could reveal also a fearsome complication that might occur in the bowel ischemia pathological process represented by bowel perforation. A hole through the wall of the intestines can develop; this results in the contents of the intestine leaking into the abdominal cavity, causing peritonitis. An interesting study conducted by Bagdwell and his group examined the management of perforation and the associated outcomes in patients with bevacizumab-associated bowel perforation. A bevacizumab-associated perforation on CT . Bowel pNivolumab determined small bowel obstruction and perforation in a patient that was on long-term therapy for metastatic non-small cell lung cancer that was confirmed after surgery . This paTherefore, it seems to be very important for radiologists to be aware as much as possible of the various chemotherapy treatment and pathological mechanisms that can promote bowel ischemia and perforation in the oncologic setting. Radiologists should talk to oncologists in multidisciplinary teams to manage together the clinical-therapeutic pathway of these patients; according to us, the knowledge of medical history in the oncologic setting is mandatory because, for example, patients could also be subjected to radiation before our observation so in this case the intestinal illness maybe not related to the therapeutic regimen. Patients with risk factors that could develop bowel perforation  should be detected before therapy –87. The Interpretation of imaging in oncologic patients has become progressively more complicated in the context of “target therapy” and thanks to the increasing number and types of therapies provided. Radiologists should know this variety of antiangiogenic treatments and immunotherapy regimens first because they can determine atypical features of tumor response and then also because of their eventual bowel toxicity. To avoid emergency surgery and significant risk of mortality among chemotherapy-induced bowel ischemia, it is necessary to give prompt diagnoses detecting drug toxicities; the dialogue with the clinician could be helpful for radiologists for this issue. After all the recognition of risk factors for chemotherapy-associated bowel ischemia and perforation will depend on the assessment of large clinical trials and observational studies.


A 76-year-old man was admitted into the ER for upper abdominal pain. Physical exam and CT scan confirmed acute cholecystitis with multiple cholelithis, and a cholecystectomy was performed. The cholecystectomy specimen showed chronic cholecystitis with exuberant inflammatory infiltrate. On careful examination of the specimen, large atypical cells with vesicular chromatin, folded nuclei, and inconspicuous red nucleoli were noted percolating into the gallbladder wall and lining vascular spaces. These cells were positive for CD117, CD43, and myeloperoxidase and negative for CD20 and CD3 stains. Further workup including peripheral blood flow cytometry confirmed a population of circulating immature myeloid precursors comprising about 38% of events. This is a rare case of acute myeloid leukemia that came to clinical attention by incidentally involving the gallbladder. Blood-based processes such as leukemia and lymphoma can be incidentally found in a myriad of pathology specimens. The best-known examples are those of chronic lymphocytic leukemia involving specimens such as colon resections . Here, wA 76-year-old man was admitted into the ER for severe upper abdominal pain. Physical exam and CT scan confirmed acute cholecystitis with multiple choleliths, and an emergent cholecystectomy was performed.Gross exam of the specimen showed multiple granular gallstones measuring up to 1.5 cm and a thickened gallbladder wall that measured up to 1 cm. On microscopic exam, the specimen showed chronic cholecystitis with exuberant inflammatory infiltrate . On caree9/L, hemoglobin 7.1 g/dL, and platelet count 37 × 10e/L.Peripheral blood smear review confirmed the presence of numerous circulating blasts showing high nuclear to cytoplasmic ratio; fine, powdery chromatin with one or more prominent nucleoli; and scant blue cytoplasm. No Auer rods were seen. Flow cytometry verified the presence of a myeloid blast population representing 38% of events, with coexpression of CD13, CD33 (dim), CD117, HLA-DR and myeloperoxidase and negative for CD34, CD3, CD7, CD11b, CD14, CD16, CD19, CD56, CD10, and TdT. Additionally, review of the patient's electronic chart showed that at presentation to the ER the patient's WBC was 79.5 × 10Upon further questioning of the patient and his family, it was found that the patient did have a history of acute myeloid leukemia, diagnosed overseas. Review of the outside medical records indicated that the patient had a bone marrow biopsy showing 86% blasts. Karyotype could not be performed and molecular studies, at his institution, detected a FLT3 mutation. He had received one week of chemotherapy and G-CSF, four months prior to his presentation at our institution.This is a very interesting and easy-to-miss case of acute myeloid leukemia presenting in a cholecystectomy specimen. The key finding that prompted further assessment of the specimen was the large, atypical intravascular cells. A limited panel of stains that included CD20, CD3, CD43, CD117, and myeloperoxidase was performed aimed at classifying these cells. The main differential diagnosis for this large, atypical intravascular infiltrate included (1) intravascular large B-cell lymphoma, (2) immature lymphoid/myeloid neoplasms such as acute myeloid leukemia and acute lymphoblastic leukemia, and (3) myeloid sarcoma.Intravascular large B-cell lymphomas represent a rare extranodal type of large B-cell lymphoma characterized by selective growth of neoplastic cells within the lumina of vessels , 3. It uIntravascular large B-cell lymphoma cells express mature B-cell antigens . CD5 and CD10 coexpression is seen in 38% and 13% of the cases, respectively [Acute lymphoblastic leukemia/lymphoma includes neoplasms of B- and T-cell differentiation. Generally, acute lymphoblastic leukemia/lymphoma is a disease of children and adolescents, although it can present in adulthood as well. In adulthood, it is more likely to be of T-cell differentiation. Acute lymphoblastic leukemia/lymphoma have a relatively low propensity of leukemic presentation being more commonly found involving nodal and extranodal sites , 6 such Myeloid sarcoma is defined as a tumor mass comprised of myeloid blasts occurring outside of the bone marrow. Tissue infiltration by myeloid blasts in a patient with leukemia is not classified as myeloid sarcoma unless it presents with tumor masses in which the tissue architecture is effaced . In thisAcute myeloid leukemia was the leading differential diagnosis on this case. This entity presents at any age, but most patients are either infants or older adults. These neoplastic cells express markers of immaturity such as CD34 and CD117, as well as myeloid differentiation markers such as myeloperoxidase. Acute myeloid leukemias have an increasingly complex classification that includes molecularly defined entities. In this case, the patient's intravascular and interstitial atypical infiltrate was positive on immunohistochemistry for CD117, CD43 and myeloperoxidase and negative for CD20 and CD3.On this case, the lack of cytogenetic information precludes final classification of the acute myeloid leukemia. However, FLT3 mutations, regardless of the cytogenetics , 14, conIn summary, this case highlights some of the morphologic clues of blasts on hematoxylin and eosin stain , reviews some of the key markers and considerations for the differential diagnosis of intravascular hematolymphoid cells, and presents an uncommon example of a hematolymphoid neoplasm inadvertently involving a specimen retrieved for unrelated reasons illustrating the intricacy of a second diagnosis in pathology.