Primary pulmonary meningioma (PPM) is a rare and benign slow growing tumor with good prognosis. It often presents as an asymptomatic, well-circumscribed, solitary pulmonary nodule. Wedge resection is the management of choice for both diagnosis and treatment. Here, we report one case of PPM with increased fluorodeoxyglucose (FDG) uptake and associated micronodules, which was clinically suspicious for malignancy. The patient was a 60-year-old female who presented with persistent shortness of breath for 1 year. Chest computed tomography showed a 1.5-cm well-circumscribed homogenous nodule in the left upper lobe with increased FDG uptake and multiple smaller well-circumscribed micronodules scattered in both lungs. Left upper lobe wedge resection confirmed the diagnosis of PPM. PPM can deceptively mimic malignancy, so recognizing this rare entity and including it in the differential diagnoses of pulmonary nodules, especially with avid uptake of FDG, is crucial to avoid misdiagnosis and overtreatment. Meningioma represents the most common central nervous system (CNS) tumor. Primary extracranial and extraspinal meningiomas are uncommon and account for 2–3% of all meningiomas . PrimaryThe patient was a 60-year-old female who presented with persistent shortness of breath for 1 year. Chest computed tomography CT;  with conLeft upper lobe wedge resection was performed. On gross examination, the nodule was tan-white, well-circumscribed, firm, homogeneous, measuring 1.5 × 1.3 × 0.7 cm, abutting the pleura. Microscopically, this tumor was composed of bland epithelioid and spindle cells with moderate amount of cytoplasm, whorl formation and occasional pseudo-nuclear inclusions . No mitoMost cases of PPM are incidental findings on chest X-ray or CT examination. Patients are often asymptomatic or with some nonspecific symptoms , 4. TherPPMs share the same histomorphology and WHO grading with that of CNS meningioma. It is well circumscribed and consists of epithelioid or spindle cells in whorl pattern. The pseudo-nuclear inclusions or psammoma bodies may present. Tumor cells are positive for EMA, PR and SSTR2A, but negative for TTF, P40, cytokeratin, melanoma markers and neuroendocrine markers , 4, 17. There are three types of pleuropulmonary meningothelial proliferation, which include metastatic pulmonary meningiomas (MPMs), PPMs and minute pulmonary meningothelial-like nodules (MPMNs). They share similar morphological and immunohistochemical features. Although MPMs is rare, lung is one of the most frequently metastatic sites . ExclusiMost PPMs are benign, slow-growing tumors with good prognosis . Wedge rAlthough tissue diagnosis of PPM does not seem to be challenging based on morphology and immunostaining profile, misdiagnosis and overtreatment do occur. One major reason is unawareness of this rare entity. Misdiagnosis for metastatic papillary thyroid carcinoma can occur in cytology when PPMs present with pseudo-nuclear inclusions and psammoma bodies , 29. PPMOf note, PPM in our case also presents with associated multiple micronodules, ranging in size from 3 to 5 mm. This manifestation is rare, and very few similar cases have been reported , 33. In PPM is a rare entity. Its diagnosis relies on pathology and exclusion of CNS meningioma. Wedge resection is so far the best choice for both diagnosis and treatment. Including PPM in the differential diagnoses of pulmonary nodules, especially the one with increased FDG uptake, can help to avoid misdiagnosis and overtreatment.


Peritoneopericardial diaphragmatic hernia (PPDH) is a communication between the abdomen and the pericardial sac generated by congenital anomalies triggered during diaphragmatic and pericardial development. This report aimed to present the case of an adult, mixed-breed cat, affected by PPDH, focusing on the period from diagnosis to successful surgical correction. The patient had a capricious appetite and weight loss for about four months and started, at the end of this period, a state of apathy. On abdominal ultrasound, the gallbladder (GB) was close to the heart, suggesting diaphragmatic discontinuity. On thoracic radiography, there were changes suggestive of PPDH, pericardial efusion or cardiomegaly with probable dilated cardiomyopathy. Based on these findings, an echocardiogram was performed, highlighting the hepatic lobe and GB internally to the pericardium, causing cardiac compression, although without severe cardiac changes. During surgery, a diaphragmatic defect of 4 cm in diameter was observed with the congested right medial hepatic lobe and hyperemic GB in the pericardial sac. The defect was sutured using the sultan pattern in separate stitches and polyamide threads. The feline returned to feeding with greater interest soon after the surgery, and after 15 days it was fed with dry food and had normal behavior. PPDH can be diagnosed in healthy adult cats, even if there are no apparent respiratory, gastrointestinal, or cardiac signs. The echocardiogram is relevant in the definitive diagnosis, in addition to excluding differential diagnoses, and simple surgical treatment with polyamide thread and sultan suture is successful. Peritoneopericardial diaphragmatic hernia (PPDH) is the most common congenital anomaly of the diaphragm and pericardium in feline species . This isThe thoracic content is usually variable, being possible to visualize the liver, small intestine, spleen, omentum, pancreas, colon, uterus , and rarThe diagnosis is made by means of radiography or ultrasound, and sometimes both are necessary . ContrasThe prognosis for cats with PPDH with surgical correction is excellent for the return to normal function , becominThis report describes the diagnostic approach to surgical treatment of an adult cat with nonspecific clinical signs affected by PPDH.A 4-year-old mixed-breed female feline weighing 3.4 kg and negative Feline Immunodeficiency Virus/Feline Leukemia Virus tests with a history of reduced appetite and weight loss in the last 4 months was attended to. The feline had a low body condition score, apathy, mild dehydration, abdominal palpation without pain and notable changes, during cardiopulmonary auscultation no muffling or other changes were observed, refused dry food, feeding only wet cat food, and homemade food. Considering the patient’s history and clinical signs, laboratory and imaging tests were requested.Only a slight increase in alanine aminotransferase was observed in laboratory tests (complete blood count and biochemistry). Abdominal ultrasonography revealed the gallbladder close to the heart , distend®; Cristália Produtos Químicos e Farmacêuticos Ltda, SP, Brazil) intramuscularly. Twenty-five minutes after premedication, anesthesia was induced intravenously (IV) with 3.0 mg/kg propofol  combined with 0.2 mg/kg midazolam . Endotracheal intubation was performed, and anesthesia was maintained with isoflurane  delivered in 100% oxygen. The dose of 0.5 mg/kg of dexamethasone was administered IV. The cat was positioned supine on a thermal blanket , and trichotomy and antisepsis of the surgical site were performed.The cat received 0.3 mg/kg of methadone , gabapentin , and tramadol hydrochloride  were prescribed. Twenty-one days of rest were indicated. Fifteen days postoperatively, the surgical skin stitches were removed and the cat was already eating only dry food with full interest. Two months after the surgery, the animal gained weight and already showed normal behavior.The peritoneal cavity of the feline is not directly juxtaposed to the pericardial cavity; the two are connected only by the caudal mediastinal pleura, which renders traumatic PPDH rare in animals . It is bThe cat did not show clinical signs associated with the presence of PPDH, such as changes in the gastrointestinal or cardiorespiratory system , being oHematological examinations in cats affected by PPDH may present subtle changes  or may nIn this report, echocardiography was essential to eliminate possible differential diagnoses, such as dilated cardiomyopathy  or pericWe opted for access by median longitudinal celiotomy because the PPDH was located in the ventral midline of the diaphragm, easily visualized using this access. In addition, accessing the linea alba allows better exposure to the sternum and abdominal wall, which can present associated birth defects . There iDuring the surgical correction of the PPDH, the cranial extension of the incision, in addition to facilitating the transection of possible adhesions, also allows a wide view of both cavities, allowing the movement of the abdominal organs found in the pericardial sac without damaging them . In thisThe suture of the defect with polyamide thread in a sultan pattern initially, in the dorsal direction towards the ventral, as suggested by The patient remains under follow-up without showing signs of recurrence, despite the reserved prognosis in patients with PPDH who have associated cardiac changes , and thePeritoneopericardial diaphragmatic hernia (PPDH) can be diagnosed in healthy adult cats, even if there are no apparent respiratory, gastrointestinal, or cardiac signs. The echocardiogram is relevant in the diagnosis and exclusion of possible differential diagnoses. The surgical treatment, through the median longitudinal celiotomy approach, using polyamide thread and sultan suture, was successful in this report.


Bile duct tumor thrombus (BDTT) is an uncommon finding in hepatocellular carcinoma (HCC), potentially mimicking cholangiocarcinoma (CCA). Recent studies have suggested that HCC with BDTT could represent a prognostic factor. We report the case of a 47-year-old male patient admitted to the University Hospital of Bari with abdominal pain. Blood tests revealed the presence of an untreated hepatitis B virus infection (HBV), with normal liver function and without jaundice. Abdominal ultrasonography revealed a cirrhotic liver with a segmental dilatation of the third bile duct segment, confirmed by a CT scan and liver MRI, which also identified a heterologous mass. No other focal hepatic lesions were identified. A percutaneous ultrasound-guided needle biopsy was then performed, detecting a moderately differentiated HCC. Finally, the patient underwent a third hepatic segmentectomy, and the histopathological analysis confirmed the endobiliary localization of HCC. Subsequently, the patient experienced a nodular recurrence in the fourth hepatic segment, which was treated with ultrasound-guided percutaneous radiofrequency ablation (RFA). This case shows that HCC with BDTT can mimic different types of tumors. It also indicates the value of an early multidisciplinary patient assessment to obtain an accurate diagnosis of HCC with BDTT, which may have prognostic value that has not been recognized until now. Colorectal liver metastases are the most frequent secondary liver tumor; on the other hand, hepatocellular carcinoma (HCC) is the most common primary liver cancer, and surgical resection is the mainstay treatment ,4,5,6,7.HCC with bile duct tumor thrombus (BDTT) is relatively uncommon, with an incidence of 0.5–12.9% .HCC with BDTT was first described by Mallory et al. in 1947, and in 1975, by Lin et al. named BDTT “Icteric-Type Hepatocarcinoma” based on the often-associated symptom of jaundice, although it may not be obvious at first diagnosis [Patients with a history of HBV or HCV infection have a higher risk of developing BDTT in the background of viral damage to the liver parenchyma. The way in which BDTT develops is controversial, but can be summarized into two main pathways: cancer cells can compose the thrombus or they can cause a cancerous thrombosis due to blood clots consequent an invasive hemorrhage of the bile duct wall .The mechanisms of these two pathways are not yet known, but four hypotheses have been formulated. Firstly, cancer cells found inside the bile duct can be directly related to the primary tumor, which expands itself until invading the bile duct and creating a thrombosis . SecondlDespite the evolving technologies in imaging diagnosis and the support of Artificial Intelligence in Hepatobiliary and Pancreatic Surgery (HPB) ,12,13,14HCCs with BDTT are always associated with both parenchymal and intraductal lesions , but theSo the incidence of BDTT without macroscopic HCC as a specific subtype is not really evident in the literature, but there are no doubts that it might further jeopardize the diagnosis of HCC with BDTT .Furthermore, another challenge concerning HCC with BDTT is represented by the clinically and radiologically mimetism with cholangiocarcinoma (CCA) ,17.Laboratory and clinical-anamnestic data can help the differential diagnosis: predisposing factors for cirrhosis such as hepatitis B (HBV) or C (HCV) virus and elevated serum α-fetoprotein (AFP) levels may suggest HCC with BDTT diagnosis .CCAs may include cholestasis  and chronic inflammation pathway ) .Carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA), as preoperative diagnostic biomarkers of CCAs, showed low sensitivity .Integration with imaging features and, if necessary, with biopsy histological reports is still required to make the final diagnosis.So considering the challenging clinical picture and the lack of evidences in literature, we aim to clearly describe the management of a HCC with BDTT compared with most relevant experiences already reported. A 47-year-old male patient was admitted to the University Hospital Policlinico of Bari  with abdominal pain in the right hypochondrium.During the initial examination, the patient incidentally tested HBV-positive, in the absence of jaundice. Subsequent blood tests revealed an untreated HBV infection and normal liver and pancreatic function tests.The laboratory findings were HBsAg 5000 IU/mL  < 0.05 IU/mL); AFP 2157 ng/mL (NV 0–5 ng/mL); total bilirubin 0.9 mg/dL (NV 0.3–1 mg/dL), direct bilirubin 0.2 mg /dL (NV 0–0.4 mg/dL), indirect bilirubin 0.7 mg/dL (NV 0.1–1 mg/dL), γ-GT 44 U/l (NV < 50 U/L), and CA19–9 222 U/mL (NV 0–37 U/mL); the CEA level was undetectable.An emergency abdominal ultrasound showed inhomogeneity hepatic echo structure. The bile duct of the third segment showed segmental dilation, furthermore the gallbladder appeared distended, without gallstones and regular wall.Subsequently, an upper-abdomen Computed Tomography (CT) scan and liver Magnetic Resonance Imaging (MRI) were performed .A mass of 1.8 cm was detected within the biliary branch for the third hepatic segment, characterized by nodular impregnation in the arterial phase and irregular and partial washout in the portal venous phase. These findings were compatible with a heterologous lesion, although it was not possible to perform a diagnosis among HCC, intrahepatic CCA or other pathological lesions. Consequently, in order to obtain a histological diagnosis, a percutaneous ultrasound-guided needle biopsy was performed.The histological report revealed the presence of a moderately differentiated HCC (Edmondson grade II); immunohistochemistry results showed positive CK7 and CD34 staining and negative HEP par-1 staining consistent with the hypothesis.Therefore, after a multidisciplinary team (MDT) discussion, third segment segmentectomy was performed through a minimally invasive approach, with intraoperative examination confirming endoluminal HCC with BDTT.The histopathological analysis of the surgical specimen confirmed endobiliary metastasis from HCC. The postoperative histological report showed hepatic cirrhosis, end-stage HBV-related, and dysplastic nodules. The invasion of the major hepatic ducts was caused by carcinomatous proliferation with the morphological features of HCC.The postoperative course was uneventful, and the patient was discharged on postoperative day 7.No recurrence was evidenced until 6 months postoperatively, while a CT scan detected a nodule with HCC typical radiological characteristics (~1 cm in greatest diameter) in the fourth segment, with AFP serum level of 280 ng/mL. MDT team decide to perform ultrasound-guided percutaneous radiofrequency ablation (RFA) of the nodule. A CT scan carried out 1 month after ablation confirmed the nodule’s complete necrosis.Our experience showed how challenging is the diagnosis of HCC with BDTT and its impact on further management of the patients. Another key point is absence of a systematic classification that includes BDTT as a prognostic factor. These two points do not allow clinicians to appropriately relate BDTT to a stage of HCC; however, surgical treatment appears to be the first treatment option ,27,28,29Furthermore, the COVID-19 pandemic era changed the surgical scenario of specialized surgical fields such as HPB surgery. A huge number of Hub and Spoke learning programs allowed the peripheral center to achieve high specialization in HPB . During Besides the diffusion of the newest surgical skills, it was necessary to support them with the earliest accurate diagnosis of cancer. This is probably the most important effort to improve patients’ survival. In oncological imaging, CT remains the main diagnostic tool for detection, follow-up and tumor staging .Therefore, the achievement of the most precise treatment for each patient requires the diffusion of standardized diagnostic protocols ,33.To better understand the results of our case, we performed literature research through the main search engines (PubMed and Medline).Regarding our literature review, we have extrapolated 20 articles with a total population of 890 patients ,48,49,50Concerning baseline characteristics, our patient is 47 years old, which is in line with the literature mean age 55.35 ± 9.49). As shown in .49. As sJaundice is the most common presenting symptom, as reported by 13 of 20 articles. A total of 53.28% (317/595) of patients had jaundice as a presenting symptom .The 57.97% (200/345) patients showed a mean AFP value >400 ng/mL .A meta-analysis conducted by Navadgi et al. in 2016 compared clinic-pathological characteristics and survival outcomes between HCC patients who underwent hepatic resection, with and without BDTT, including 6,051 patients from 11 studies, mostly conducted in Asia [Patients with HCC with BDTT had worse histological features compared to those without BDTT in terms of higher rates of macrovascular and lymphovascular invasion and poorer differentiation. However, in the BDTT group after hepatectomy, this meta-analysis revealed an inferior long-term survival rate, with no decrease in the 3-year survival rate .Another retrospective analysis, conducted by Wong et al., compared outcomes between all 37 HCC patients with BDTT and 222 control patients who underwent hepatic resection between 1989 and 2012. Notably, it also revealed similar 5-year overall survival (OS) and disease-free survival (DFS) when matched for tumor stage and adverse prognostic factors, which seems to suggest that BDTT was not relevant for patients’ prognosis .So BDTT is not included as a prognostic factor in the most common HCC staging systems, such as Barcelona Clinic Liver Cancer (BCLC) and American Joint Commission on Cancer (AJCC) ,53.Anyway, recent evidences are still debating on the topic.A retrospective study by Lu et al. analyzed 622 HCC Chinese patients who underwent hepatic resections, considering that the BCLC staging system is mainly based on data from Western HCC populations. The most commonly underlying liver disease was HBV (77%). This study revealed that patients with HCC with BDTT had a worse OS at 1, 3, and 5 years compared to those without BDTT , limited, however, to the early stages of the disease (BCLC 0 and BCLC A). After recategorizing HCC with BDTT 0-A as BLCL B, the modified BLCL staging system showed a better prediction of OS and mortality .In our review, 485 485/838 57.87%) patients had a positive HBV test  57.87% p,47,48,501-, 3-, and 5-year OS are reported in Huang et al. analyzed outcomes of 1021 patients with HCC underwent R0 resection at 9 hepatobiliary referral centers. A total of 177 (17.34%) presented BDTT and it seems to be an independent risk factor. Furthermore, HCC with BDTT without macrovascular invasion was classified as BCLC B and AJCC IIIA, whereas HCC with BDTT with macrovascular invasion was classified as BCLC C and AJCC IIIB .In addition, an higher incidence of post-liver-transplant recurrence in HCC patients with BDTT has been reported in the literature, although not in large-volume studies .These results appear consistent with our clinical experience.A single lesion ≤ 2 cm in diameter, such as the one we have described, with preserved liver function, is currently staged as BCLC 0, whereas nodular recurrence, which occurred in our case report, appears to be more consistent with a worse prognostic pattern.HCC with BDTT is both clinically and radiologically difficult to distinguish from other primary biliary cancers, especially CCA.CCAs are divided by anatomical localization into three types: perihilar, intrahepatic, and peripheral. This classification has also a prognostic and therapeutic value .Perihilar CCA or Klatskin tumor is the most common one. Its growth is more often of the “periductal-infiltrating” type. It tends to be diagnosed earlier, with a smaller size compared to the intrahepatic one, due to the earlier presentation of symptoms.Intrahepatic CCA more often has “mass-forming” growth, well limited from the surrounding hepatic parenchyma .It is the most common type in the absence of other tumors or cirrhosis, although it can coexist with such diseases.Peripheral CCA has histological features similar to the perihilar type .A misdiagnosis between HCC with BDTT and CCA is described with an incidence of 4–55% ,36.However, it is important to recognize both of them in order to define patient management.CCA patients are usually not candidates for liver transplantation because, despite radical surgery, they recur in 60% of cases, mainly in the first 2 years ,58.Surgery for CCA, if resectable, varies based on the location. For example, perihilar CCAs are usually treated with the resection of the biliary convergence with the main biliary duct, with major hepatic resection and caudectomy, while peripheral CCAs are treated with pancreatic-duodenectomy .Conversely, partial hepatic resection or hemihepatectomy with bile duct preservation is the main surgical option for HCC with BDTT ,59. ReceHCC with hilar bile duct tumor thrombus (HBDTT) is a common subtype of HCC with BDTT, and it shares some imaging features with perihilar CCA: hilar mass, obstructed hilar bile duct, and upstream bile duct dilatation .However, some other features can help in the differential diagnosis.HCC typically has an increased arterial blood supply, so it usually shows hyperattenuation in the arterial phase and hypoattenuation in the portal venous phase, compared to the hepatic parenchyma.Most HBDTTs should show the same enhancement pattern. However, some HCCs can show iso- or hypoattenuation in the arterial phase, with the enhancement in the arterial phase inversely correlated with the degree of blood clots and necrosis. So, hypoattenuation in the portal venous phase seems to be the most important imaging feature to distinguish HCC with BDTT from perihilar CCA .Furthermore, HBDTT rarely infiltrates into the bile duct wall, which, consequently, is often regular without relevant enhancement.Conversely, perihilar CCA more frequently reproduces the “periductal-infiltrating” type, so it usually shows a narrowed hilar bile duct with irregular or even obliterated wall thickening, with typically progressively delayed enhancement.Washout in the portal venous phase is also the main feature to distinguish HCC with BDTT from intrahepatic CCA, together with the presence of tortuous tumoral vessels .In conclusion, the diagnosis of HCC with BDTT can be reasonably considered in the presence of lesions of both hepatic parenchyma and bile ducts with a cirrhotic underlined liver disease, especially if they show typical washout in the portal venous phase.However, several factors can jeopardize the diagnosis.Furthermore, as already pointed out, the primary parenchymal tumor can be undetectable by preoperative imaging once the thrombus appears. These findings support the value of an early multidisciplinary patient assessment to obtain an accurate diagnosis of HCC with BDTT, which may have prognostic value that has not been recognized until now.


The most common cause of pneumoperitoneum is perforated hollow viscus, which generally necessitates emergent surgical intervention. Idiopathic spontaneous pneumoperitoneum (ISP) is a rare condition less commonly described. This report outlines the case of a 79-year-old male with recurrent idiopathic spontaneous pneumoperitoneum managed by repeated laparotomy. Knowledge of this rare phenomenon and appropriate workup may allow for the avoidance of unnecessary laparotomies. Despite this, definitively ruling out perforated hollow viscus is difficult outside of the operating room, and many patients will ultimately be taken for surgical exploration and definitive diagnosis. Pneumoperitoneum is the presence of free air within the peritoneum. When seen on radiographic imaging, it is most commonly due to intra-abdominal emergencies such as perforated viscus . PneumopA 79-year-old male presented to the emergency department with two days of nausea, vomiting, and abdominal pain. His past medical history was significant for coronary artery disease, hypertension, and diabetes. He had no past surgical history. He smoked one pack per day with no drug or alcohol use. On physical examination, his heart rate was in the low 100s but otherwise was hemodynamically stable. He had moderate abdominal distention but was nontender and otherwise unremarkable. Laboratory tests saw a mild leukocytosis of 12,100 cells per μL but were otherwise within normal limits. Computed tomography (CT) scan was the initial imaging and saw moderate pneumoperitoneum (Figure The patient returned to the emergency department two years later. He complained of nausea and vomiting for the past 12 hours but denied any abdominal pain. Vital signs remained stable. His physical examination again saw abdominal distention but was otherwise unremarkable. Laboratory tests again saw a mild leukocytosis of 14,700 cells per μL but were otherwise within normal limits. CT again saw moderate pneumoperitoneum (Figure ISP is a rare condition with only a few case reports -3. ThereThe most common cause of pneumoperitoneum, and that which is generally of the most immediate concern, is perforated hollow viscus, as seen in over 90% of patients . Other iThe first step in the workup is a detailed history and physical examination. Although a plain radiograph may demonstrate pneumoperitoneum, CT is a critical tool in evaluation. CT can predict the site of GI perforation with 86% accuracy . EndoscoIt has been stated that most cases of spontaneous pneumoperitoneum can be managed conservatively . “Treat ISP is a rare condition. This report outlines a case of recurrent ISP managed by repeated laparotomy. Knowledge of this rare phenomenon and appropriate workup may allow for the avoidance of unnecessary laparotomy. Despite this, definitively ruling out perforated hollow viscus is difficult outside of the operating room, and many patients with ISP will ultimately be taken for surgical exploration and definitive diagnosis.


Chylous ascites is a rare form of ascites usually associated with cirrhosis, abdominal malignancies, surgeries or infections. We presented a case of chylous ascites after robotic laparoscopic prostatectomy (PLDN-RALP), in which the correct diagnosis was achieved by SPECT/CT lymphoscintigraphy. A 72-year-old male developed chylous ascites after surgery and underwent lymphoscintigraphy with radiolabeled albumin nanocolloids for the supplementary study of the lymph flow and to detect a possible site of leakage. The scintigraphic imaging demonstrated the abdominal effusion and lymph stasis in the left iliac region. The combination of planar imaging with SPECT/CT can resolve the assessment of chylous disorders. Chylous ascites (CA) is a rare form of ascites, defined as a leakage of triglyceride-rich lymph into the abdominal cavity, with an accumulation of lipid-rich, milk-like peritoneal fluid. Any source of lymph vessel obstruction or leakage can potentially result in CA. The causes of these disorders lead to lymph accumulation in the abdominal cavity and the inability to recycle the accumulated lymph ,2,3,4.CA incidence rates are low, and often it is associated with underlying etiologies such as cirrhosis and malignancies. Moreover, non-portal etiologies can cause the exudation of lymph material and can be classified as congenital or acquired. In adults, lymphatic damage can result from trauma, surgeries, or infections .CA has been reported after surgical procedures including retroperitoneal lymphadenectomy and genitourinary surgery, but rarely after laparoscopic procedures such as robotic laparoscopic radical prostatectomy (PLDN-RALP), which have lymphocele formation as the main complication .After surgery, CA can occur early (around 1 week) most frequently due to disruption of the lymphatic vessels; the late onset (weeks to months) can be due to adhesions or extrinsic compression of lymphatic vessels. CA represents a critical clinical situation with whole-body mechanical, nutritional and immunological consequences, associated with high morbidity rates and mortality rates of 40–70% ,5,6,7,8.CA early diagnosis is crucial and radiological assessment play an important role but neither computed tomography (CT) nor magnetic resonance (MR) is specific for it. Among all lymphatic vessel examination, lymphoscintigraphy is a milestone due to its versatility and the wide spectrum of data that can be analysed ,9,10.We present the case of a patient who developed chylous ascites after laparoscopic surgery in whom lympho-SPECT/CT was decisive for the choice of the therapy approach.A 72-year-old male underwent pelvic lymphadenectomy during robotic-assisted laparoscopic radical prostatectomy (PLDN-RALP) for prostate carcinoma eradication (Gleason score 7 = 4 + 3). The patient was discharged on day 6 after surgery thanks to the lack of side effects and the good result of the procedure.Unfortunately, he was readmitted 7 days later with abdominal distension and dyspnoea. During hospitalization, thorax and abdominal contrast-enhanced CT was performed which confirmed a massive ascites and described the presence of left pleural effusion without the presence of liver diseases .In order to better assess the post-surgery pelvic region, abdominal MR was performed which did not show evidence of surgical injuries and liver diseases .Due to copious ascitic fluid, in order to reduce symptoms, he was submitted to paracentesis (1500 mL) and the biochemical analysis of the fluid confirmed the chylous ascites. Four days later, the paracentesis, abdominal distension and respiratory symptoms onset again.The patient was then submitted to lymphoscintigraphy in order to identify the possible etiology of the relapsing chylous ascites; the day before the scan, the patient observed a diet with high-fat meals in order to decrease the possibility of false-negative results. Superficial lymphoscintigraphy was performed, administering 99mTc-labelled human serum albumin nanocolloids (185 MBq) simultaneously on the dorsum of each foot subdermally, about 1–2 cm proximally to the first interdigital space.Images were acquired with a dual-head gamma camera  with low energy high-resolution parallel hole (LEHR) collimators (set 20% window centered on the 140 KeV photopeak).The patient was positioned supine and a dynamic anterior image of the pelvic region was acquired with a rate of 1 frame per min for 20 min that showed only the left inguinal lymph node, revealing delayed and asymmetric lymphatic drainage from lower limbs. After, anterior whole-body images were acquired at 30 and 60 min and after a high-fat meal at 2 and 3 h after administration . Images Abdominal and thorax single photon emission tomography/computed tomography (SPECT/CT) images  were acquired 3 h after administration. The integrated CT scan was obtained with 110 kV, 75mAs, and pitch 1.3; it allows anatomical localization and image correction attenuation.Abdominal SPECT/CT images confirmed the radioactive spot in the left iliac region and the diffuse abnormal accumulation of radiotracer in the peritoneum more intense in the left iliac fossa; the CT co-registration images showed that there was no internal iliac lymph node in that site but a dilatation of the lymphatic pathway at the site of surgical interruption, surrounded by a greater intensity of radioactivity in the ascitic effusion. The cause of chylous ascites was then identified as a consequence of the exudation of chyle through the lymphatic dilatation into the peritoneal cavity .Furthermore, thorax SPECT/CT did not show radioactivity distribution in the left pleural effusion excluding the presence also of chylothorax and demonstrating its reactive aetiology of it .The patient was then submitted again to paracentesis and treated with conservative therapy: diet (high-protein and low-fat diet with short- and medium-chain triglycerides), and pharmacological measures (to inhibit lymph fluid excretion). The weekly follow-up for the next 3 months revealed a progressive improvement of the clinical condition without CA recurrence and also the disappearance of the reactive pleural effusion.The diagnosis of chylous ascites is mainly based on the observation of the ascitic effusion which appears as turbid yellow fluid on its chemical, cytological and microbiological analysis ,11.CA is not a common event and presents with the symptom of abdominal discomfort (81% of cases) usually 1–14 days after laparoscopic surgery, as well as in our patient that presented abdominal distension and dyspnea 13 days later. The following pain may result from distension of the mesenteric and retroperitoneal serosa as well as in all forms of ascites including neoplastic ones ,11,12.The main cause of CA is the presence of chronic liver disease, but in the case of surgery, the possibility of injuries must be considered, even if recent robotic technologies have been implemented and complication rates are even lower .CT is the imaging modality of choice to evaluate intraperitoneal fluid accumulations and may be particularly helpful in the setting of postoperative causes of CA to determine the extent and location of possible injuries ,11. In oLymphangiography and lymphoscintigraphy are modalities that can study the lymphatic system detecting vessel damage such as fistulas or leakage from lymphatic channels. Studies have reported a lymphangiography detection rate of 64–86% for leakage sites in patients with CA. Some reports have also suggested a therapeutic role in cases with lymphatic leakage probably thanks to the inflammatory and granulomatous reaction on extravasation induced by contrast agents during the procedure. Otherwise, it is an invasive procedure associated with complications such as infection, pain, intra-alveolar hemorrhage, contrast emboli in the lungs, extravasation of lipiodol into the soft tissue and allergic reactions ,13.Lymphoscintigraphy is a nuclear medicine non-invasive procedure, with no adverse effects, no contraindications, and the ability to perform repetitive studies. It allows a functional evaluation of the lymphatic system and has proven valuable in the identification of the sentinel lymph nodes in radio-guided surgery and in the study of limb lymphatic drainage in pre and post-surgical evaluations. Lymphoscintigraphy allows studying both deep and superficial lymphatic vessels by providing a map of the active vessels that drain the injection site, and thus being able to distinguish the altered radiocolloid drainage, the existence of short-circuits, stenosis, bypass or dermal reflux ,10. In pIn our patient, lymphoscintigraphy was used to assess the presence of lymphatic changes after the surgery that involved lymphadenectomy of the iliac lymph nodes. Delayed lymphatic drainage in the right lower limb was found; in subsequent acquisitions, the images showed the presence of radioactivity in the abdominal area confirming the presence of CA and a spot in the left iliac region, which in the two-dimensional planar images could be attributable to an iliac lymph node.Recent technologies significantly enhanced the diagnostic accuracy of this already valid procedure. Modern gamma cameras allow the acquisition of tomographic and CT co-registration images which improved the diagnostic performance of all scintigraphic examinations.For the study of lymphatic vessels, lympho-SPECT/CT moved from an ancillary role to being fundamental due to the high accuracy in detecting even minor lesions and the possibility of correlating them anatomically. Our patient is an exemplary case because lympho-SPECT/CT was decisive in characterizing the spot in the iliac area not as a lymph node but as a lymphatic dilatation and in describing the proximal greater peritoneal accumulation of radioactivity.Images provided by lympho-SPECT/CT then allowed us to identify the CA aetiology in the exudation of chyle through the lymphatic dilatation identified, which is one of the three possible causes of postsurgical CA .Another significant piece of information provided by thorax lympho-SPECT/CT is the absence of radioactivity at the site of the pleural effusion; this allowed us to identify the reactive nature of the effusion, excluding the presence of damage to the connecting lymphatic vessels .The therapy cornerstone for CA regards correcting the underlying cause and applying conservative measures to improve patient comfort, reduce recurrence and optimize outcomes. CA conservative treatment is centered on the use of diuretics and nutritional optimization with a low sodium, low fat, and high protein diet with medium-chain triglycerides in order to reduce the production and flow of lymph. Treatment should be individualized and adjusted for the severity of chylous ascites but refractory cases of CA may require interventions such as embolization, TIPS, peritoneovenous shunting or surgery ,6. ThankIn conclusion, CA after a surgical procedure is a relatively rare complication but still requires a prompt assessment due to the elevated risk of morbidity and mortality. Lympho-SPECT/CT with 99mTc-nanocolloids should be considered in the management with CA thanks to its capability to whole-body assess lymphatic vessels in all three spatial planes. This non-invasive technique allows for identifying the sort and the site of lymphatic drainage in order to promptly begin the correct therapy.


Background: The purpose of the present case report was to investigate a very rare ectopic third molar removal by a trans-sinusal approach and report the study findings through a systematic review of the literature on this topic. Case presentation: A 38-year-old female patient was visited for pain at the level of the right maxillary region. No relevant medical history was reported. The CBCT tomography assessment revealed an impacted third tooth at the level of the postero-lateral maxilla. Review Methods: An electronic search was performed through Boolean indicators query on Pubmed/Medline, EMBASE, Cochrane Library databases. The clinical reports were identified and selected in order to perform a descriptive analysis. The surgical approach concerned a trans-sinusal access to the site for the ectopic tooth removal with a lateral antrostomy. No evident inflammatory alteration was associated to the ectopic tooth and a non-relevant post-operative sequelae was reported at the follow up. Results: A total of 34 scientific papers were retrieved from the database search. Only two cases reported a wait-and-see radiographical follow-up approach, while the most common treatment was surgical removal, also for asymptomatic cases. Conclusion: The third-molar ectopic tooth into the maxillary sinus is an uncommon occurrence that is beast treated by an in-chair intraoral tran-sinusal approach, with a consistent reduction of the invasivity, a mild morbidity and a successful functional outcome. Problems with mandibular and maxillary third molars together with maxillary canines are frequently observed in oral surgery and their extraction is one of the most widespread procedures in oral surgery. Clinical and radiologic evaluation of surgical difficulty can help the practitioner plan the surgical technique for avoing the possible complications. Different surgical techniques has been proposed for maxillary ectopic teeth that described trans-oral and Caldwell-Luc approaches, extra-oral accesses , nasal eUsually, the diagnosis of impacted third molars is performed during the first dentistry visit or during primary care. The extraction of a maxillary wisdom tooth involves the risk of complications. The most frequent complications reported are the displacement in the maxillary sinus , oroantrThe present study was conducted in accordance to the ethical laws and the World Medical Association Declaration of Helsinki  and the A 38-year-old female had chronic pain in the maxillary right region and was diagnosed with having an impacted third tooth by orthopantomogram (OPG) .Clinical examination revealed absence of the right maxillary third molar, radiologic examination excluded the presence of carious or periodontal disease borne by neighboring teeth . The sub®  with epinephrine of 1:100,000.. Written informed consent was acquired from the patient for publication of the case report. A modified triangular flap without anterior release was performed as previously described for access to the sinus maxillary [After explaining the different surgical possibilities to the patient, we decided to perform a transinusal access. The wisdom extraction was scheduled in an ambulatory setting and under local anesthesia. Prior to surgical treatment, the patient’s mouth was rinsed with a chlorhexidine 0.2% digluconate solution  for 2 min. The local anesthesia was performend by the administration of Articaineaxillary ,12. A wiThe tooth was observed in the posterolateral aspect of the maxillary sinus, no bone was present around the dental crown and no pericoronal lesion was detected. The maxillary sinus was entered through the Schneiderian membrane and the tooth was dislocated with a lever and then grasped with a klemmer and removed.The maxillary sinus window was covered by pericardium membrane  . The flaScreening of the articles was performed in accordance to the Standards for Reporting Qualitative Research principles (SRQR) and the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) guidelines. The search strategy was conducted on a keywords search strategy as described in The criteria necessary for inclusion in the qualitative synthesis were limited to human clinical trials, prospective and retrospective studies with a minimum follow up of 1 month with no restriction of surgical technique, alternative medical approach, post-operative sequelae, and number of protocol stages. The exclusion criteria were systematic and literature reviews, letters to the editor, and in vitro and laboratory simulation. The articles written in non-English language were eliminated from the assessment.The eligibility assessment was conducted independently by two expert reviewers . Also, a manual search was conducted to increase the article pool for the full-text assessment. The articles written in English that satisfied the inclusion criteria were considered while the duplicates and the articles excluded were categorized reporting the exclusion reasons.The data of the articles was evaluated independently by the reviewers using a special designed electronic form according to the following categories: study model design, patient’s age, major symptoms, neoplasms or associated neoformations, treatment protocol, surgical technique, post-operative sequelae, position of the teeth, number of subjects and study findings . The perThe manuscript screening and eligibility, as presented in The review selection included a total of 6 case series and 28 case reports for a total of 78 patients, 81 cases and 3 bilateral. The patients’ ages were between 8 years old and 61 years old. No clinical trial/randomized clinical trial related to the review search topic were identified. A total of 12 papers reported asymptomatic cases ,17,18,19Very few information has been detected concerning the peri-operative antibiotics and analgesic protocols in the included studies. An heterogeneous antibiotics prophylaxis administration was reported while the most common were amoxicillin ,46, amoxIn the present case report we describe the clinical characteristics of a patient with a wisdom tooth in the maxillary above the second molar that which caused chronic pain. Maxillary third molar extraction is a frequent surgical intervention in oral and maxillofacial surgery. As also evinced by the review of the literature, in this particular case the clinical presentation of the ectopic tooth was very rare and associated to the postero-lateral wall of the maxilla. In fact, the rationale of the present investigation was to contextualize the literature recurrency of this particular clinical condition and support a transinusal approach for impacted upper third molar. Many factors can influence ectopic tooth, including trauma presence of benign or malignant lesions including rhinogenic and odontogenic infections or iatrogenic activity ,49. The In conclusions, the ectopic teeth localization could deeply influence the clinical manifestation, symptoms and the surgical approach to reduce the post-operative morbidity and complications sequelae. In order provide a useful guidance for surgeons and dentists for the management of ectopic wisdom in clinical practice, the transinusal pathway approach combined with the antibiotic prophylaxis and corticosteroid administration could reduce the post-operative symptoms reducing the face edema and accelerate the recovery period.


The differential diagnosis between cholangiocarcinoma and groove pancreatitis is quite challenging. Groove pancreatitis is commonly misdiagnosed as periampullary tumors. We reported a case of distal extrahepatic cholangiocarcinoma mimicking groove pancreatitis.A 57-year-old male patient was transferred to our hospital after endoscopic retrograde cholangiopancreatography (ERCP) with stent placement in the common bile duct due to obstructive jaundice at a local hospital. Groove pancreatitis was considered based on the clinical manifestations and multiple examinations . The patient’s symptoms and laboratory results almost returned to normal after conservative treatments. Interestingly, his symptoms and laboratory results worsened after the stent was removed. We performed a second EUS process and found a lesion in the lower common bile duct. Finally, the patient underwent pancreatoduodenectomy, and the diagnosis was confirmed as moderately differentiated adenocarcinoma of the common bile duct.Our case highlights the fact that distal extrahepatic cholangiocarcinoma, which is a malignant disease, can mimic a benign condition like groove pancreatitis. Our case also raises the concern that performing stent placement through ERCP to relieve jaundice without a clear diagnosis could interfere with further evaluation of the disease. Cholangiocarcinoma (CCA) is a relatively rare malignant disease that originates from the epithelium of bile ducts. Jaundice and abdominal pain are the most frequent symptoms. Groove pancreatitis is an uncommon form of chronic pancreatitis involving the area between the pancreatic head, duodenum, and common bile duct. The symptoms mainly include chronic abdominal pain, vomiting, and weight loss. Due to the specific pathogenic site, groove pancreatitis poses diagnostic challenges and should be differentiated from other periampullary diseases mainly including pancreatic and biliary carcinomas . PublishA 57-year-old man who suffered from upper abdominal pain for over 1 year and worsening for 2 months was admitted to a local hospital initially. He had progressive xanthoderma and lost 4 kg of weight in 2 months. This patient had a previous history of recurrent duodenal ulcer and alcohol abuse for over 30 years. Physical examination suggested right-upper abdominal pain and jaundice. The laboratory results of the local hospital showed a significant increase in the serum levels of carbohydrate antigen 19-9 , total bilirubin , γ-glutamyl transpeptidase , alkaline phosphatase , alanine aminotransferase , and aspartate aminotransferase . A rough patch of mucosa was found in the descending duodenal region through gastroscopy, and the following biopsy suggested chronic inflammation. In order to relieve the symptoms of jaundice, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent deployment in the common bile duct at a local hospital.He was transferred to our hospital for further evaluation and treatment. All the clinical indicators of laboratory results were better on his admission compared to the results before stent deployment . Unexpectedly, symptoms of upper abdominal pain recurred, and the results of laboratory investigations worsened after the stent was removed. Then he underwent the second EUS examination through which a lesion in the lower common bile duct was confirmed , could provide access to targeted lesions for cytology samples. However, brushings alone may result in low diagnostic yield due to a limited number of cells (in situ hybridization (FISH) combined with brush cytology could raise the sensitivity (35%–60%) (vs 49%)  , 20. EUS(vs 49%) . However(vs 49%) . These mvs 90%)  . Althougvs 90%) . HoweverGroove pancreatitis is a rare form of chronic pancreatitis. Most patients are male with a history of alcohol addiction. Obstructive jaundice could be observed in a large number of patients with alcohol addiction and stenotic common bile duct . ImagingOur case highlights the fact that distal extrahepatic cholangiocarcinoma, which is a malignant disease with a poor prognosis, can mimic a benign condition like groove pancreatitis. The differential diagnosis between dCCA and groove pancreatitis is challenging but important for subsequent treatments. Our case also raises the concern that performing stent placement through ERCP to relieve jaundice without a clear diagnosis could interfere with further evaluation of the disease. Hence, clinicians should consider comprehensively in terms of the hard diagnosis of ampullary diseases.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.This study was reviewed and approved by Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology. The patients/participants provided their written informed consent to participate in this study.CH and XL performed the literature search, data extraction, and drafting of the manuscript. LS helped with data collection. MY provided pathologic findings. RL and ZD designed the study and edited the manuscript as the corresponding authors. All authors contributed to the article and approved the submitted version.This study was supported in part by the National Natural Science Foundation of China .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.


ABC  is a rare, benign and osteolytic lesion. Diagnosis of ABC can be challenging because of its uncommon radiographic and clinical presentation. The case of an 8-year-old female with a rapidly growing painful swelling in her left mandible is presented. Incisional biopsy showed an aneurysmal bone cyst. Surgical curettage and en bloc surgical excision are the main choices of treatment. We report embolization technique as a complement treatment for surgical curettage with accurate zone control lessening the extent of operation and surgical complications. Key words:Aneurysmal bone cyst, embolization, mandible. ABC is defined as a non-neoplastic lesion of the bone characterized by replacement with fibro-osseous tissue containing blood-filled sinusoidal spaces . The terA case of ABC in an 8-year-old female is presented. Consults for a two month-old rapidly growing painful swelling of the left mandible. No significant medical history, apart from mother’s Chagas disease nor history of trauma. Physical examination shows an intraoral mass in body and angle of the left mandible of about 5cm causing regional tooth displacement Figs. -3. No paAs this ABC was classified as a vascular type lesion, prior to definitive curettage of the lesion, a vascular map of the feeding vessels was obtained and supraselective catheterizations with the following embolization with Embosphere® 300-500 microns (Tris-acryl microspheres) is performed Fig. D. EmboliThe term ABC was introduced by Jaffe and Lichtenstein in 1942. BernierCraniofacial skeleton is a rare presentation site however the mandible, particularly retromolar area, as in the case presented Fig. , is moreRadiographic characteristics are not pathognomonic and definite radiographic diagnostic criteria should be established for future studies. The lesion morphology varies and can become very large >10cm) . They ma0cm . TheThe gold standard treatment for ABCs is open surgical curettage of the lesion. Nevertheless, therapeutic options will depend on the size, position, patient age and the pathology’s extension. In adults and in very bulky lesions to perform subperiostal resection it is not technically viable. It is posible in children like in the case we are analyzing. The remaining periosteum will contribute to good bone consolidaton. Other treatments are described such as: sclerotherapy, en bloc resection or primary therapeutic embolization. Radiotherapy is not recommended because of the probability of radiation-induced sarcoma and its high failure rate ,3,7.Massive bleeding is the main complication throughout surgical curettage especially in vascular type lesions, like the one we are studying. Selective arterial embolization is indicated in the treatment of ABC, especially in these patients at high risk of extensive intraoperative bleeding.et al.  ,5,7 was Benefits from embolization in the reported case include: a) decrease blood supply to limit intraoperative blood loss and the need for multiple blood transfusions; b) achieve bloodless surgical field which allows complete removal of the lesion reducing recurrence c) decrease surgical time. Recurrence rate after curettage in the jaws vary widely in literature, from 0 to 53% No recurMassive hemorraghe in need of ligation of the external carotid artery has also been described in order to diminish bleeding risk . In our Articles from the literature where evaluated showing different forms of embolization of ABC localized in the appendicular skeleton ,5. To ouIn conclusion, the present case shows a primary ABC affecting a child where aggresive surgery has been avoided by the use of embolization prior to mandibular surgical curettage. Either percutaneous or selective arterial lesion embolization, seem a useful procedure to improve surgical outcomes as it avoids intra-operative bleeding.


Hysterectomy is one of the most common non-obstetric gynecological surgical procedures carried out in Western countries . In the The surgical approach to performing hysterectomy include abdominal, vaginal, traditional laparoscopic, robot-assisted laparoscopic, single-port laparoscopic/robotic surgery, and vaginal natural orifice transluminal endoscopic surgery (vNOTES) ,10. The The use of MIS techniques has increased for the treatment of gynecological cancers too, particularly for early-stage cervical cancer (ECC) . The utiDespite the high diffusion of the minimally invasive approach, abdominal hysterectomy remains a very common surgical intervention. The knowledge of this surgical intervention is essential for new generations of gynecologists. The most common indications for the abdominal hysterectomy are large uterine size, previous abdominal surgeries, severe endometriosis and adhesions history. However, there are no specific indications for uterine weight or size and abdominal hysterectomy, and studies show that minimally invasive techniques, such as laparoscopy, can safely remove large uteri too ,26.There are also obstetric indications for abdominal hysterectomy, in most cases in an emergency regime: severe postpartum hemorrhage (PPH)/atony refractory to pharmacological treatments, placenta accrete spectrum disorders (PAS), hypertensive disorders, disseminated intravascular coagulation (DIC) . NonetheHysterectomy is a surgical procedure with potential surgical complications, with the highest rate within 30 days: infectious consequences, hemorrhage, thromboembolic disease, urinary and/or intestinal tract injury, nerve injury and vaginal cuff dehiscence . The comHysterectomy can be a difficult choice for women, with sexual and psychological changes that may led to a non-negligible risk of post-traumatic stress . Therefo


Oesophageal resection is a challenging procedure, and it is more so in patients who have undergone bariatric procedures, especially after laparoscopic sleeve gastrectomy. We present the case of a patient with a history of an laparoscopic sleeve gastrectomy who underwent a hybrid Ivor-Lewis oesophagectomy in which the sleeve was successfully used to reconstruct the upper gastrointestinal tract. A 56-year-old man presented with a 6-cm Siewert I poorly differentiated oesophageal adenocarcinoma, staged as cT3N2M0. A 56-year-old man presented with a 6-cm Siewert I poorly differentiated oesophageal adenocarcinoma, staged as cT3N2M0. He lost 20% of his body weight, which was 88 kg on admission. His medical history was significant for a laparoscopic sleeve gastrectomy (LSG) 7 years ago, severe symptomatic diverticulosis of the descending and sigmoid colon, and a giant sigmoid diverticulum.Following neoadjuvant therapy , partial downstaging was achieved. The oesophageal mass could not be detected, and only 2 lymph nodes showed decreased, yet persistent, fluorodeoxyglucose (FDG) uptake Fig. . The opeThe patient underwent a hybrid Ivor-Lewis oesophagectomy (Video 1). We used a 5-port approach. After freeing the gastric sleeve from previous adhesions, the left gastric vessels were divided. The length of the stomach seemed appropriate for reconstruction. The stomach was divided 4–5 cm distal to the gastro-oesophageal junction and sent for frozen section analysis, the results of which were negative. As the stomach, now based on the right gastric vessels, seemed well perfused on gross inspection, a decision was made to use it as a conduit. A feeding jejunostomy was fashioned, and dissection of the distal oesophagus was carried out via 4-port right video-assisted thoracoscopy. The oesophagus was circumferentially dissected up to the level of the azygos vein, and the gastric conduit was brought into the thoracic cavity. The stomach safely reached above the tumour, ensuring clear proximal margins. The oesophagus was transected 3 cm distal to the azygos vein. A gastrotomy was performed, but the shaft of the circular stapler could not be safely delivered. A mini-thoracotomy was performed, and an end-to-side anastomosis was performed using a 25-mm EEA OrVil stapler . The patient had an uneventful postoperative course and was discharged on postoperative day 9.The final pathological report was consistent with ypT2N3(11/16)M0 adenocarcinoma because only a few tumour cells were identified in the muscularis. Lower mediastinal and coeliac nodes were positive. All upper mediastinal level 7 and 8 nodes were negative.et al. [Patients who have had a sleeve gastrectomy pose a challenge during oesophagectomy, because the greater curvature is resected during the index procedure. Reconstruction options include the colon and the jejunum. Only 2 cases have been reported in which the gastric sleeve was used for reconstruction. Pallabazzer et al.  reportedThe second case was that of a 61-year-old man , 4 yearsThe greater curvature of the stomach provides ample length for reconstruction. The length of the sleeve conduit is less predictable. In the case presented here, no Kocherization was performed to minimize injury risk to the conduit vascular supply, which reached the level of the carina. Because this was a Siewert I tumour, an intraoperative evaluation was performed to assess the conduit length. At least 10–12 cm of conduit could reach the hiatus, ensuring adequate proximal resection margins. Among patients who underwent LSG, the stomach could safely be used for reconstruction in tumours of the distal oesophagus and the gastro-oesophageal junction. It may not be applicable in patients with mid-oesophagus tumours, because a standard Ivor-Lewis oesophagectomy with a high mediastinal anastomosis may not always be possible, as in this case. Another limitation to this approach, even when adequate margins are achieved, is a somewhat limited lymphadenectomy, especially in the upper mediastinum and along the lesser curvature.The other concern among patients who underwent an LSG is conduit perfusion. This, however, might not be an issue, mainly due to the interval from the bariatric procedure, which may provide ischaemic conditioning to the stomach. Laparoscopic ischaemic conditioning with division of the left gastric vessels prior to oesophagectomy has been proposed to allow neovascularization of the conduit  and decrAmong patients who underwent an LSG, the stomach could safely be used for reconstruction in tumours of the distal oesophagus and the gastro-oesophageal junction. Previous bariatric surgery might contribute to a lower risk of an anastomotic leak because of the ischaemic preconditioning.The authors have no disclosures or conflict of interests.Interactive CardioVascular and Thoracic Surgery thanks Hasan Fevzi Batirel, Olli Helminen and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.


Mucopycocele of the middle turbinate is an uncommon disease. Most mucoceles are situated in the frontal and/or ethmoid sinuses. In this paper we will describe a mucopyocele of the middle turbinate associated with pansinus disease. Mucoceles are mucous retention cysts without epithelial lining. Pyocele occurs when mucocele becomes infectedEven though it is relatively uncommon, mucopyocele are not rare. Most of them occur in the fronto-ethmoidal complex and expand preferably into the orbit, leading to ocular symptoms. However, middle concha mucopyoceles are rare and the etiology is varied and includes previous nasal surgeries, polyp resection and/oronasal tumors and nasal traumaN. C., 64-year-old Caucasian male patient, resident of Sao Paulo. His main complaint was pain on the left brow region. He reported that 30 days before he had started to feel a pain on the left brow region with conjunctiva hyperemia. He went to the ER and was prescribed an eye drop on the left eye for 4 days. He experienced no improvement, so he went back to the ER complaining of left palpebral edema, diplopia, visual acuity impairment and frontal to left headache.He reported that 40 years before, he had had the same symptoms on the right eye and he was medicated and improved. After that time, he started to present nasal obstruction and intermittent greenish nasal discharge, more on the left, and controlled with clinical approach. He did not report hyaline rhinorrhea, sneezing or nasal pruritus. He reported systemic blood pressure . In the ENT examination, we observed palpebral edema and ptosis on the left with present pupil reflex and left conjunctiva hyperemia.Rhinoscopy: nasal fossa with abundant yellowish rhinorrhea, preventing better visualization of nasal structures; hyperemia and hypertrophy of lower conchae.Oroscopy: no abnormal findings. Otoscopy: no abnormal findings.We ordered complementary exams: nasal and paranasal sinuses CT scan that revealed left frontal, ethmoidal and maxillary sinuses velamentum with expansion of left middle concha and increase in its density, with no destruction of papyraceous lamina . ConsideMucocele is the preferred term for cysts without epithelial layer caused by trauma. When the term is applied for paranasal sinuses mucoceles, it has a different understanding, because almost all mucoceles in this region are real mucous retention cysts with epithelial layer normally caused by obstructionIn the formation of mucoceles there is true bone destruction owing to its expansive character that determines bone reabsorption. In previous studies, Lund et al.Middle concha is a bone plate that is placed inferior-medially to the complex of ethmoid air cells and runs along its anterior limit, and it may be aired . The first description of bullous concha was made in 1893 by ZuckerlandlIn the present case, the patient presented chronic rhinosinusitis for many years, and had been clinically treated, but we do not know if appropriately. We then decided for surgery, in which we performed opening of middle concha with drainage of purulent material and resection of meatal aspect, followed by opening of drainage ostium of impaired paranasal sinuses. The patient presented significant improvement at early postoperative care, with complete resolution of the clinical manifestations on postoperative day 7.CT scan and MRI (Magnetic Resonance Imaging) support the diagnosis because they are high resolution exams, allowing differential diagnosis with cysts, expansive masses, erosive lesions, secretion, benign tumors . In this case, paranasal sinuses CT scan allowed the distinction between damage and paranasal sinuses secretion. CT scan showed that apparently it was a nonvascularized lesion, without brain impairment and located on the left middle meatus . DespiteEven though middle concha mucopyocele is an infrequent entity, it should be part of the differential diagnosis in cases of rhinosinusopathy with dissatisfactory resolution and in intranasal masses and tumors. Paranasal sinuses CT scans are very important for the diagnosis and in some cases, MRI with gadolinium contrast is also recommended to reach better delineation of the lesion and to distinguish expansive processes of the nose, paranasal sinuses or even cerebral lesions. After confirmation of the diagnosis, endoscopic surgical treatment produces very satisfactory outcomes. In the presence of concomitant paranasal sinuses diseases, such cases should also be surgically treated.


Carotid body tumours (CBT), also called carotid paragangliomas, are highly vascular glomus tumours that originate from paraganglionic cells of the carotid body. They are frequently asymptomatic, insidious, and non-secretory in nature. They typically present as a large, non-tender, pulsatile neck mass. Careful evaluation of a neck mass, with the aid of imaging, is necessary to avoid a misdiagnosis. We herein describe a case of a 77-year-old gentleman with a background of chronic B-cell lymphocytic leukaemia, who was found to have a rapidly enlarging, asymptomatic neck mass along with multiple enlarged lymph nodes in the axillae. Given his past medical history, the preliminary diagnosis was Richter’s transformation. However, the characteristic splaying of the internal and external carotid arteries on imaging prompted us to consider the diagnosis of a CBT. The patient was referred to vascular surgeons for surgical excision of the tumour. Histology confirmed that the neck mass was indeed a CBT. Ultrasound-guided core biopsy of the axillary lymph nodes revealed a concomitant Hodgkin-like Richter’s transformation. This case exemplifies how we were able to differentiate between a CBT and nodal mass with the aid of various imaging modalities. An accurate diagnosis allows clinicians to deliver the appropriate management; the treatment for CBT is surgical excision, whereas chemotherapy is the first-line treatment for Richter’s transformation. Carotid body tumours (CBT), also called carotid paragangliomas, are highly vascular glomus tumours that originate from paraganglionic cells of the carotid body . They arA 77-year-old Caucasian gentleman, with a history of B-cell chronic lymphocytic leukaemia (CLL), had a whole-body computed tomography (CT) scan prior to commencing chemotherapy. The CT scan showed a large, 2.24 cm lymph node located at the bifurcation of the right CCA with no other supraclavicular lymphadenopathy Figure .Additionally, there was an enlarged right axillary lymph node measuring 1.2 cm in diameter , the patient was clinically asymptomatic except for a visible, mobile neck swelling noted on the right side with horizontal mobility and restricted vertical mobility (Fontaine sign). The neck swelling had reportedly over a period of 2-3 weeks. A rapidly enlarging lymph node on a background of B-cell CLL was suggestive of Richter’s transformation. Following a discussion in a multidisciplinary team (MDT) meeting, the consensus was to proceed with an ultrasound scan (USS) with possible fine-needle aspiration cytology (FNAC). The USS of the axillae showed a few abnormal, hypoechoic lymph nodes within the right lower axilla. It demonstrated loss of central fatty hilum and central vascularity. The short-axis diameter of the largest lymph node within the right axilla measured 12 mm Figure . In addiA USS of the neck demonstrated an oval, heterogeneously hypoechoic, and highly vascular lesion at the right CCA bifurcation. It measured approximately 25 x 20 mm  CT scan confirmed the diagnosis of a CBT with a very intense uptake seen within the soft-tissue abnormality at the right CCA bifurcation, measuring approximately 2.2 cm x 2.5 cm. The maximum standardised uptake value (SUV max) was 29.3 and the Deauville score was 5 Figure . No otheA USS-guided core biopsy of the pathologically enlarged right axillary lymph node was performed. The histology confirmed Hodgkin-like Richter’s transformation. Subsequently, the patient was referred for chemotherapy.CBT, also called chemodectomas or carotid body paragangliomas, are slow-growing and highly vascular glomus tumours that arise from paraganglionic cells of the carotid body . They arRichter’s transformation is a term that describes the progression of chronic B-cell lymphocytic leukaemia (CLL) into an aggressive or high-grade non-Hodgkin’s lymphoma (NHL). It reportedly occurs in approximately 5-10% of patients with CLL. Patients usually present with rapidly enlarging lymph nodes, hepatosplenomegaly, and/or elevated serum lactate dehydrogenase (LDH) levels. Non-specific systemic signs include weight loss, night sweats, and fever. Abdominal pain is usually due to an enlarged liver and/or spleen . The nodA non-secretory CBT usually presents as a non-tender, pulsatile neck mass, which is insidious in nature. Patients are usually asymptomatic. It is typically located anterior to the sternocleidomastoid muscle, near the angle of the mandible, and at the level of the hyoid bone . When paIn this particular case, the patient had a known diagnosis of chronic B-cell lymphocytic leukaemia. A CT scan identified a rapidly enlarging, asymptomatic lesion in the neck along with multiple enlarged lymph nodes in the axillae. Given his past medical history, the initial impression was Richter’s transformation. However, a PET-CT scan and the characteristic splaying of the internal and external carotid arteries prompted us to reconsider the diagnosis. Eventually, the diagnosis of CBT or paraganglioma was confirmed on histology. US-guided core biopsy of the pathologically enlarged right axillary lymph node confirmed a concomitant Hodgkin-like Richter’s transformation. Therefore, this case exemplifies how we can use various imaging modalities to help differentiate between a CBT and a pathologically enlarged lymph node or nodal mass. This case highlights the importance of doing so, since the management of these two entities differs; a CBT is usually surgically resected, whereas chemotherapy is the first line of treatment for Richter’s transformation.A contrast-enhanced CT scan characteristically shows a well-defined, rapidly enhancing lesion, causing splaying of the internal and external carotid arteries (Lyre sign). Heterogenous enhancement with contrast is suggestive of haemorrhage within the tumour . On the The choice of treatment for CBT is determined by several factors, including its location, the spread of the tumour, the patient’s age, and comorbidities. CBT are usually surgically resected and have a favourable prognosis ,11,14. IIn the case described above, the patient had a history of chronic B-cell lymphocytic leukaemia and was noted to have an enlarged, asymptomatic neck pass on a CT scan. It was initially misdiagnosed as a malignant cervical lymph node. However, with the aid of imaging and histology, the diagnosis of a CBT or carotid paraganglioma could be established. This is a unique case, in which the patient was also noted to have a pathologically enlarged right axillary lymph node. A USS-guided core biopsy revealed a concomitant diagnosis of a Hodgkin-like Richter’s transformation. Therefore, this case exemplifies how we can use various imaging modalities to help differentiate between a CBT and a pathologically enlarged lymph node or nodal mass. This case highlights the importance of doing so, since the management of these two entities differs; a CBT is usually surgically resected, whereas chemotherapy is the first line of treatment for Richter’s transformation.


BackgroundColonic duplication may present in different anatomic variants. The surgical approach towards these anomalies can be challenging and has implications for subsequent future continence.Case Description We report on a 1-year-old girl with congenital heart defect and pacemaker who was referred to us with an anorectal malformation. The patient was stooling from both an anus and a perineal fistula. Examination under anesthesia revealed an orthotopic and age-appropriate sized anus with surrounding sphincter and a second rectal lumen ending as a perineal fistula. A computed tomography and contrast enema indicated colonic duplication. Exploratory laparotomy showed a duplicated terminal ileum leading to two ceca and appendices, which joined to a duplicated colon with a septum and common mesentery. At the rectosigmoid junction, one part of the duplication ended as a perineal fistula, the second one led to the (orthotope) anus. The common colonic wall was divided using a stapler. The rectal duplication leading to the perineal fistula was not completely resected but treated by mucosectomy only (Soave plane) leaving its muscular cuff in place. Finally, an ileostomy was created. The postoperative course was uneventful. A contrast enema prior to ostomy takedown demonstrated a well-configurated colon and rectum without stenosis or impaction. The girl is currently continent with a complete resolution of her constipation.Conclusion In cases of complete colonic duplication division of the common wall is simple and safe. Mucosectomy of the ectopic rectum limits pelvic dissection and preserves the entire muscular wall of the duplicated orthotope rectum. Duplications of the alimentary tract are rare congenital malformations that can occur in any part of the gastrointestinal tract. Duplications mostly affect the esophagus and ileum with only 4 to 18% involving the colon.A 1-year-old girl with congenital heart defect and pacemaker was referred to our institution with severe constipation and a suspected anorectal malformation.The child was born via cesarian section at 36 1/7 gestational age  at an outside hospital. Postnatal examination revealed an orthotopic anus with a perineal fistula and passage of meconium via both orifices. The sacrum was normal to palpation. Ultrasound excluded tethered cord and a renal pathology. Due to low oxygen saturations between 90 and 95%, an echocardiography revealed complete atrioventricular septal defect. Chromosome analysis was normal.At the age of 4 months, the girl underwent cardiac surgery followed by insertion of a pacemaker 1 month later. On examination under anesthesia after 3 months both the orthotopic rectum and the perineal fistula could be intubated with Hegar dilatators without connection of the two orifices.The child was referred to our department at the age of 13 months because of the congenital anomaly with severe constipation. Examination under anesthesia and electrostimulation confirmed an orthotopic and age-appropriate sized anus with surrounding sphincter and a perineal fistula . The fiCongenital duplications of the alimentary tract are rare anomalies with a reported incidence of approximately 1 in 4,500 live births.Duplications of the large bowel constitute approximately 13% of all duplications and are divided into two subgroups, including cystic and tubular duplications. The duplicated segment may be present on the mesenteric or antimesenteric side of the colon, sharing vascular blood supply and a common wall with the intestine, although each has its own mucosal lining. Symptoms and clinical presentation may depend on the location and size of the lesion, including intestinal bleeding, abdominal pain, and vomiting, or it may be an incidental finding on physical examination.The patient in our case report was initially suspected to have an anorectal malformation and presented with an orthotopic anus and perineal fistula passing meconium from both orifices. However, when an examination under anesthesia was performed the fistula could be intubated with a Hegar dilator size 6. To define the preoperative anatomy a CT, which was chosen due to the cardiac pacemaker, and contrast enema were conducted showing colonic duplication.Alimentary tract duplications may represent a diagnostic challenge as their clinical and anatomical presentation can be variable requiring selective radiologic imaging studies to determine the precise anatomy.The present combination of an anorectal malformation with complete duplication of the colon and rectum is uncommon with only few case series or reports being available in the literature. Jellali et al presented a case series of three patients with anorectal malformation and complete tubular colonic duplication. In all patients the anorectal malformation was discovered at birth, whereas the colonic duplication was found during creation of colostomy preceding the pull-through procedure.Several surgical approaches have been described in the management of long segment colonic duplication with shared blood supply. We performed an exploratory laparotomy which revealed a long segment of duplicated colon including the terminal ileum with two ceca and appendices, which joined to a completely duplicated colon with one septum and common mesentery. The common colonic wall was simply divided using a stapling device as successfully described in previous case reports.Division of the common wall of the duplicated rectum and resection of the fistula can be challenging and may require an extensive pelvic dissection potentially violating healthy tissue. On the other hand, leaving a small blind pouch of rectum may result in fecal impaction, constipation, or a recurrent fistula.The majority of case reports have shown excellent functional outcomes in terms of regular bowel movements and also satisfying cosmetic results following surgery for colonic duplication. Only few authors have described postoperative complications, including reoperation for incomplete division of the distal rectal septum and death due to ongoing sepsis.We report on a 1-year-old girl with a very rare association of complete colorectal duplication with perineal fistula. Preoperative diagnosis was made by examination under anesthesia, CT, and contrast enema. For the management of colonic duplication, a single lumen was created by simple division of the common wall, followed by mucosectomy of the distal ectopic rectum.The association of anorectal malformation with complete colonic duplication is rare. Therefore, careful preoperative examination is vital to avoid unexpected findings during surgery. Limited dissection in the submucosal plane preserves the muscular wall of the duplicated orthotopic rectum to ensure normal future continence.


Chronic recurrent multifocal osteomyelitis (CRMO) is an unusual form of non-microbial chronic osteomyelitis. It is an exclusion diagnosis that can only be considered after ruling out infectious osteomyelitis and bone tumors. We report the case of a 13-year-old girl who was admitted for a painful swelling of the left thigh. Biological examinations did not find an inflammatory syndrome. X-rays and Magnetic Resonance Imaging were very suggestive of malignant bone tumor. But the biopsy disclosed a nonspecific osteomyelitis. Considering the strong suspicion of a malignant origin, a second biopsy was performed and confirmed the diagnosis of osteomyelitis. During the hospital stay, the patient developed a second location in the left humerus. Thus, the diagnosis of CRMO was retained. The patient was treated by NSAIDs with good clinical and radiological outcomes. This case report reminds the diagnostic challenge of this pathology that can mimic malignant tumor. It affects mainly children and adolescents and especially females. It is often considered as the juvenile form of the SAPHO syndrome  [Chronic recurrent multifocal osteomyelitis (CRMO) is an unusual form of non-microbial chronic osteomyelitis. It was initially described by Giedion steitis) . Chronicsteitis) . We repoA 13-year-old girl was admitted in our department with painful swelling of the left thigh evolving for 3 months, without other symptoms. Physical examination found a hard and painful swelling of the distal part of the left thigh with knee stifness. The laboratory tests did not find an inflammatory syndrome. X-ray revealed a moth-eaten osteolysis in the distal metaphysis of the left femur, extending to the epiphysis and the diaphysis, with a Codman triangle type periosteal reaction and edema of the surrounding soft tissues . Based oChronic recurrent multifocal osteomyelitis is an aseptic bone inflammatory disease that affects the pediatric population, mainly girls . It usually occurs between the ages of 2 and 17 years old . The diaThe role of the biopsy is still debated. In fact, the histological features are not specific, but it is very important to exclude all other causes of bone pain such as infectious osteomyelitis or, like in our case, a malignant bone tumor ,11. SomeWe reported the case of a girl with CRMO presenting with a confusing radiological appearance simulating a malignant bone tumor. The histological study and the multifocal character were essential to reach the diagnosis. This case report reminds the diagnosis difficulties of this still poorly known entity that can mimic malignant bone tumors.


Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor primarily involving the lower genital tract of reproductive females. It often shares pathologic morphology with other mesenchymal lesions, which result in diagnostic difficulties for pathologists.We described the case of a 32-year-old female presenting with a pelvic mass. Imaging examination showed a “swirling sign” within the mass. The mass was 10.2 × 10 × 7.7 cm, located in the right front of the uterus, with unclear demarcation from the surrounding organs and tissues. The gross appearance was grayish brown with a solid section and a myxedematous cut surface. Microscopically, it was a mesenchymal tumor with a presence of perivascular smooth muscle fibers radiating from the blood vessel and an infiltrative growth pattern. The pelvic AAM was diagnosed based on clinicopathologic and imaging features.A surgery with local excision of the mass was performed. The patient experienced 1 relapse during 2-year follow-up and underwent the radiation therapy.When the pathological morphology of AAM overlaps with other mesenchymal lesions, the comprehensive understanding of tumor clinicopathological characteristics combined with imaging features is important for the accurate diagnosis of AAM. The clinicopathological features of AAM partially overlap with other mesenchymal lesions, leading to diagnostic difficulties for pathologists.–4 In the present case, the morphological features overlap with those of angiomyofibroblastoma (AMF). Our report highlights the importance of the clinicopathological and imaging features in the diagnosis of AAM.Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor that primarily involves the female lower genital tract during reproductive period, with the characteristics of local infiltration, local recurrence and distant metastasis.In March 2020, a 32-year-old woman presented to our hospital with a pelvic mass on routine ultrasound examination. By enhanced computed tomography and enhanced magnetic resonance imaging, the mass size was 10.2 × 10 × 7.7 cm, located in the right front of the uterus, with unclear demarcation from the right vaginal wall, right levator ani muscle and obturator muscles. A “swirling” characteristic was observed within the mass , progesterone receptor (PR), desmin, vimentin and CD99, focally positive for CD34 and B-cell leukemia/lymphoma 2 gene, and negative for S-100, murine double minute 2, P53, signal transducer and activator of transcription 6, epithelial membrane antigen, inhibin, calretenin, human melanoma black 45, CD10 and H-caldesmon. Smooth muscle actin (SMA) was positive for the smooth muscle differentiated cell bundles around blood vessels but negative for the muscular layer of blood vessels , which suggest that hormones may manipulate the occurrence and/or development of AAM. Patients often present with a mass, with or without compressive symptoms and the manifestations are not specific.At present, the clinical characteristics of AAM have been well documented. AAM mainly involves the lower genital tract of reproductive women, with a peak incidence in the fourth decade of life. The ratio of male to female is 1:6.6. prevent the recurrence of the tumor and also treat the residual and/or recurrent tumor.–15 The reported recurrence rate varied from 35% to 72% and the relapse usually occurred in the first 5 years after surgery. The longest recurrence time reported in the literature is 20 years. There are even reports of lung metastasis,18 and death in patients. Therefore, patients need long-term follow-up after operation.Surgical resection is the main treatment for AAM, and gonadotropin releasing hormone agonists have also been used as adjuvant treatment. Gonadotropin releasing hormone agonists can reduce the tumor volume before operation,,20 The tumor cells had variable expressions of vimentin, desmin, CD34, SMA, ER and PR, but these markers are not specific for the pathological diagnosis of AAM.The formulation and implementation of an effective therapeutic schedule for AAM patients are based on the accurate pathological diagnosis of the mass. However, the pathological morphology of AAM may resemble that of other mesenchymal lesions, leading to diagnostic difficulties for pathologists. The mass of AAM described in the literature is usually deep and typically poorly demarcated, ranging from 1 to 60 cm in diameter. Microscopically, the tumor is composed of myxoid stroma interspersed with numerous blood vessels of different calibers and types. The tumor cells are sparsely and uniformly distributed, with spindle and/or stellate shapes, without mitotic activity and nuclear atypia. Delicate smooth muscle bundles are often seen adjacent to blood vessels, which are considered a characteristic feature of AAM.In the present case, the mass was located in the pelvis, showing a grayish brown appearance and a myxedematous cut surface. The microscopic feature was characterized by the presence of perivascular smooth muscle fibers radiating from the blood vessel and the infiltrative growth pattern. These findings were consistent with those reported in previous literature. However, the microscopic appearance was of some interest beyond those described in the literature. The tumor cells showed areas of hypocellularity and hypercellularity with oval- and spindle-shaped nuclei, pale and/or eosinophilic cytoplasm, overlapping with AMF. Therefore, the distinction between AAM and AMF is the focus of pathological diagnosis. and a characteristic “whirlpool sign” within the mass is considered to be a distinctive diagnostic feature of AAM. In our case, the mass extended into perineum and there was a characteristic “whirling sign” within the mass. These imaging features were consistent with AAM but not AMF. Finally, the tumor was diagnosed as AAM.In contrast to AAM, AMF usually involves the vulva, and the mass is usually less than 5 cm in diameter. Microscopically, AMF has a well-defined boundary, and the typical feature of AMF is plump spindled- and epithelioid-appearing cells arranged in corded and nested patterns and commonly concentrated around blood vessels. In our case, the mass was located in the pelvis, infiltrating the surrounding adipose tissue. Furthermore, smooth muscle bundles, as a pathological diagnostic feature of AAM, were seen adjacent to blood vessels. These clinicopathologic features were consistent with that AAM rather than AMF. Additionally, a large pelvic mass with abdominal/perineal extension in reproductive age female patient should lead to suspicion of AAM,In addition to AMF, AAM also needs to be differentiated from other mesenchymal lesions that occur in the lower genital tract, including fibroepithelial stromal polyp, cellular angiofibroma, superficial cervicovaginal myofibroblastoma, and superficial angiomyxoma. The clinical and pathological features of mesenchymal lesions in the female lower genital tract are summarized in Table In conclusion, AAM is a rare mesenchymal tumor characterized by local infiltration, recurrence, distant metastasis and even death. Patients with AAM need long-term follow-up after surgery. AAM may share histological features with other mesenchymal lesions, resulting in diagnostic difficulties for pathologists. A comprehensive understanding of tumor clinicopathological characteristics combined with imaging features is important for the accurate diagnosis of AAM.Conceptualization: Qiong Wang.Data curation: Xue-Mei Lin, Li Wang, Qiong Wang.Formal analysis: Xue-Mei Lin, Qiong Wang.Investigation: Xue-Mei Lin, Li Wang.Methodology: Xue-Mei Lin, Li Wang.Project administration: Qiong Wang.Supervision: Qiong Wang.Writing – original draft: Xue-Mei Lin.Writing – review & editing: Xue-Mei Lin, Li Wang, Qiong Wang.


Malignant primary lymphoma represents only 1%–5% of all gastric tumours. Spontaneous gastric perforation in the absence of chemotherapy in these cases is extremely rare. The vast majority of primary gastric lymphomas have a B-cell phenotype that originates from mucosa-associated lymphoid tissue and primary gastric lymphomas with a T-cell phenotype are rarely reported. This report describes a case of a primary gastric T-cell malignant lymphoma associated to spontaneous perforation and peritonitis.An 80-year-old woman referring 24 hours of abdominal pain associated to cognitive impairment consulted to our Emergency Department. Her past medical history revealed smoking, hypothyroidism, dilated cardiomyopathy, hypertension, celiac disease with poor adherence to gluten-free diet and a Non-Hodgkin T cell lymphoma associated to enteropathy in 2010. At physical examination, she presented with tachycardia, hypotension and abdominal tenderness. Lab test revealed low red cell count and an abdomen computed tomography scan showed pneumoperitoneum secondary to a large gastric perforation located in the anterior wall of the antrum. Urgent surgery was performed. At exploratory laparoscopy, a 5 cm perforation of the anterior wall of prepyloric antrum was observed associated to a 4-quadrant peritonitis. Conversion to open surgery was decided to perform an open antrectomy and Billroth II gastro-jejunostomy. The patient was transferred to ICU after surgery under mechanical respiratory assistance for closed monitoring but evolved with a cardiogenic shock and deceased on the first postoperative day. The final histopathological and immunohistochemical analysis reported enteropathy-associated T-cell lymphoma of gastric localisation with concomitant celiac disease.We present a rare case of a patient with a history of celiac disease who developed a gastric perforation secondary to an enteropathy-associated T-cell lymphoma of gastric localisation. To the best of authors’ knowledge, there have been reported less than 30 cases of spontaneous perforation of gastric lymphoma in the absence of chemotherapy in the last 35 years. Malignant gastric lymphoma, accounting only for 1% of primary gastric malignancies, is usually a diffuse large B-cell lymphoma. Incidence of perforation of gastric lymphomas in patients receiving chemotherapy rounds 0.9%–1.1%. However, it is a rare condition in patients not receiving chemotherapy.This is a rare case of a patient with an enteropathy-associated T-cell lymphoma of gastric localisation, who developed a spontaneous gastric perforation in the absence of chemotherapy. Despite it is a rare condition, it must be suspected in patients with a history of lymphoma in the context of acute abdominal pain. The gastrointestinal tract is the most common extra-nodal site of non-Hodgkin’s lymphoma, accounting for approximately 4%–18% of cases in Western countries. Malignant primary lymphoma represents only 1%–5% of all gastric tumours .Even though the exact incidence and risk of lymphoma in celiac patients is still a debated issue , it is wPerforation of a gastric malignant lymphoma during chemotherapy is a well-known event. However, the incidence is not high, occurring in about 0.9%–1.1% of cases , 8. FurtAn 80-year-old woman consulted to our emergency department presenting abdominal pain of 24 hours of onset associated to cognitive impairment. Her past medical history revealed smoking, hypothyroidism, dilated cardiomyopathy, hypertension, celiac disease with low adherence to gluten-free diet and a Non-Hodgkin T-cell lymphoma associated to enteropathy diagnosed in 2010 secondary to an enterectomy performed in context of an acute abdominal pain at another medical centre. After the resection, the patient underwent chemotherapy .Physical examination evidenced hypotension (90/50 mm Hg), tachycardia, cognitive impairment and abdominal tenderness. Laboratory tests showed only low red blood cell count  with no other abnormalities. Fluid replacement and vital support were initiated with immediate haemodynamic improvement. An abdominal computed tomography (CT) scan was then requested, evidencing pneumoperitoneum and gastric mucosal enhancement with a clear stop in continuity in the greater curvature prior to the antropyloric junction with no other abnormal findings . ImmediaGrossly, the resected specimen showed an ulcerated whitish tumour of 5.6 × 3.8 cm. The lesion involved and perforated the gastric wall with extension into the serosa .The histological sections of material, embedded in paraffin and coloured with haematoxylin and eosin, showed a neoplastic proliferation of diffuse medium to large cells with abundant cytoplasm and round or angulated nuclei, accompanied by a pronounced and polymorphic inflammatory background and extensive areas of necrosis . NeoplasThe immunohistological techniques were carried out on histological sections of 3 microns by means of an automated system in accordance with the manufacturer’s guidelines . Atypical cells showed positivity for CD45, CD3, CD7 and CD8, according with T-Cell lineage. Staining for CD30, CD4, CD5, CD56, anaplastic lymphoma kinase-1 and keratin cocktail (AE1AE3) as well as B-cell differentiation markers  was found to be negative .There was no expression of Epstein–Barr virus latent membrane protein 1.The histopathological and immunohistochemical findings, together with the patient’s medical history, allowed the diagnosis of enteropathy-associated T-cell lymphoma of gastric localisation in a patient with celiac disease.We present a rare case of a patient with a history of celiac disease who developed a gastric perforation secondary to an enteropathy-associated T-cell lymphoma of gastric localisation. To the best of authors’ knowledge, there have been reported less than 30 cases of spontaneous perforation of gastric lymphoma in the absence of chemotherapy in the last 35 years.Helicobacter pylori infection, immunosuppression after solid organ transplantation, celiac disease, inflammatory bowel disease and human immunodeficiency virus infection. Malignant gastric lymphoma, accounting only for 1% of primary gastric malignancies, is usually a diffuse large B-cell lymphoma.Gastrointestinal lymphoma is an uncommon disease but it is the most frequent site of extranodal lymphoma and it is almost exclusively of the non-Hodgkin type. Primary gastrointestinal lymphoma most commonly involves the stomach but can affect any part of the gastrointestinal tract from the oesophagus to the rectum. Risk factors for the development of a gastrointestinal lymphoma include et al [et al [et al [It is relatively well known that malignant gastric perforations often take place during chemotherapy secondary to the weakening of the gastric tissue associated with rapid tumour necrosis, tumour lysis and exuberant granulation . Maisey et al  and Yoshl [et al  reportedl [et al  found thet al [In recent years, the standard treatment for aggressive gastric lymphoma has shifted from surgery to chemotherapy. Despite this, there are some authors like Ohkura et al  who suggThis is a rare case of a patient with an enteropathy-associated T-cell lymphoma of gastric localisation who developed a spontaneous gastric perforation in the absence of chemotherapy. Despite the fact that it is a rare condition, it must be suspected in patients with a history of lymphoma in the context of acute abdominal pain.None declared.The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Drs Joaquin Fernandez-Alberti, Matías Mihura Irribarra, Agustín Rancati, Nicolás Panzardi, Maria Florencia Cora, Daniela Speisky and Daniel Enrique Pirchi. The first draft of the manuscript was written by Joaquín Fernandez-Alberti and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.