Lumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by excessive overgrowth of extradural fat within the lumbar spinal canal. Surgical decompression is commonly performed to treat symptomatic SELs. Fenestration or laminectomy with epidural fat debulking was a routine surgical procedure according to the literature, that may be causing postoperative lumbar instability. In the present study, we presented a brief report of lumbar SEL and introduced another surgical approach.A 55-year-old man complained of severe low back pain and right leg radicular pain for a year, accompanied by neurogenic intermittent claudication. He received a variety of conservative treatments, including non-steroidal anti-inflammatory drugs, acupuncture, and physical therapy. However, his pain did not diminish. Finally, a posterior epidural mass in the dorsal spine extending from the L3 to L5 level, which caused dural sac compression was found on lumbar magnetic resonance imaging. This mass was homogeneously hyperintense in both T1W1 and T2W1 images, suggestive of epidural fat accumulation.Lumbar SEL.The patient underwent lumbar laminectomy, epidural fat debulking, and spinous process-vertebral plate in situ replantations.The patient presented with complete recovery of radiculopathy and low back pain after surgery. Postoperative magnetic resonance imaging showed that the increased adipose tissue disappeared, and the dural sac compression was relieved. A computed tomography scan revealed the lumbar lamina in situ. He was able to walk normally and remained relatively asymptomatic for 12 months after the operation at the last follow-up visit.Lumbar laminotomy and replantation provide an ideal option to treat lumbar SEL because it can achieve sufficient and effective decompression, simultaneously reconstruct the anatomy of the spinal canal, and reduce the risk of iatrogenic lumbar instability. Surgical interventions will be suggested when patients exhibit acute neurological deterioration or when conservative treatment is ineffective. Fenestration or laminectomy with epidural fat debulking is a routine surgical procedure according to the literature,,5 which damages the structure of the posterior spine and affects stability. In the current report, we present a case of lumbar SEL (L3–L5); lamina osteotomy and replantation in situ were performed, and the patient showed significant improvement in neurological symptoms and low back pain postoperatively.Spinal epidural lipomatosis (SEL), a rare space-occupying lesion in the spinal canal, is defined as the diffuse overgrowth of epidural adipose tissue causing spinal canal compression and neurologic deficits.22) presented with a 1-year history of low back pain and right leg radicular pain, with neurogenic intermittent claudication. The patient reported a pain score of 8 on the visual analog scale score (0 = no pain and 10 = extremely painful), and the Oswestry Disability Index was 78%. He denied a history of steroid use and a history of endocrine and metabolic diseases.A 55-year-old man  of the lumbar spine showed a posterior epidural mass in the dorsal spine extending from the L3 to L5 level, causing dural sac compression. This mass was homogeneously hyperintense in both T1W1 and T2W1 images, suggestive of epidural fat accumulation  were exposed, and an effort was made to preserve the facet joint capsule. An ultrasonic bone curette was used to resect the spinous process lamina ligament complex (L3–L5). The epidural adipose tissue was removed, and titanium plates and screws were used for spinous process-vertebral plate in situ replantations .,13,14 Additionally, approximately 20% of the cases are reported as idiopathic, similar to the current case, associated with unknown reasons. In addition, Greenish et al reported an extremely rare situation, in which a case of acute SEL appeared at the adjacent level directly following bilateral spinal decompression surgery by treatment of lumbar spinal canal stenosis at the L4–L5 level, which indicates that SEL should be recognized as a possible complication of spinal decompression surgery.The pathogenesis of SEL remains unclear. According to previous research, long-term exogenous steroid use, epidural corticosteroid injection, metabolic diseases, hypothyroid disease, obesity, and male sex are thought to be risk factors for SEL.,16,17,18While SEL can be asymptomatic, surgical intervention should be considered in patients who have failed conservative treatment or in the presence of progressive and severe neurological deficits. Surgical decompression is commonly performed to treat symptomatic SELs. A variety of surgical treatment strategies for SEL have been reported, such as small laminotomy, endoscopically guided fat aspiration, microscopic laminotomy or multilevel laminectomy, fat debulking, and instrumented posterolateral fusion.Several studies have demonstrated that extensive laminectomy can induce intervertebral instability and spinal deformities. Although intervertebral fusion and pedicle screw fixation can guarantee the stability of the spine, however, it also brought some relative complications and disadvantages, such as the decreased lumbar mobility, accelerated adjacent segment degeneration, false joint formation,etc.In our case, an MRI of the lumbar spine showed severe spinal canal stenosis at the L3–L4, L4–L5, and L5–S1 levels, due to extensive epidural lipomatosis. Owing to the wide multi-level involvement, and there was no obvious disc herniation or lumbar instability, we performed fat debulking, lamina osteotomy and replantation in situ, and titanium plate fixation for the patient. At present, there are no reports on the surgical treatment of lumbar SEL with laminectomy and in situ replantation. In this way, it not only achieves the purpose of thorough decompression and removal of excess fat from the epidural but also maintains the immediate stability of the spine, preserves lumbar spine mobility, and prevents the formation of spinal scars. In this study, the surgical results were satisfactory during the follow-up.4At present, there is no uniform consensus on the surgical treatment of symptomatic lumbar SEL, and the surgical approach depends on the specific situation of the patient. The technology of laminotomy and replantation for lumbar SEL can achieve a sufficient and effective decompression, and at the same time, reconstruct the anatomy of the spinal canal. It has the advantages of better maintenance of lumbar stability, preservation of mobility, and reduction of adjacent segment degeneration. Therefore, it is an effective and safe treatment option.The authors would like to thank the patient for his consent to this case report and for sharing and providing a detailed medical experience.Conceptualization: Hui Xu.Investigation: Changbin Ji, Dawei Luo.Project administration: Dawei Luo, Kunpeng Li.Writing – original draft: Keshi Yang.Writing – review & editing: Kunpeng Li, Hui Xu.


Meningiomas are the most commonly encountered intracranial tumors, usually showing indolent behavior. Extra-axial spreading and distant metastases are seldom detected in these tumors, and lung metastasis from a low-grade meningioma is a rare event.This case report aimed to present the clinical, imaging, and pathological features of a 37-year-old Caucasian pregnant woman with bilateral lung metastases incidentally detected during preoperative workup ahead of surgery for a primary intracranial meningioma. The possible metastatic routes and risk factors of dissemination to the pulmonary circulation were discussed as well.Metastasis must be considered in patients with intracranial meningiomas accompanied by venous sinus invasion and extension through the calvarium. Thorough paraclinical investigations are suggested in such cases. Meningiomas are extra-axial tumors that are derived from the meningothelial cells of the arachnoid membrane. They are the most common types of primary brain tumor, and females are affected more than males, with a 2:1 ratio. Ionizing radiation and genetic syndromes such as neurofibromatosis type 2 (NF2) have been considered as the risk factors for meningiomas.Meningiomas are mainly slow-growing. However, they can be aggressive or may even undergo malignant transformation in a small proportion of cases , 2. AccoA 37-year-old Caucasian female presented at 18 weeks of gestation with the complaint of a slow-growing scalp mass. She had no history of headaches, blurred vision, nausea, or vomiting. In her past medical history, she had two pregnancies with no complications. On palpation, a well-defined round-to-oval mass was detected with hard consistency. However, the physical examination was unremarkable. Her full-term baby was delivered via cesarean section without any fetal or maternal complications. One month postpartum, the patient was visited by a general surgeon and a tissue biopsy was obtained from the scalp mass. The pathology result was in favor of a grade I meningioma with skull bone involvement. Hence, the patient was referred to the neurosurgery ward. Therein, a brain magnetic resonance imaging (MRI) was done, and an extra-axial 39 × 33 × 25 mm mass isointense in T1, hyperintense in T2, was noted high in the parafalcine region of the left parietal lobe. The mass had a dural tail appearance. Adjacent hyperostosis and enhancement of the adjacent involved calvarium in the high parietal scalp were mentioned as well. The findings were suggestive of an intraosseous meningioma with both intra- and extracranial components  scan Figs. , 3. TherA wedge resection of the left lobe lesion 4 × 5 cm) was performed along with a Tru-Cut biopsy of a pleural-based mass in the right lower pulmonary lobe. The histological feature of the lung tumor was the same as that of the brain mass, and the diagnosis of metastatic meningioma was confirmed by immunohistochemistry (IHC). Accordingly, the tumor cells were positive for EMA, PR, and Ki67 (low) and negative for P63, TTF1, and chromogranin  and progesterone receptor (PR) has been found in a significant percentage of meningiomas . These fet al. conducted a study on the pathology specimen of meningiomas during pregnancy and disclosed that the frequency of PR positivity was similar to that of the control group [Lusis ol group . Althougol group , 11. Addol group .et al. explored the expressions of ER and PR in meningioma specimens via IHC and assessed their correlations with gender, histological subtypes, and grade. The expression rates of ER and PR were 2% and 66%, respectively. No significant correlation was detected between the positivity of PR and the above-mentioned variables [Recently, Telugu ariables . TherefoAnother hypothesis that prevails to date is that meningioma growth is associated with vascular changes during pregnancy such as intratumoral hypervascularity and tissue edema . The exaAlthough meningiomas are more common among females, metastasis has not been reported to be more common in this population. For instance, multiple pulmonary metastases from preexisting intracranial meningiomas are rare in females. To the best of our knowledge, 33 such cases have been reported in the literature Table  1, 2, 77, 13–41.Surgical resection is the current standard of care for primary low-grade meningiomas. For high-grade lesions, surgical resection is combined with adjuvant radiotherapy to prevent local recurrence. Thoracotomy to surgically excise the lung mass is the treatment of choice for metastatic lung masses. Due to the rarity of metastatic meningiomas, few clinical trials have been performed and no standard treatment is available. Previous studies assessed the efficacy of hydroxyurea, external beam radiation, and sunitinib in treatment of high-grade metastatic cases , 44.In patients with intracranial meningiomas accompanied by venous sinus invasion and extension through the calvarium, metastasis must be considered and thorough paraclinical investigations are suggested. From a practical point of view, these seemingly benign lesions may not be as they appear, which emphasizes the importance of follow-up for such lesions beyond the scope of neurosurgery.


Case Summary. A 30-year-old farmer presented with an elastic firm nonreducible, nontender swelling at inguinoscrotal region with positive cough impulse and history of laparoscopic inguinal hernia repair 3 years ago. Ultrasonography of the swelling revealed a heteroechoic lesion of size 7 × 6 centimeter with probable features of lipoma or desmoid. Fine needle aspiration drawn in consideration of the diagnostic dilemma reported a benign lipomatous swelling which on final histopathology turned out to be a fibro lipoma of size 7 × 6 × 5 cm.  Fibro lipoma of the spermatic cord is a very rare tumor with few cases reported in literature. Atypical presentation and site of swelling mystifies the diagnosis and creates bewildering situation intraoperatively.  Considering the age and presentation of the patient, it was astonishing. It provided an insight to the occurrence of fibro lipoma even in younger age group which in fact is the first case of its kind as per best of our knowledge. Malignancy should be ruled out in such cases, and complete excision is the treatment of choice. Paratesticular tumor of primary origin accounts for only 7 to 10 percent of all intrascrotal tumor, of which majority arises from the spermatic cord .A 30-year-old male, farmer by occupation, presented to the general surgery outpatient department of our tertiary care center with a history of swelling in the left inguinoscrotal region since past 2 years. Swelling has gradually progressed in size over the past 2 years from its initial size of 2 × 2 cm to its present size of 8 × 6 cm. Patient had no history of pain and change in the size of swelling with change in posture (supine or erect position). There is no significant history of trauma. Patient had history of left sided inguinal hernia repair through transabdominal preperitoneal approach three years ago. No significant medical comorbidities were present. There is no significant family or psychosocial history. Thorough clinical examination revealed an elastic firm, nonreducible, nontender swelling in the left inguinoscrotal region measuring 8 × 6 cm with smooth surface and no signs of inflammation. Testis was palpable separately with positive cough impulse. Abdominal examination was insignificant, and other hernial sites were intact. As an adjunct to clinical examination, an ultrasonography of inguinoscrotal region was done, which showed a heteroechoic lesion of size 7 × 6 cm in the left inguinoscrotal region with probable features of lipoma or desmoid. In view of persisting diagnostic dilemma, a fine needle aspiration cytology from the swelling was done which suggested the features of fat containing benign lesion probably lipoma. Surgical exploration of the swelling was conducted by a team of surgeon headed by an additional professor of surgery with 12 years of surgical experience. Intraoperative findings revealed that tumor is originating from the spermatic cord . The excBeauty of surgery lies in the uncertainties of diagnosis and dilemmas sorted till intraoperative findings and histopathological confirmation. Among all intrascrotal tumor, primary paratesticular tumor constitutes only 7 to 10%  in a 68-Spermatic cord fibro lipoma is rare kind of paratesticular tumor. Atypical presentation creates diagnostic dilemma and may lead to intraoperative astonishment. Surgical excision of the tumor after preoperative evaluation is the treatment of choice. Although it is reported to effect older individuals, but it may be encountered in younger population as well.


Uterine lipoleiomyoma is a rare benign neoplasm that falls under the umbrella of uterine leiomyoma. Upon histological examination, leiomyoma is primarily composed of smooth muscle cells of the uterus. Whereas, lipoleiomyoma reveals a characteristic pattern of mature adipocytes interspersed in uterine smooth muscles. This paper is discussing a case of a 60-year-old postmenopausal grand multiparous woman who presented with postmenopausal bleeding. A primary diagnosis of leiomyoma was made, however, histopathological diagnosis revealed its rare variant, lipoleiomyoma. Uterine leiomyoma is a benign neoplasm that has been reported to be the most prevalent pelvic mass. The cumulative incidence of leiomyomas in the United States has been estimated to be 70% in Hispanic women and 80% in women of African origin by the age of 50 . The neoA 60-year-old postmenopausal grand multiparous woman presented to the emergency department (ED) with a history of postmenopausal bleeding for a one-week duration. The patient’s last menstrual period was reported to be four years prior to her presentation. A similar episode of postmenopausal bleeding was reported in 2018, in which she sought medical advice; both pap smear and endometrial biopsy were obtained, and results illustrated the absence of malignant cells or atypia. Additionally, her past medical history was significant for osteoporosis secondary to hyperparathyroidism as well as uterine leiomyoma diagnosed 18 years prior to her presentation. Her general assessment and physical examination were unremarkable. However, pelvic examination revealed minimal blood upon the inspection of the vaginal introitus. Moreover, a vaginal swab was obtained and the results were consistent with bacterial vaginosis. A pap smear was also taken and the results were negative for both intraepithelial lesions or malignancy. However, a sufficient endometrial sample could not be obtained. Routine hematologic investigations were all within the normal range. Moreover, pelvic ultrasonography (US) showed a heterogeneous lesion, measuring approximately 5.9 × 3.6 cm, representing subserosal leiomyoma. Imaging also reported an endometrial thickness of 5 mm, and a right ovarian cyst measuring 1.4 × 1.2 cm. Further imaging was not done and a primary diagnosis of subserosal leiomyoma was established. The patient was counseled regarding the available management options, which included total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) or hysteroscopy with dilation and curettage (D&C), and the patient preferred to undergo TAHBSO.Post-operatively, the pathology report revealed a gross description of the specimen; two right ovarian cysts were observed; a large whitish cyst and a small translucent cystic lesion measuring 1.5 cm and 0.5 cm in diameter, respectively. According to the pathologists, the endometrial cavity was distorted, measuring 5 cm longitudinally. Nonetheless, the uterine wall was found to have two intramural well-circumscribed fibroids, which were characteristically white tan in color and measuring 5.5 × 3.5 cm and 3 × 3 cm. Cut section of the fibroids showed a whorly pattern, with no identified hemorrhage or necrosis. The left ovary and bilateral fallopian tubes were unremarkable on sectioning. Microscopically, the tumor was composed of bundles of smooth muscle fibers running in various directions and expressing desmin and smooth muscle actin (SMA). In addition to the presence of intervening fat cells that were positive for S100 protein. Moreover, the tumor did not express Human Melanoma Black-45 (HMB-45), which ruled out the rare mesenchymal tumor; perivascular epithelioid cell neoplasm (PEComa). The mentioned microscopic findings were highly suggestive of the rare variant lipoleiomyoma Figures , 3. The Uterine lipoleiomyomas are a very rare sub-entity of uterine leiomyomas, in which the literature reported its incidence to be 0.03% to 0.2% in 1978 . The menContrary to the well-known types of leiomyomas, the peak incidence of lipoleiomyomas has been stated to be in perimenopausal or postmenopausal women. A study concluded that 90% of women diagnosed with lipoleiomyomas were above the age of 40 . In addiThe diagnosis could be established by clinical presentation, imaging, and histopathology. Clinical symptoms are variant and size-dependent. While most patients are asymptomatic, some may complain of pelvic pain, abnormal uterine bleeding, urinary frequency, and constipation ,5. RadioLipoleiomyoma is a condition of favorable prognosis, and can rarely progress to leiomyosarcoma. Furthermore, treatment protocols are consistent with those of uterine leiomyomas, and treatment of asymptomatic patients is not recommended .To our knowledge, the literature remains scarce in discussing the pathogenesis, prevalence, prognosis, specific management, and other aspects of uterine lipoleiomyoma. Thus, we recommend conducting high-quality advanced studies that include a fair number of participants. This recommendation would aid in filling the shortfalls related to this topic, and therefore, improve the patient’s outcome, quality of life, and survival rate.


Carriers of the m.3243A>G variant typically manifest with stroke-like episodes (SLEs), of which the morphological correlate on imaging is the stroke-like lesion (SLL). The pathophysiology of SLLs is poorly understood but acute and chronic stages are delineated. Here we present the case of an m.3243A>G carrier who presented with hypometabolism during his second SLL.The patient was a 56-year-old male who was diagnosed with MELAS  at the age of 50 upon a third SLE, muscle biopsy, and the detection of the m.3243A>G variant in the muscle. A fluorodeoxyglucose-positron emission tomography (FDG-PET) during the second SLE revealed hypometabolism in the occipital lobes bilaterally. The patient was misdiagnosed for years and was repeatedly exposed to mitochondrion-toxic drugs . The previous data and the present findings indicate that the hypometabolism on FDG-PET together with reduced oxygen-extraction fraction (OEF) on OEF-MRI and hyperperfusion on perfusion-weighted imaging (PWI) characterise best the acute stage of an SLL.In conclusion, an acute SLE in m.3243A>G carriers typically manifests with a mismatch between hyperperfusion on PWI or single-photon emission computed tomography (SPECT) and hypometabolism on FDG-PET and hypointensity on OEF-MRI. Since SLEs are not vascular events, they should be managed by a multispecialist approach and not by general or stroke neurologists. The variant m.3243A>G manifests with syndromic or non-syndromic phenotypes . Among tThe patient is a 56-year-old Caucasian male  with a history of visual impairment on the right eye since childhood, bilateral hypoacusis, and cholecystectomy. At age 42 years, he presumably experienced the first SLL in the right parieto-occipital area manifesting with a transient flickering of the left eye, quadrantanopia to the lower left, left-sided ataxia, depressive mood, multimodal memory deficits, and a holocrane headache. Echocardiography revealed concentric thickening of the left ventricle in the absence of arterial hypertension. Mild hyperCKemia and hyperlipidemia were noted for the first time.At age 49 years, the patient was admitted for a presumed second SLE manifesting with recurrent, focal myoclonic seizures, right-sided hemiparesis, gait disturbance, memory deficits, and dysarthria. Cerebral MRI showed a T2-hyperintense, cortical, and subcortical lesion in the left parieto-occipital area. Cerebrospinal fluid (CSF) investigations revealed elevated protein and lactate exclusively. Immune-encephalitis was suspected. To exclude paraneoplastic syndrome, a whole-body 18F-FDG-PET was performed. Interestingly, 18FDG-PET revealed hypometabolism in the left>right occipital lobes  was suspected, being confirmed by a muscle biopsy. Genetic workup revealed the MT-TL1 variant m.3243A>G in muscle (heteroplasmy 70%). Since the third SLE, he experienced gait disturbance, easy fatigability, progressive memory disturbance, difficulties in finding words, and recurrent panic attacks, triggered by fear from experiencing a seizure.At age 56 years, the patient experienced a fourth SLE, manifesting as vertigo, confusional state, speech disturbance, and difficulties in finding words, starting two days prior to admission, in addition to ataxic gait and impaired concentration.The family history was positive for diabetes (mother), valve replacement (mother), myocardial infarction (mother), and carcinoma . His medication included bisoprolol, clopidogrel, metformin, pantoprazole, levetiracetam, pregabalin, and ciprasidone.Clinical neurologic exam revealed a weakness for head anteflexion (M5-), cerebellar speech, severe visual impairment bilaterally with only light/dark discrimination, severe hypoacusis, mild ptosis bilaterally, diffuse wasting of the upper limbs, bradydiadochokinesia bilaterally, wasting of the thighs, marked ataxia on the lower limbs, and reduced Achilles tendon reflexes. There was an ataxic stance, but he could walk with a walker. Blood chemical investigations revealed lactic acidosis, hyperuricemia, folic acid deficiency, and hyper-triglyceridemia. MRI of the brain revealed an SLL in the right parieto-occipital area Figure  and an aThe presented patient is interesting for multisystem MID due to the variant m.3243A>G, phenotypically manifesting in the brain in recurrent SLEs, ataxia, epilepsy, cognitive impairment, psychiatric disease, eyes , ears (hypoacusis), endocrine system , heart , muscle (myopathy), and the peripheral nerves (neuropathy). Protein-S deficiency was regarded rather as second trouble than causally related to the mitochondrial DNA (mtDNA) variant. Polyneuropathy has been previously described as a manifestation of MELAS [The most interesting feature of the index patient was occipital hypometabolism on FDG-PET during the second SLL at age 49 years. Hypometabolism within SLLs has been previously reported and can be explained by the reduced ability of the mitochondria to utilise glucose ,6. HypomThe patient is a typical example a year-long misdiagnosis and unnecessary investigations and therapies. Early diagnosis of MELAS is warranted to prevent patients from being exposed to mitochondrion-toxic drugs, such as metformin, steroids, valproic acid, oxcarbazepine, zolpidem, and from undergoing repeated unfocused, costly investigations. Why the patient received metformin despite having been diagnosed with MELAS remains unknown. It is well known that metformin may worsen MELAS .Whether the tongue-root cyst was part of the phenotype remains speculative. An argument in favour of a causal relation is that cysts in MIDs have been reported in the brain, liver, kidneys, pancreas, thyroid gland, and bones. In the brain, cyst-like lesions have been reported in the white matter of MELAS patients. Cyst formation can be attributed to impaired cell adhesion, which may require adequate adenosine triphosphate (ATP) supply for appropriate functioning.Limitations of the study are that the index patient had not undergone perfusion studies or OEF-MRI during any of the four SLLs and that the SLLs were never treated with L-arginine or antioxidants.In conclusion, this case shows that acute SLLs present with a mismatch between hypometabolism on FDG-PET and hyperperfusion on PWI/SPECT. Patients with an acute SLE should undergo perfusion studies and FDG-PET to clearly delineate an SLL from ischemic, vascular lesions. The treatment of SLEs is at variance from that of an ischemic stroke.


The arc of Buhler (AOB), a rare anastomosis connecting the superior mesenteric artery (SMA) to the celiac trunk (CA), was found in a patient suffering from an adenocarcinoma of the pancreatic head.Oncologic pancreaticoduodenectomy required resection of the AOB to achieve complete tumor removal. After an uneventful clinical course in the first days, the patient suffered a severe complication. Due to ischemia of the stomach and spleen, complete resection of the stomach, spleen, and remaining pancreas had to be performed.The hemodynamic impact of this arterial variant has been discussed mainly for liver perfusion, which remained intact at all times in our case. Because of the serious obstacles mentioned above, we strongly recommend that the presence of AOB be considered in preoperative diagnosis and preservation when possible. If the AOB is likely to be ligated, stenosis of the SMA or CA should be excluded and resolved before surgery. Variants and anomalies of the abdominal visceral vessels are frequently found in patients . HoweverA 66-year-old patient was admitted to the hospital because of painless jaundice and pathologic elevated cholestasis parameters. Conventional sonography revealed a malignancy-suspect tumor of the pancreatic head with dilatation of the common bile duct. Subsequently, endoscopic retrograde cholangiopancreatography was conducted with papillotomy and stenting of the common bile duct. No malignant cells were detected in the biopsies taken, although the suspected diagnosis of a malignant pancreatic head tumor was supported by endoscopic ultrasound. Contrast-enhanced computed tomography of the thorax and abdomen showed no metastases, and therefore curatively intended pancreaticoduodenectomy was evaluated.3D reconstruction of the upper abdominal vessels from CT data was performed to plan the surgical treatment. There was no evidence of local irresectability, but an arterio-arterial shunt was discovered originating from the dorsal part of the SMA and leading to the common hepatic artery (CHA), just after its branching from the CA Fig. . The vesA median arcuate ligament compression syndrome (Dunbar syndrome) could also have been the cause of the described stenosis. Because of the leading oncologic diagnosis, no further investigation of asymptomatic CA stenosis was performed.The AOB showed close proximity to the tumor and possible tumor infiltration Fig. . We planIntraoperatively, we found a locally advanced tumor with regional inflammatory changes. After mobilization of the duodenum and pancreatic head, the gastroduodenal artery (GDA) was ligated.As the dissection progressed toward the pancreatic body, the AOB was identified cranial to the tumor.Further caudal tumor infiltration could not be excluded, making preservation of the shunt for oncologic resection impossible. After clamping the AOB close to its termination at the CHA, there was no evidence of ischemia of the liver or stomach. This was verified by Doppler ultrasonography. The AOB was resected. The proper hepatic artery (PHA) showed a steady pulse at all times. Pancreatic anastomosis was constructed as a pancreaticogastrostomy. Single-loop reconstruction was performed for bilio-jejunal and gastro-jejunal anastomosis.The early postoperative course was uneventful. On postoperative day 2, a planned gastroscopy showed no evidence of anastomotic insufficiency or ischemia. Having already received regular meals, the patient developed abdominal pain and elevated infection laboratory markers on postoperative day 9. An immediate CT scan of the abdomen indicated an insufficient pancreatic–gastric anastomosis. Emergency relaparotomy revealed gastric ischemia with insufficiency of the pancreatogastrostomy and gastrojejunostomy and necrosis of the remnant pancreas. In addition, the splenic artery (SA) showed a relatively small diameter and thrombosis. We performed gastrectomy, splenectomy, resection of the remaining pancreatic and reconstruction as esophago-jejunostomy. The patient stabilized quickly with ICU-treatment. After drainage of the pleural effusion, treatment of wound dehiscence, and wound infection, the patient was discharged from the hospital on postoperative day 44.The result of histologic examination confirmed complete resection of a 37-mm, moderately differentiated ductal adenocarcinoma of the pancreas with infiltration of the duodenum and common bile duct , L 1, Pn 1, G 2, R 0). There was no evidence of tumor infiltration of the resected arterial shunt.For the successful performance of surgical procedures in the upper gastrointestinal tract, it is important to recognize and consider vascular anomalies, especially in pancreatic surgery . AlthougUsing PubMed for a literature review with the keywords “pancreaticoduodenectomy” and “arc of buhler”, we could identify only four cases involving pancreaticoduodenectomy and the coincidental presence of an AOB Table . In all The discussion in the case reports above emphasized the importance of AOB preservation for liver perfusion. This results from the frequently associated CA stenosis, especially when no other collateral hepatic artery arises from the SMA. In contrast, our patient did not show signs of liver malperfusion at any time; however, major complications from ischemia of the stomach and spleen occurred. The vascular reconstruction of the postoperative CT scan (postoperative day 9) revealed a tremendous loss of vascularization regarding the CA Fig. . CompareIn the presence of an AOB, caution should be exercised during pancreatic or hepatobiliary surgery. Preoperative angioplasty and stenting should be considered if there is evidence of CA or SMA stenosis. In circumstances requiring AOB resection, liver and gastric perfusion should be critically assessed. Surgeons should be prepared to extend the abdominal resection and possibly perform further vascular reconstruction.


Osteoblastomas are rare bone-forming tumors that may be locally aggressive, they account for 1-3% of all primary bone tumors with the majority presenting in young adults between their second and third decades of life. This tumor predominantly affects the vertebral column and long tubular bones. Skull involvement is markedly less frequent, and particularly parietal bone involvement is extremely rare, osteoblastoma is a rare tumor older than 50 years of age. Here, we describe a case of a 70-year-old woman who presents with headache and swelling of the vault of the skull, computed tomography (CT) of the head, which demonstrated an expansible, mixed lucent and sclerotic mass in the parietal bone with a suggestion of osteoid matrix calcifications. In its largest extent, the mass measured up to 5.7 cm, and magnetic resonance imaging (MRI) revealed a mass lesion in parietal bone with low to intermediate T1 signal intensity and intermediate to high T2 signal intensity. The patient underwent surgical resection with complete removal of the parietal mass. Histopathological examination revealed an osteoblastoma. Osteoblastoma is a rare tumor older than 50 years of age, but it should be considered in the differential diagnosis of bone lesions of the calvarium in adulthood and in the elderly, to avoid a delay in the treatment.


Hiatal hernia (HH) with intrathoracic migration of the gastric pouch (IMGP) is a rare long-term complication of laparoscopic Roux-en-Y gastric bypass (LRYGB); however, its management remains poorly documented , 2. SevePatients with IMGP may present with epigastric/retrosternal pain, dysphagia, and regurgitations. In addition to the conventional imaging techniques used for the diagnosis of IMGP, such as CT scan and barium transit, the swallow magnetic resonance imaging (MRI) has been recently described as a new dynamic method to assess the anatomy of the gastric pouch, as well esophageal dysmotility after LRYGB, and could be of great use in the diagnostic armamentarium of swallowing difficulties after RYGB . VariousThe purpose of the present work is to illustrate the main technical aspects of a laparoscopic-modified Nissen fundoplication with the excluded stomach to correct IMGP after RYBG.2. The patient lost 45 kg during the first 2 years after surgery but regained almost 20 kg over the last 5 years with a current BMI of 38 kg/m2. She presented with epigastric pain, reflux, and dysphagia to solid food with occasional postprandial vomiting. Although upper endoscopy did not reveal any anatomical anomaly, a barium swallow and a thoraco-abdominal CT scan showed herniation of the gastric pouch with an associated kinking effect at the level of the hiatus. Surgical management of the IMGP was therefore proposed.This video shows the case of a 54-year-old female patient, with an ante-colic LRYGB performed 14 years earlier in our institution for an initial BMI of 46 kg/mThe laparoscopic exploration, lysis of adhesions, reduction of the HH, posterior crural repair, and the modified Nissen fundoplication with the gastric remnant are demonstrated step-by-step in this video. The postoperative course was uneventful and she was discharged on POD3. At 6-month follow-up, she no longer had any abdominal pain and gastric reflux, and food tolerance was excellent.IMGP is a well-known but rare complication of LRYGB, and bariatric surgeons need to be familiar with its management. In case of symptoms suggesting IMGP, a thorough pre-operative work-up is essential before proceeding to surgery. Surgical correction of IMGP with a modified Nissen fundoplication using the excluded stomach is a technically demanding procedure, but in experienced hands, it can be safely performed with minimal morbidity.Supplementary file1 (MP4 116884 KB)Below is the link to the electronic supplementary material.


We present a unique case of inflammatory pseudotumour involving gluteal subcutaneous tissue with the sparing of superficial fat and report its contrast-enhanced CT, F-18 fluorodeoxyglucose positron emission tomography/CT and pathological findings. Although rare, inflammatory pseudotumours have been reported with a diverse spectrum of locations; however, the involvement of the subcutaneous tissue overlying the gluteal muscles with sparing of the most superficial fat has not been reported. This prompted additional examination with a CT of the chest, abdomen and pelvis.Our patient is a 57-year-old male with no significant medical history who presented to the emergency department with chest pain at rest and shortness of breath. Additional history included unintentional 23 kg weight loss. On physical exam, right flank tenderness was noted, otherwise, the physical exam was unremarkable. Laboratory results showed anaemia with a haemoglobin of 6.8 gm dlCT imaging demonstrated a confluent soft-tissue density throughout the anterior chest , retropeThe case was presented at the institutional tumor board, and a decision was made to do an F-18 fluorodeoxyglucose positron emission tomography/CT (F-18 FDG PET/CT) to better evaluate the infiltrative soft-tissue in the chest, abdomen and pelvis as it was concerning for a second malignancy such as lymphoma.F-18 FDG PET/CT was performed 60 min after the i.v. administration of 559 MBq of F-18 FDG on a GE Discovery 690 16-slice PET/CT scanner. PET/CT images showed low-level metabolic activity within the diffuse infiltrative soft-tissue involving the pericardiophrenic fat, retroperitoneum and mesorectal region, all illustrated in Histological findings of the subcutaneous gluteal region were essentially morphologically identical to the prior biopsy. Specifically, it demonstrated marked lymphoplasmacytic inflammatory infiltrate intracytoplasmic inclusions within a hyalinized, collagenous background. Focally, Russell bodies, eosinophilic intracytoplasmic inclusions of immunoglobulins within plasma cells, were seen. Intermixed with the inflammatory infiltrate were bland fibroblastic cells, with histiocytes only rarely present. Scattered thin-walled, dilated blood vessels were present, and no phlebitis was identified. Mitotic figures were sparse. The fibroinflammatory process was also seen interdigitating with focally necrotic adipose tissue, suggestive of at least microscopically infiltrative borders . Given t1–4 Likewise, IgG4 immunohistochemistry revealed only rare positivity, ruling-out a diagnosis of IgG4-related disease.4 While S100 immunohistochemistry was positive, morphological features of RDD – large, epithelioid histiocytes with abundant cytoplasm and emperipolesis – were not appreciated.5 Special stains for acid-fast organisms were negative, excluding a diagnosis of mycobacterial pseudotumour. In situ hybridization for κ and λ light chains revealed polytypic plasma cells; furthermore, flow cytometry was performed on material from the retroperitoneal lesion and failed to identify any clonal hematolymphoid proliferations. Subsequently, fluorescent in situ hybridization and immunohistochemistry assessing for amplification of MDM2 each resulted in negative, precluding a diagnosis of WDLS.6 Together, the above morphology and lack of any specific findings on ancillary studies were most in keeping with a diagnosis of inflammatory pseudotumour.Ancillary histological studies were performed to help resolve the differential diagnosis. The aforementioned morphological findings, coupled with negative Anaplastic Lymphoma Kinase (ALK), immunohistochemistry rendered a diagnosis of IMT unlikely.Following an investigation with imaging and pathology, the patient was referred to rheumatology for further management. The presence of inflammatory pseudotumours is suspected of having relations with infection, inflammation, trauma or other malignancies. Given the supposed association with malignancy, it was determined that the presentation of inflammatory pseudotumour was likely resulting from the concomitant renal cell carcinoma. Treatment with high dose steroids was held, and the patient underwent an uncomplicated right nephrectomy.To our knowledge, superficial sparing of the subcutaneous tissue in the gluteal tissue in conjunction with inflammatory pseudotumour is an unreported finding. It was felt that the treatment of the patient’s primary malignancy might reduce the presence of inflammatory pseudotumour. Following an uncomplicated right nephrectomy, the patient will be scheduled for follow-up PET/CT imaging to determine if there is a need for further intervention or treatment of the inflammatory pseudotumour.7,8 The morphological findings are non-specific, and, consequently, it is a diagnosis of exclusion with reported associations of infection, inflammation, trauma or other malignancies.7,9,10 Furthermore, inflammatory pseudotumour has been described in the literature by many names, including inflammatory myofibroblastic tumour (IMT), calcifying fibrous tumour, fibrous pseudotumour, inflammatory myofibrohistiocytic proliferation and inflammatory fibrosarcoma, all of which demonstrates variable histological characteristics and behaviour of these lesions.7,11Inflammatory pseudotumour encompasses a group of non-neoplastic, reactive proliferations comprised of a variable number of fibroblasts and mononuclear inflammatory cells, which has been known to be mistaken for malignant lesions clinically and radiologically. Although a benign process, treatment consists of excision, irradiation, chemotherapy agents or high-dose steroids for unresectable lesions. These rarely recur or progress following complete surgical removal.1–4,9 While used interchangeably, it has been stated that there are differences between the widely reported IMT and inflammatory pseudotumours.12 The distinction between the two is widely controversial, with reports suspecting that some types of inflammatory pseudotumours and IMT may represent both ends of a spectrum of one entity and is beyond the scope of this report.2,11IMT, the term that has been most used in literature in conjunction with inflammatory pseudotumours, which is reported to exhibit malignant transformation, is most commonly found in the lungs, orbit, or retroperitoneum with histology noting proliferation with prominent myofibroblastic spindle cells and histiocytes. It is noted to have varying levels of fibrosis, necrosis, and chronic inflammatory cells. At the molecular level, chromosomal translocations leading to activation of the ALK, a receptor tyrosine kinase suggesting a neoplastic cause, is observed in ~40–100% of IMT cases, depending on the anatomical sites at which they arise.7,13–16 When imaged FDG, there is uptake similar to malignancy due to the infiltrating inflammatory cell composition.17,18 Contrast-enhanced CT may show a homogeneous or heterogeneous lesion with low, equal or high attenuation compared with the surrounding tissue. Ultimately, the characteristics of the imaging findings depend on the site of origin of the lesion and histological composition.9 Multiple imaging findings have been reported in the literature of histologically confirmed IMT, although imaging of inflammatory pseudotumours, specifically without mention of IMT, has yet to be reported.Radiographically, inflammatory pseudotumours are non-specific, featuring variable degrees of locations and attenuation that can present as distinct masses or infiltrative tissue possibly due to the fluctuating degrees of fibrosis, cellular infiltration and dynamic change during the inflammatory process.9,17,19 Ultimately, for the diagnosis of inflammatory pseudotumour, multiple radiological studies should be compared, although an accurate finding will require histological examination. When a diagnosis of inflammatory pseudotumour or IMT is considered, surgery is considered the treatment of choice if it is resectable. However, it may be avoided or delayed if the extent of disease is monitored using F-18 FDG PET/CT.8 Other treatment options include irradiation, chemotherapy agents and high-dose steroids for unresectable lesions.7,8Diagnosis of inflammatory pseudotumours radiographically is challenging given they can mimic a malignant process with variable known anatomic sites. For example, reported appearance using F-18 FDG PET/CT in the liver, lung, mesentery, kidney and colon shows varied features of uptake intensity and distribution.In our case, CT images demonstrated a complex right renal mass  along with diffuse infiltrative soft-tissue involving the mediastinum, retroperitoneum and subcutaneous tissues. The FDG uptake was mild, although heterogeneous in appearance, which may be attributed to the varying characteristics of infiltrating inflammatory cell composition or fibrosis. The increased uptake likely reflects the activity of the inflammatory cells while the intervening fibrosis limits activity to be mild. Inflammatory pseudotumours centered in the soft-tissue usually displace and distort adjacent tissues, while in this case, there was no distortion in the surrounding subcutaneous tissues. Although rare, further knowledge of this entity can help in preventing overdiagnosis and aggressive treatment as a malignancy.Inflammatory pseudotumour is an uncommon benign disease that can arise anywhere in the body with clinical and radiological appearance mimicking malignancy.F-18 FDG shows a varying degree of uptake and is highly sensitive but not specific for the diagnosis of inflammatory pseudotumour. F-18 FDG PET/CT, however, could be useful in identifying the site for biopsy and monitoring treatment response in non-surgical candidates.


A tooth in the nasal cavity is an uncommon phenomenon. The exact mechanism is unclear, and patients may present with non-specific nasal symptoms. We encountered a 24-year-old patient with history of cleft palate repair, presenting to us with unilateral nasal discharge not improving with conventional medications. Rigid nasal endoscopy revealed a rhinolith-like foreign body at the floor of the left nasal cavity. Removal of the rhinolith was done under general anesthesia, and it turned out to be an intranasal tooth. Intranasal tooth is often misdiagnosed due to its non-specific symptoms. Detailed dental and oropharyngeal examination as well as imaging studies are essential in diagnosing an intranasal tooth. Early surgical removal is the mainstay of treatment in order to prevent further complications. Patients with unilateral nasal symptoms not responding to conventional treatment require proper ear, nose, and throat (ENT) evaluation to rule out other pathology. The presence of tooth in the nasal cavity is a rare phenomenon, though it occurs more frequently in patients with associated cleft lip or cleft palate . The exaA 24-year-old female patient presented to us with complaints of left nasal obstruction, intermittent foul-smelling blood-stained nasal discharge, which was unprovoked for the past six months. There were no aggravating or relieving factors. She denied history of frequent rhinitis prior to that and had no associated symptoms such as frontal headache, facial pain, or facial numbness. She also had no ear symptoms. There were no history of trauma or foreign body insertion. She had a history of cleft palate defect during childhood for which palatal repair surgery was done. She was seen by her local general practitioners and was treated for rhinitis. Her symptoms were only alleviated slightly by steroidal nasal spray and antihistamines.She was eventually referred to otolaryngology for further management. Physical examination was unremarkable. She had no cleft lip, and her palate appeared intact. However, there was a slight deformity over her left incisor region, and it appeared to be misaligned. The incisors appeared misaligned Figure . Cold spRigid nasal endoscopy revealed a rhinolith on the floor of the left nasal cavity with surrounding granulation tissue. The nasal cavities were normal, with clear osteomeatal complexes bilaterally. Nasopharynx was also normal. The lesion was embedded on the floor of the left nasal cavity, and the attempts to remove it were abandoned as the patient was in severe pain.She was subjected for examination under general anesthesia whereby the rhinolith was removed under endoscopic guidance. Intraoperatively, the surrounding granulation tissue was removed, and the rhinolith was scooped out with a freer elevator, with minimal manipulation Figure . The rhiPost removal, the patient was well with no more nasal symptoms. She was referred for proper dental assessment; however, due to financial constraints and the resolution of her nasal symptoms, she is yet to present for the follow-up.A tooth in the nasal cavity is uncommon. Though it occurs more frequently in patients with associated cleft lip or cleft palate , the repMost commonly an intranasal tooth occurs unilaterally and as a single tooth. Bilateral involvement and multiple teeth are rare. Lee  reportedPatients may be asymptomatic or may present with non-specific nasal symptoms such as unilateral nasal blockage, foul-smelling nasal discharge, epistaxis, facial pain, headache, or even communicating oronasal fistula ,6,7. RouClinical examination such as anterior rhinoscopy or nasal endoscopy may reveal a hard whitish mass on the floor of the nose, midway in the nasal cavity . HoweverThe diagnosis of rhinolith was made in this case, and no further imaging was done. However, imaging studies such as conventional radiographs or computed tomography could be useful in determining the position of the tooth , detectiIn this case, the intranasal tooth removed cannot be determined as supernumerary or malformed permanent tooth due to the absence of proper dental imaging such as orthopantomogram (OPG). OPG provides valuable information regarding other dental anomalies such as hypodontia, impaction, and microdontia. Clinically, her two incisors are missing, but concomitant hypodontia and hyperdontia  are a very rare dental anomaly with prevalence rate of 0.002%-3.1% .The mainstay of treatment for an intranasal tooth is early removal or extraction to prevent further complications such as abscesses, dental deformities, nasal deformities, oronasal or intranasal fistula, as well as cavernous sinus thrombosis ,4. In viPatients with unilateral nasal symptoms not responding to conventional treatment require proper ear, nose, and throat (ENT) evaluation to rule out other pathology. Intranasal tooth is uncommon; however, it should be one of the differential diagnoses to be considered for patients presenting with unilateral nasal symptoms. Early endoscopic evaluation is essential for optimal diagnosis and treatment.


Ductus deferens may manifest in a variety of anomalies such as its absence, duplication, ectopy, or diverticulum. Ectopic seminal tract opening has two main types, ectopic ejaculatory duct opening, and ectopic vas deferens opening. Generally, ductus deferens anomalies affect approximately 0.05% of the population. Patients may be asymptomatic or complaining of urinary tract infections and/or epididymitis. Most of these cases are associated with renal dysplasia. To confirm the diagnosis Cystourethroscopy catheterization and retrograde urethrogram should be performed, but the definitive diagnosis is done by vasography. The definitive treatment is complete surgical resection of the pathological urogenital connection. This case is commonly discovered while exploring other findings such as testicular torsion and inguinal hernia.We report a rare case of an 11-year-old male who presented with gross hematuria and numerous congenital malformations including a left polydactyly clubfoot, polyorchidism, with several surgical procedures, and left kidney dysgenesis. Surgery was performed for a left inguinal hernia, during which a third undescended testicle was discovered incidentally and was eradicated. A retrograde urethrogram was performed to establish the diagnosis. A fistula- that is connected with the left ureter- was resected. The histopathologic findings confirmed the diagnosis of true duplication of the Vas deferens, with communication between the ureter and the vas deferens. By follow-up, the kidney function tests were within normal limits.This case report aims to highlight the early diagnosis and management of the duplicated vas deferens and the associated congenital malformations to improve the prognosis and kidney function and to avoid long-term complications. The congenital anomalies of the ductus deferens, which are rare, affect approximately 0.05% of the general population. This phenomenon has two main types, ectopic ejaculatory duct opening, and ectopic vas deferens opening . In geneAn 11-year-old male presented to the Department of Urology with gross hematuria in the last few days. The medical history included numerous congenital malformations: a left polydactyly clubfoot with several surgical procedures and left kidney dysgenesis. Surgery was performed for a left inguinal hernia at the age of 1.5 years, during which a third undescended testicle was discovered incidentally and was eradicated without the vas deferens that were only ligated. There was no oliguria, dysuria, or any significant symptoms. Physical examination and laboratory findings were within normal limits, excepting hyperphosphatemia 7.3 mg/dl). A sample urine test demonstrated increased protein and creatinine in urine 84.6 mg/dl) and (380 mg/dl) respectively. A urinalysis result revealed 72 RBC (per cubic mm), 95% of them isomorphic (lower urinary tract origin). Furthermore, no schistosome eggs were observed in the urine. Abdominal Contrast-Enhanced Computed Tomography (CECT) demonstrated important details that the left kidney was relatively smaller with diagonals (5 × 3 cm), (8 mm) cortical thickening, and atrophy in its artery . Moreover, a mild dilation in the upper half of the left ureter was discovered without hydronephrosis along with scoliosis in the lower and sacral part of the vertebral column along with malformation in the pelvis form (Fig.  mg/dl. A.6 mg/dl The ectopic seminal tract opening was first reported in 1895. There is a variety of ductus deferens anomalies that could be observed such as absence, duplication, ectopy, and diverticulum. The duplication of ductus deferens differs from the double vas deferens. The first term refers to the presence of two separated ductus deferens within the spermatic cord, whereas the latter is described with an ectopic ureter draining into the ejacularity system . Embryol


It is often not diagnosed until crepitus is palpable in the scrotal wall with spreading cellulitis, at which point it has reached an advanced stage. This case report details a 55-year-old man with poorly controlled diabetes who presented with an acute scrotum that failed to resolve with oral antibiotics in primary care. Following rapid detection of EEO on an early scrotal ultrasound scan, the patient had surgical debridement and a near-total orchidectomy with only a small stump of testis and tunica albuginea left behind. This case highlights the importance of timely imaging, particularly in diabetic men with an acute scrotum with a high clinical suspicion of intratesticular abscess. An incidental but significant finding of EEO would warrant early surgical intervention to prevent a catastrophic sequelae i.e. Fournier’s gangrene.We hereby present a rare cause of acute scrotum secondary to  Urinary tract infections are not uncommon in middle-aged men who are immuno-compromised or have diabetes, and this may get further complicated by infection with gas-producing organisms resulting in severe epididymo-orchitis . EmphyseUpon surgical debridement, the appearance of gas bubbles during incision helps confirm the diagnosis. Testicular involvement with total parenchymal and tunical destruction is rather unusual.Escherichia coli, originating from the lower genito-urinary tract, is one of the most common bacteria implicated in gas producing infections in diabetic patients [patients . Howeverpatients , such clDespite epididymo-orchitis being a common finding in diabetic and non-diabetic men , only a A 55-year-old diabetic man presented with an acute scrotum with previous history of being treated with three courses of oral antibiotics for 7 days each in the primary care and failure of resolution of his symptoms. He has poorly controlled type I diabetes. He had no history of recent endo-urological intervention, radiation, trauma or any other history to suggest any anatomical abnormalities.Clinical examination showed grossly swollen right hemiscrotum, tender, erythematous with hard leathery skin. Digital rectal examination demonstrated non-tender benign small prostate. He was tachycardic (110 beats/min) and afebrile (37.3°C) with normal blood pressure (125/70 mmHg).9/L), raised C-reactive protein of 200 mg/L and deranged renal function: . Random blood glucose was 22 mmol/L and ketone levels were unreadable. A venous blood gas (VBG) performed revealed metabolic acidosis with lactate 2.7 mmol/L. No previous bloods or urine cultures were available.Blood chemistry showed leucocytosis  but the more serious complication of EEO in diabetic men who present with acute scrotum as the latter most certainly warrants surgical debridement. To establish an early diagnosis, it would be desirable to have a low threshold for organizing appropriate imaging, which is highlighted in this case, with scrotal ultrasound scan clinching the diagnosis of EEO much earlier than would be feasible on clinical assessment with palpable crepitus under the scrotal skin, which is a late development.E. coli that is usually seen in emphysematous pyelonephritis [The wound swabs reported abundance of ephritis  but rareephritis .An early, rapid access imaging with a scrotal ultrasound is essential to establish an early diagnosis as it is paramount to implementing appropriate changes to the management and care of these patients from conservative to interventional i.e. surgical debridement.This is in contrast with the treatment of emphysematous pyelonephritis, in which surgical intervention (nephrectomy) is reserved only for cases that completely fail to respond to conservative management and require percutaneous surgical drainage.In conclusion, since ultrasound scanners and small part probes are easily available in most emergency radiology settings, imaging ought to be sought in selected clinical scenarios as this case clearly underpins the role of an early scrotal ultrasound scan in diabetic men with an acute scrotum to clinch an early diagnosis well ahead of clinical signs noticeable only at an advanced stage.


A dermoid cyst (DC) is a rare, benign congenital skin lesion that can occur anywhere on the skin and take any shape. DC is clinically diagnosed through imaging and biopsy. The usual treatment of choice for DC is surgical excision to prevent any local complications, such as inflammation, infection, and bone resorption. The type of surgery depends on the size, location, and extension of the cyst. When the cyst presents in certain areas, such as the nose, face, and scalp, surgery can be difficult owing to the possibility of an intracranial connection. Therefore, imaging is usually performed before intervening surgically. Here, we present the case of a two-year-old boy with no medical or surgical history who presented to our dermatology clinic with a slow-growing mass on his nose. During the consultation, the mass was examined, a complete medical history was obtained, and the patient was advised to undergo imaging, which revealed that the mass was a DC. Nevertheless, no deep connection was observed on imaging, and the mass was surgically removed without any complications. A dermoid cyst (DC) is a benign, cystic lesion formed when the ectoderm fails to separate from the neural tube. It is lined by stratified squamous epithelium and typically presents on the neck, scalp, and face . DC usuaDuring the surgical removal of DC, intracranial communication is possible; therefore, an exclusion is required before biopsy or surgical intervention . When a A two-year-old boy was brought to our clinic by his parents who were concerned about the presence of a growing mass on the upper right side of the child’s nose since birth. A detailed history of the patient revealed that he lived a healthy life devoid of any medical complications or surgery. However, the mass continued to slowly increase in size with age. Prenatal, natal, and postnatal histories were unremarkable. Family history did not reveal any similar conditions, and the parents were not consanguineous.Skin examination showed a 1 × 1 cm dome-shaped, subcutaneous nodule on the upper right side of the nasal bridge that was erythematous, firm, noncompressible, and nontender Figure .Based on these findings and clinical presentation, a diagnosis of DC without intracranial extension was made. The patient was referred to a pediatric surgeon, and the lesion was excised and sent for histopathological examination. The histopathology report confirmed the diagnosis of DC, showing a polypoidal tissue covered by unremarkable keratinized stratified squamous epithelium and underlying skin adnexal, including hair follicles and sebaceous glands . Lobules of mature adipose tissue and skeletal muscle bundles separated by a thin, fibrous capsule  were also noted Figure .A nasal DC is a rare congenital and developmental condition. It presents as a nontender, mobile subcutaneous nodule. Although it commonly appears around the ages of 1-3 years, it can appear at any age . It can The differential diagnoses in our patient included nasal glioma, encephalocele, congenital hemangioma, sebaceous cyst, and lipoma ,8. A nasNasal DC is a rare congenital skin lesion that should be differentiated from nasal glioma and encephalocele. Imaging studies should be performed for midline masses to rule out intracranial connections and prevent the occurrence of complications. In our case, the presenting DC was near the midline; therefore, imaging was performed with caution before any surgical intervention.


Klebsiella pneumoniae (hvKp) K1-ST23 strain, presenting as motor aphasia. Our patient presented with ruptured EPA concurrent with various severe systemic pyogenic complications . Whole-body computed tomography (CT) and next-generation sequencing (NGS) were useful for the detection of ruptured EPA and its systemic complications, and for identification of K1-ST23 hvKp strains, respectively. Subsequently, the infections were successfully treated with aggressive antimicrobial therapy and multiple surgical procedures. This case highlights the significance of awareness of this rare entity, the clinical importance of CT for the early diagnosis of EPA and the detection of its systemic complications in view of hvKp being an important causative organism of severe community-acquired UTI, and the usefulness of NGS to identify hvKp strains.Emphysematous prostatic abscess (EPA) is an extremely rare but potentially fatal urinary tract infection (UTI). Here, we describe a case  of ruptured EPA caused by a hypervirulent  Prostatic abscess is an uncommon sequela of urinary tract infection (UTI). In the post-antimicrobial era, the incidence is low at approximately 0.5% . Among tA 69-year-old Japanese man was admitted to our hospital with a 7-day history of slurred speech. He had no past history of prostatic manipulation. On admission, the patient had a low-grade fever of 37.8°C, tachycardia of 109 beats/min, blood pressure of 122/90 mmHg, and oxygen saturation of 97% on ambient air. Motor aphasia was recognized on neurologic examination. Digital rectal examination revealed a soft and non-tender enlarged prostate. Laboratory testing revealed neutrophilic leukocytosis, elevated levels of C-reactive protein , fasting blood glucose , and HbA1c . Mild hepatorenal dysfunction was also observed. Urinalysis was positive for bacteriuria and pyuria. Cerebrospinal fluid analysis was unremarkable. Brain computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lesion in the left lenticular nucleus, suggestive of a brain abscess . We subsKlebsiella pneumoniae, which was susceptible to conventional antimicrobials, yet naturally resistant to ampicillin. Although the K. pneumoniae isolate was negative for the string test, we performed next-generation sequencing (NGS) for capsular genotyping, virulence factors, and multilocus sequencing typing (MLST). The isolate was found to belong to a sequence type (ST) 23 serotype K1 strain harboring virulence-associated genes, including kfuA (an iron uptake system), magA (specific to K1 capsule serotype), rmpA (regulator of mucoid phenotype), ybtS (yersiniabactin gene), iroN , and mrkD . Based on the antimicrobial susceptibility test results, antimicrobial de-escalation was performed . On day 14, a left scrotal abscess developed progressively, presumably originating from the adjacent epididymal abscess, and required surgical drainage. On day 21, follow-up CT showed a decrease in the size of the EPA, and multiple intrapelvic abscesses, liver abscess, and pulmonary septic emboli.On day 5, all the urine culture and two sets of blood cultures collected on admission yielded However, on day 24, we performed an additional brain abscess drainage on a CT-guided stereotactic procedure because follow-up brain MRI confirmed a gradual progression of the existing brain abscess and multiple new ones . SubsequK. pneumoniae (hvKp) K1-ST23 strain. Within a few days, the patient developed abscess rupture concurrent with various serious systemic pyogenic complications successfully treated with aggressive antimicrobial therapy and multiple surgical interventions. Our case illustrates several valuable clinical pearls.Herein, we describe a rare case of EPA caused by a hypervirulent Escherichia coli is the main causative organism; the most common causative organism of EPA is K. pneumoniae (50%), followed by Escherichia coli (18%) and Candida albicans (14%). EPA is often misdiagnosed as the usual type of UTI, leading to time delay  in the accurate diagnosis and proper treatment. EPA can have a variable presentation, ranging from asymptomatic to lethal. Frequent complications of EPA include localized spread of infection to adjacent areas, ascending infections, or disseminated hematogenous spread. Although rare, the most feared sequelae include a urethro-prostatic fistula or abscess rupture into the urethra, perineum, bladder, or rectum , CT/MRI screening was useful for early detection, and the infection was successfully controlled by aggressive antimicrobial therapy and multiple surgical drainage procedures.K. pneumoniae infections in healthy subjects. The hvKp is a major causative agent in invasive community-acquired infections characterized by pyogenic liver abscess (PLA) with a high mortality, and has been reported in the Asian Pacific Rim, starting in Taiwan since the 1980s, and is now spreading worldwide (K. pneumoniae (cKp) strain due to its high toxicity and metastatic potential, resulting in grave secondary infections such as endophthalmitis, meningitis, and septic pulmonary emboli. Thus, early diagnosis and prompt treatment are required; however, the following three clinical issues for hvKp infection were exemplified by our case.Second, our case underscores the significance of early diagnosis of invasive orldwide . The hvKAs the first clinical issue, hvKp-related primary extrahepatic genitourinary infections are increasingly being reported. Although the exact pathogenesis of hvKp remains unknown, many studies have indicated that hvKp initially colonizes the gastrointestinal tract, from where it preferentially infects other organs, mainly the liver. Therefore, UTI caused by hvKp has been considered secondary to hematogenous spread from preceding bacteremia. In fact, there are several reported cases of PLA with hematogenous spread to the kidney, perirenal tissues, and prostate, leading to local abscess formation . ConversK. pneumoniae in our case. To our knowledge, the present case is the first case of EPA caused by serotype K1 hvKp infection presenting with a brain abscess. The K1 strain has a strong propensity to cause metastatic ocular and neurologic complications. In a single-center, retrospective study of 177 patients with PLA in Taiwan, the incidence of metastatic complications was 13% (p = 0.007). Multivariate logistic regression analyses demonstrated that the K1 strain was the sole significant risk factor for metastatic complications , strongly suggesting that the K1 strains should be recognized as a distinct virulent organism. In addition, such metastatic complications have been reported in patients with K1 strains without hepatic involvement, suggesting that their development is unrelated to the presence of PLA , supporting this notion /16fk0108307h0402]. Other parts of this study were not funded by any institution.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.


Oesophageal squamous cell papilloma is a very rare entity with a limited number of reports in the literature. The exact aetiology is uncertain, and it commonly overlaps with gastro-oesophageal reflux. Human papilloma virus (HPV) is deemed responsible for some cases. Although incidental discovery during upper gastrointestinal endoscopy for other reasons is the commonest presentation, symptomatic cases do occur. Endoscopic excision is the standard treatment. We report a case of HPV-positive squamous papilloma of the upper oesophagus, presenting with lateralising throat pain and diagnosed with office transnasal oesophagoscopy. We also discuss features of HPV-positive oesophageal squamous papilloma and the role of transnasal oesophagoscopy as a recent diagnostic modality of increasing popularity. Oesophageal squamous cell papilloma (OSP) is a rare benign epithelial lesion that is usually asymptomatic but can present with a spectrum of upper gastrointestinal symptoms . With noA 38-year-old female patient presented to our fast-track ENT clinic with persistent left-sided throat discomfort and pain for several months. The throat pain lateralised to the left and radiated to her left ear. She also reported positive reflux symptoms with heartburn. At the time of review, medical management had been implemented ; however, this yielded no symptomatic relief. Voice Handicap Index (VHI) was 11 and Eating Assessment Tool (EAT-10) score was 1. She was a non-smoker, and her past medical history was insignificant.Office examination of the neck, oral cavity and oropharynx was unremarkable. Flexible nasendoscopy was performed, which revealed some post-cricoid oedema consistent with laryngopharyngeal reflux Figure . A contrHistological examination of the specimen revealed squamous cell papilloma of benign appearance with prominent papillae and acanthotic stratified squamous epithelium without cellular atypia. The specimen tested positive for human papilloma virus (HPV). Oesophageal manometry and 24-hour oesophageal pH monitoring indicated borderline pathological reflux with some proximal penetration (DeMeester score [DMS] = 15.9).The patient then underwent complete endoscopic excision of the lesion. Histology confirmed HPV-positive squamous papilloma. Anti-reflux treatment, including lifestyle changes, was continued. Following excision, the patient’s symptoms resolved and a yearly follow-up confirmed their complete remission. It is yet uncertain whether symptomatic relief was a result of excision, continued anti-reflux treatment, or even a placebo effect associating the procedure.The prevalence of OSP has been reported to range from 0.01% to 0.45% [The exact aetiology of OSP is not yet certain with multiple proposed theories including chronic irritation as with GORD, mechanical and chemical injury, smoking and alcohol . These fHistologically, neutrophils have been identified in papilloma biopsies taken from the lower oesophagus; however, no neutrophils have been identified in papilloma biopsies from the mid or upper oesophagus . In our Whilst OSP is a benign lesion, its malignant potential is still debatable. Some cases of malignant transformation have been reported. In a cohort of 78 patients with OSP, 1.3% of lesions developed into squamous cell carcinoma at two-year follow-up endoscopy [The use of TNO in the office setting as a diagnostic tool for persistent upper aerodigestive symptoms has gained wide popularity recently. It has been shown to be a sensitive tool for small lesions, even with normal imaging . It is nPatients with persistent unilateral throat pain and discomfort should be investigated for upper aerodigestive lesions. Laryngopharyngeal reflux commonly co-exists with different pharyngeal and oesophageal pathologies, which need to be excluded if there is no response to reflux treatment. TNO is an excellent diagnostic modality for direct visualisation of oesophageal mucosa, particularly in very small lesions that are commonly missed by MRI. Whilst malignant neoplasms of the oesophagus are much more common, benign oesophageal squamous papillomas have been reported.


Ovarian vein thrombosis is not well understood, and there is no consensus regarding treatment. It can present with subtle symptoms and is not usually high on the list of differentials. Traditionally, most cases are linked to pregnancy and postpartum state, but our case adds to the growing list of non-puerperal patients diagnosed with ovarian vein thrombosis after an outpatient procedure. In an era where there is a drive for minimally invasive procedures and shorter hospital stays, there is a need to have specific guidelines to direct the diagnosis and treatment of this rare form of thromboembolism. An ovarian vein thrombosis (OVT) is a rare form of venous thromboembolism, which occurs in 0.02% to 0.18% of all pregnancies . We repoA 39-year-old gravida 5 para 3 female was admitted for sharp, right lower quadrant, non-radiating, abdominal pain, which started three weeks prior and was progressively worsening to the point where it had become unbearable. She denied abdominal distension, nausea, vomiting, diarrhea, fever, chills, vaginal discharge, polyuria, dysuria, and hematuria. She reported that she had a progesterone intrauterine device for three years, which was removed uncomplicated four weeks prior under ultrasound guidance due to malposition. She had a history of two first trimester miscarriages. She had no previous history of blood clots and no family history of thromboembolic or bleeding disorders.She was afebrile and normotensive at the presentation. Her abdominal examination revealed a soft and diffusely tender abdominal wall, with deep tenderness in the right lower quadrant. No guarding or rigidity was noted, no palpable organs, and there were no signs of free fluid. A pelvic exam performed by the gynecology team revealed normal external genitalia, pink cervix, anteverted uterus with no palpable adnexal masses. Her urine pregnancy test was negative. The initial laboratory values showed a white blood cell count of 8.1 (4.8-10.8 k cells/µL), platelets 379 (150-400 k cells/µL), hemoglobin 10.7 (12.0-16.0 g/dL), serum lipase 27 (≤61 U/L), prothrombin time 12.5 (9.9-13.3 seconds), and partial thromboplastin time 37.9 (27.2-39.6 seconds). Her reverse transcription-polymerase chain reaction (RT-PCR) for SARS Coronavirus was negative.The computerized tomography imaging of her abdomen and pelvis with intravenous and oral contrast revealed an enlarged and thrombosed right gonadal vein Figure . No otheOVT was first described in 1956 . The truThe diagnosis of OVT is a clinical challenge. The most common symptoms reported are fever 80%), abdominal pain(55%), malaise, nausea, vomiting, and rarely, shortness of breath, and a palpable intra-abdominal mass. Our patient did not experience a fever at any point, and abdominal pain had a waxing-waning course. There are a myriad of conditions that can present similarly, including ovarian torsion, tubo-ovarian abscess, pelvic inflammatory disease, puerperal endometritis, appendicitis, inflammatory bowel disease and pyelonephritis -8. The d0%, abdomAnticoagulation forms the crux of treatment, however, the agent of choice, dose, and duration of treatment is debatable. Duration of treatment ranges from three to six months among authors and lifelong treatment for hypercoagulable diseases . While sOVT is now being increasingly recognized as a cause of vague abdominal symptoms in puerperal and nonpuerperal females. A high index of suspicion is required to facilitate prompt diagnosis, early treatment and to help reduce morbidity and mortality due to dreadful complications. There is a need for further prospective studies to establish guidelines regarding management.


Intraductal papillary mucinous neoplasms (IPMNs) constitute a group of rare conditions with a potential for malignant degeneration. The appearance of symptoms should suggest degeneration. This case demonstrates an unusual case of a patient presenting an intestinal type IPMN that was revealed by a large abdominal mass.47-year-old woman with a history of hydatid cyst of the liver. The patient was admitted to our hospital for management of large abdominal mass measuring 185 × 128*190 mm. Intra-operative findings showed a voluminous tumor, of approximately 20 cm in all its dimensions, with double solido-cystic component at the expense of the neck and the body of the pancreas. The patient underwent splenopancreatectomy. The histopathological examination confirmed the presence of intestinal type of IPMN of pancreas.Acute pancreatitis is revealed in the majority of cases of IPMNs, related to duct obstruction by secreting mucus plug. IPMNs are rarely the cause of a large abdominal mass. They are cystic lesions of slow evolution, macroscopically visible and rarely macrocystic, unlike serous cystadenoma. The tumor size is a powerful indicator of the malignancy of IPMNs. The current definitive and ideal treatment for main duct and mixed type IMPNs is a surgical resection.IPMNs are a cystic lesion, rarely revealed by a large mass. •IPMNs are rarely the cause of a large abdominal mass.•The tumor size is a powerful indicator of the malignancy of IPMNs.•The current definitive and ideal treatment for main duct and mixed type IMPNs is surgical resection. These mucin-producing cystic entities present 1% of pancreatic exocrine tumors. According to their anatomic ductal involvement, IPMNs are classified into: main duct, branch duct and mixed type [Although histologically benign, IPNMs progress to pancreatic ductal adenocarcinoma. These cysts are often asymptomatic and more frequent at sixteen decade . The appThe diagnosis of IPMNs is typically established based on histopathological proof, rather than radiological imaging. Despite the lack of specific features, imaging remains essential in risk staging, description of anatomical site, and follow-up. A clear consensus on the management of IPMNs have developed, which can be simple monitoring up to radical treatment . The aim2A 47-years-old female patient, nulligravida, presented to our hospital chiefly complaining of painless abdominal mass that was gradually increasing in size over a period of 6 months. She reported anorexia and weight loss associated with the mass. The patient had a history of hydatid cyst of the liver and she underwent resection of the protruding dome at age 36 years. No other comorbidities were reported. She was a non-smoker with no drug use, and had no history of allergies. She had no family history of cancer, or psychological history.During the physical examination, vital parameters were within normal limit. The abdominal examination has exhibited a well-defined, fixed with regard to the deep plan, non-pulsatile, left sided abdominal mass.Abdominopelvic computed tomography CT scan showed a large left and paramedian intra peritoneal mass, of undetermined origin, roughly oval, well-defined, of mixed nature with a pure septale cystic component, mucinous impure cystic component and a solid component enhanced after injection of contrast, without presence of calcifications, measuring 185 × 128*190 mm. The mass pushes back left liver without any sign of noticeable invasion . A recurSurgical approach was decided with an open laparotomy. The procedure was performed by a professor of surgery with over 15 years of surgical experience at an academic hospital. On exploration, a voluminous mass, of approximately 20 cm in all its dimensions, with double solido-cystic component at the expense of the neck and the body of the pancreas, closely related to the portal vein, without infiltration. There were no peritoneal implants, hepatic metastases, or adenomegaly. The tumor was firmly united by multiple adhesions with the adjacent structures, with displacement of the surrounding organs. Splenopancreatectomy involving the mass with omentectomy were performed after isolating the tumor from the portal vein and suture of a breach by single stitches prolene 5–0 B. The opMacroscopically, the specimen weighs 742g, ranges from 14 cm to 18.5 cm in size, poorly limited. It shows a solido-cystic, hemorrhagic, necrotic, friable, multilocular, and heterogeneous appearance. Histopathological examination of the specimen showed a pancreatic parenchyma, site of chronic pancreatitis and of intraductal mucinous tumor proliferation. The pancreatic ducts were largely ectatic lined by a unified or multi-layered muciparous cylindrical covering. The nuclei are sometimes regularly and sometimes atypical with a mitotic activity estimated at 5 mitoses per 10 pools of mucus resting a fibrous and very inflammatory chorion. This proliferation remains confined to the canal without any source of invasion B. The imPostoperatively, the patient was doing well without any complications and she was discharged 14 days after the operation. After a follow-up of 6 months, the patient remains in good health, and there is no recurrence detected.3Intraductal papillary mucinous neoplasms IPMNs are the most common cystic tumors of the pancreas. They are characterized by the uncontrolled intraductal proliferation of the papillary-type epithelium due to accumulation of mucus leading to dilation and obstruction of the ducts, and the development of chronic pancreatitis lesions .IPMNs are benign, precancerous lesions, located in the head of the pancreas in 60% of cases, and present a different degree of risk of malignant transformation to invasive ductal adenocarcinoma. They are observed at any age with a high incidence in the age group ranging from 60 to 65 years, constituting 15% of pancreatic tumors .The location of the papillary proliferation and the morphology of the pancreatic ducts can be divided into 3 forms of IPMNs: “main duct type”, “brunch duct type”, and “mixed type”. The main duct and mixed type present a higher risk of dysplasia compared to branch duct type .Four histological types depending on tissue architecture and cell differentiation: intestinal, pancreato-biliary, gastric, and oncocytic . In our Risk stratification for IPMNs is assessed by main pancreatic duct dilation, cyst size, presence of wall nodules, or symptoms. Three categories of stratification can be distinguished: high risk of stigmata, lesions suspected of malignancy and “no risk” lesions. Surgical management is recommended in the event of a main pancreatic duct size greater than 10 mm, the presence of obstructive jaundice linked to a pancreatic head injury, the presence of a tissue component in the pancreatic ducts .The clinical symptomatology of IMPNs is not specific. Its modes of revelation are variable. Acute pancreatitis is revealed in the majority of cases, related to duct obstruction by secreting mucus plug . In termThe other main telltale symptoms are weight loss, diabetes, jaundice, and chronic pancreatitis. IPMNs are rarely the cause of a large abdominal mass as in our case . They arIn imaging, IPMNs are manifested on CT scan by dilation of the Wirsung's duct or secondary ducts without organic obstacles. They show cysts in a bunch of grapes. Intraductal and intracystic tumor adenoids can be observed, even calcifications on sections without injection of contrast product. CT is a modality of choice in assessing signs of degeneration ,14. In oThe current definitive and ideal treatment for main duct and mixed type IMPNs is a surgical resection. Clinical and radiological monitoring is recommended in most cases of IMPNs-type brunch . In our 4IPMNs are a cystic lesion, having a significant malignant potential. Its classic appearance is generally small sized tumor, rarely revealed by a large mass without an invasive component.The authors declare that they have no conflict of interest.The author(s) received no financial support for the research, authorship and/or publication of this article.No ethical approval necessary.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Dr Harouachi Abdelhakim: Have written the article, have consulted the patient, prescribed all of the tests and prepared the patient for surgery and participated in the surgery.Dr Marouane Harhar: have helped writing the article, data collection.Dr Kharkhach Ayoub: have helped writing the article, data collection.Dr Nabil Khomsi: have helped writing the article, data collection.Dr Chafik Rhoul: have helped writing the article, data collection.Pr Bouhout Tariq (oncology surgery professor): supervised the writing of manuscript.Pr El Harroudi Tijani (oncology surgery professor): have supervised the writing of the paper.Pr Serji Badr (oncology surgery professor): Writing, review and editing of the manuscript, and had been the leader surgeon of the case.Our paper is a case report; no registration was done for it.Harouachi Abdelhakim.The authors declared no potential conflicts of interests with respect to research, authorship and/or publication of the article.


Management of renal mass during pregnancy is challenging. There is no consensus regarding the fundamental timing issues (which trimester) of the interventions and patient positioning during the procedures. We present three pregnant women with renal mass and their management, focusing on patient positioning and timing of surgical intervention. All patients were positioned supine with a 30-degree rotation to the left lateral without signs of compromising fetal circulation. This report's three major takeaway points are the following: (1) Renal mass biopsy might be more beneficial in pregnant women than the normal population (unless CT findings suggest vascular angiomyolipomas) to achieve a definite diagnosis and avoid unnecessary interventions during pregnancy. (2) Surgical interventions, if indicated, should be performed as soon as possible and are applicable in all trimesters of pregnancy. (3) A minimum of 15-degree left lateral tilt  can provide enough venous return during the nephrectomy. Renal tumors are rare findings during pregnancy. Neoplasms complicate approximately 0.1% of all pregnancies; 0.013% are urological in origin . Renal cManaging such tumors usually involves a nephrectomy . However, we found no disclosure and consensus on the optimal positioning of the pregnant woman during nephrectomy. Positioning should warrant sufficient venous return from the inferior vena cava to the heart, therefore enough cardiac output and placenta perfusion . Herein,th week of gestation. The patient was positioned supine with a 30-degree rotation to the left lateral. Both the mother and baby were monitored during surgery via the nonstress test (NST) which remained stable during surgery. Macroscopically, a multicystic mass (80∗60∗15 mm) containing serous fluid was examined , was presented with abdominal pain and heaviness more prominent in the left flank attributed to the pregnancy at first. However, the abdomen's progressive unequal distention in five weeks urged the patient to seek a further assessment. The physical exam was remarkable for a left flank mass. On the noncontrast MRI, a cystic multiloculated mass with numerous holes separated with thin septa was observed in the left kidney. Maximal dimension in the axial plane reported 191 mm. No solid components were seen. The radiologist suggested hydatid cyst strongly and cystic renal cell carcinoma (RCC) as another differential. After consultation with the gynecologist and infectious disease specialist, the consensus was obtained to perform a nephrectomy because of the rapid tumor growth. We performed the surgery at the 16examined . Microscnd gestational week in the same position as the first case. For the macroscopic findings, a cream-colored mass sized 120∗90∗90 mm was examined. It was attached to the adrenal gland with no invasion. For the microscopic findings, a neoplastic growth composed of monomorphic spindle-cell proliferation with tortuous thick vasculature without necrosis and atypical was seen. Immunohistochemistry (IHC) studies were positive for actin, desmin, and HMB45 and negative for CD10, Ki57, CD117, CD34, S100, creatine kinase, and MELAN-A. These findings were consistent with angiomyolipoma of the kidney. She was healthy at her last follow-up visits with no complaints two years after surgery.A 24-year-old woman, gravida 2, para 1 (GA: 20 weeks), was presented with right flank pain. The Ultrasound (US) reported a hypoechoic hypervascular exophytic mass sized 50∗65∗110 in the right kidney's superior and middle pole. Mild pyelocaliceal distention was also reported. Color-Doppler US affirms the previous findings. MRI revealed a solid poor-fat renal tumor suggesting the RCC. After multidisciplinary consultation, radical nephrectomy was planned. The patient underwent an open nephrectomy at the 22A 20-year-old primigravid woman (GA: 20 weeks) was referred to our tertiary clinic with right flank pain. The US reported a right renal mass of 60∗80∗40 mm. MRI showed an exophytic, low signal mass on T1 . T2-weigManagement of renal mass during pregnancy is a challenging topic. There is no consensus regarding the fundamental timing issues (which trimester) of the interventions and patient positioning during the procedures. All solid renal tumors during pregnancy should be considered RCC unless proven otherwise. To rule out this possibility, a timely nephrectomy  should be performed to make a definite diagnosis. Ohyama et al. presented a case of renal mass in pregnancy in which the diagnosis was confirmed preoperatively via fine-needle biopsy; however, one should remember that the negative results do not rule out malignancy .The kidney is best accessible when the patient is positioned lateral decubitus on a flexed table. Table flexion may increase the uterus' pressure; thus, we suggest a straight table. Therefore, a tilted table to the right or left can reduce this effect. Here, we proceed to review two possible positions for the nephrectomy of a pregnant woman. Of note, these positions started with the adjective “relative” to show their difference with full left and right decubitus positions.At the second and third trimesters, aortocaval compression can cause hypotension and impaired placental perfusion . It can A recent study on ten pregnant women showed a 35% lower venous return in RRLP than RLLP; however, this difference in cardiac output and blood flow of the abdominal aorta  is insignificant between left and right lateral decubitus positions . Fujita RCC is the most common tumor in pregnancy and seems heterogeneous; each patient showed variable tumor size, manifestation, and growth rate . A meta-Although interventions during the first trimester have an increased risk of spontaneous abortion, we recommend surgery unless there is a previous infertility history . In caseth week of gestation; however, this time limit can be brought forward to the 28th week of pregnancy (lung maturation point via steroids) [Surgical interventions for renal tumors diagnosed in the third trimester  can be delayed after fetal lung maturation in the presence of reliable patient follow-up and the absence of a concerning growth rate. Typically, lung maturation is completed enough for breathing out of the mother's body after the 35teroids) . Simultateroids) .Venous thromboembolism and abortion are two major reported complications of RCCs during pregnancy , 20. ForWomen of reproductive age who have planned to conceive should consider kidney imaging before pregnancy .This report's three takeaway notes are the following: (1) Biopsy should be considered (unless CT findings suggest vascular angiomyolipomas) to achieve a definite diagnosis and avoid unnecessary interventions during pregnancy. (2) Surgical interventions, if indicated, should be performed as soon as possible and are applicable in all trimesters of pregnancy. (3) A minimum of 15-degree left lateral tilt  and 30-degree right lateral angle  can provide enough venous return during the nephrectomy.


Microscopically, the right ovarian mass displayed nests of large polygonal cells and fibrous septa which were focally concentrated by theca-like plump spindle cells. Immunohistochemistry revealed that the spindle cells expressed various steroidogenic enzymes involved in estrogen biosynthesis including P450 aromatase. The tumor was diagnosed with pure dysgerminoma with estrogen-producing functioning stroma. After the operation, serum E2 declined below the detection limit; LH and FSH returned within the normal range. This case demonstrates that even a conventional dysgerminoma can present endocrine manifestation through functioning stroma.Dysgerminoma is a malignant ovarian germ cell tumor, and unlike sex-cord stromal tumors, endocrine manifestation is considered rare. Here, we report the first case of dysgerminoma presenting precocious puberty. The patient is a 7-year-old girl who presented with a breast development in Tanner stage 3. Serum estradiol (E Dysgerminoma is a malignant ovarian germ cell tumor, and unlike sex cord-stromal tumors, endocrine manifestation is considered rare . To date2) level was 41.7 pg/mL and markedly elevated for her age while luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were suppressed below the detection limit  and 28.9 kg in weight (+1.62 standard deviation). Physical examination revealed a breast development in Tanner stage 3, but pubic and axillary hair was not observed. Abdominal ultrasonography revealed a solid mass at the right side of the rectouterine pouch. Serum estradiol , 3β-hydroxysteroid dehydrogenase (HSD), P450arom (aromatase)  , P450C17omatase) , 17β-HSD2 level declined below the detection limit; LH and FSH returned within the normal range. The serum β-hCG level was constantly low throughout the observation (The postoperative course was uneventful, and the patient was discharged three days after the surgery. Serum Eervation . The patWe reported a case of dysgerminoma with estrogen-producing functioning stroma. Although three similar cases have been reported to date, the mechanism of estrogen biosynthesis in our case was distinct from the previous cases –4. Functarom is the most important factor as it catalyzes the final step of estrogen biosynthesis. Nevertheless, since it is widely distributed in the peripheral tissue, determining how much the functioning stroma contributes to aromatization is difficult. Previous studies reported that 9 to 80% of the ovarian tumors with functioning stroma expressed P450arom; however, the authors conceived that most aromatization may have occurred in the peripheral tissue rather than the ovary as the expression of P450arom was focal [arom suggesting that most stroma-derived androgen were aromatized by the stromal cells in an autocrine manner.Among these enzymes, P450arom, could be utilized in the future study to reveal subclinical endocrine manifestation in dysgerminoma.Our case demonstrates that even a conventional dysgerminoma can produce estrogen through functioning stroma. Since most dysgerminomas occur during the reproductive age where endogenous estrogen can mask hyperestrogenism , 6, many