We report a rare case of bilateral HCG-secreting gonadoblastomas (Gb) in a 5.25-year-old girl of 45, X Turner syndrome (TS) with gonadal Y chromosome mosaicism. The clinical data were summarized, and the literatures were reviewed. The patient had enlarged breasts for 2 years and 3 months, with elevated β-HCG of blood found for 8 months. The level of β-HCG of cerebrospinal fluid, cranial MRI, chest and abdominal CT, and pelvic MRI were normal. After surgical gonad exploration, biopsy and excision, gonad venous blood hormone examination and SRY gene detection of gonad tissue, the diagnosis was confirmed as HCG-secreting Gb  and TS  with gonad Y chromosome mosaicism. The patient received 4 courses of chemotherapy, and regular outpatient follow-up. At 9 months after gonadectomy, there was no clinical, laboratory, or radiological evidence of recurrence. We reported a nonclassical case of 45, X Turner syndrome (TS) with gonadal Y chromosome mosaicism, who presented with breast development as the first manifestation and then virilization due to bilateral HCG-secreting gonadoblastomas. Detection of serum β-HCG and AFP is requisite for the diagnosis of precocious puberty, karyotyping is important for virilizing phenotypic female, and virilization in Turner syndrome implies the existence of Y chromosome(substance)  and the occurrence of gonadal tumors. Turner syndrome (TS) is one of the most common sex chromosome anomalies, with a prevalence of 1:2,000–1:4,000 live-born girls. It's characterized by a complete or partial loss of one X chromosome (E2) <10 ng/L, testosterone (T) 0.71 μg/L, and prolactin (PRL) 12.31 μg/L. Bone age (BA) was 3 years old. Gynecological B ultrasound: uterus 16 mm × 13 mm × 10 mm, left ovary (LO) 14 mm × 10 mm × 6 mm, and right ovary (RO) 15 mm × 11 mm × 6 mm. Echocardiography: partial pulmonary vein ectopic drainage and atrial septal defect (secondary hole type). She underwent “Pulmonary venous malformation drainage correction and Secondary hole atrial septal defect repair” in another hospital when her CA was 3 years and 4 months. She recovered well after surgery, but her breasts continued to rapidly grow and enlarge.A 5-year 3-month-old girl was admitted to our hospital with a history of enlarged breasts for 2 years and 3 months, as well as elevated β-HCG for 8 months. When the patient's chronological age (CA) was 3 years, she was found to have enlarged breasts, prompting her to visit a local hospital for examination. At that time, the physical examination for this patient revealed: height (Ht) 93 cm (−1SD), weight (Wt) 14.05 kg (0SD), Tanner stage: B3 (diameter of the mammary gland nodes: 2.5 cm), and a grade 2–3/6 systolic murmur audible on split second heart sound. Blood tests revealed: follicle-stimulating hormone (FSH) 0.83 IU/L, luteinizing hormone (LH) 0.04 IU/L, estradiol  0.77 μg/L, basal FSH 0.46 IU/L, LH 0.15 IU/L, and peak LH/FSH was 0.25 after GnRHa stimulation test. Pituitary MR scan as well as chest, adrenal gland, and pelvic CT scans did not reveal any abnormalities. In the higher-level hospital, further diagnosis and treatments were recommended. Due to rapid breast development, the patient experienced accelerated height and weight gain (2 (P90th). Her heart rate was 100 beats/min, the rhythm was regular, and a grade 2/6 systolic murmur was audible in the second intercostal space on the right sternum. Tanner staging: A1, B3 (diameter of the mammary gland nodes: 9.0 cm), PH3, female vulva, and clitoral hypertrophy (2.5 cm × 1.0 cm).At the age of 3 years and 7 months, she visited the local hospital again. Physical examination revealed that her height was 97 cm (−0.8SD). BA: about 5 years old. Gonadotropin-releasing hormone analogues (GnRHa) stimulation test (60 min): FSHght gain , and sheE2 28.00–30.00 ng/L (<10.00 ng/L); β-HCG 32.33–46.02 IU/L (<1.20 IU/L); AFP 0.94–0.90 μg/L(<20.00 μg/L); T 1.96–2.53 μg/L (<0.27 μg/L); progesterone (P) 0.10 μg/L; anti-Müllerian hormone (AMH) 0.57 μg/L (0.05–7.02 μg/L)  244 IU/L (<250.00 IU/L); insulin-like-growth-factor-1 (IGF-1) 230.00 μg/L (143.70–319.10 μg/L); 8AM cortisol 8.90 ug/dl (5.00–19.40 ug/dl); adreno-cortico-tropic-hormone (ACTH) 8.61 pmol/L(4.50–18.00 pmol/L); 17α-hydroxyprogesterone 0.56–1.27 μg/L (<2.00 μg/L); androstenedione <1.05–1.66 nmol/L; dehydroepiandrosterone (DHEAs) 0.25–0.28 umol/L; Basal FSH 0.12–0.16 IU/L; LH 0.02–0.03 IU/L; PRL 11.72 μg/L (<30.00 μg/L); x-ray, MR of the pelvic cavity, and the hearing test did not reveal any abnormalities.BA was 10.5 years old . EchocarPeripheral blood SRY gene  was negative. Abnormal peripheral blood sex chromosome number detection  showed that there were 494/500 cells exhibited 1 X centromere, 6/500 cells exhibited 2 X centromeres, and there was no Y centromere signal.E2, T, etc., and there were indications for gonadal examination.Based on the above findings, the patient was 45, X TS, with masculine characteristics, and peripheral blood T levels progressively increased. The patient was postulated to have a Y chromosomal material. The SRY gene was negative and there was an abnormal number of blood sex chromosomes , indicating the absence of Y chromosomal material in peripheral blood. Therefore, we suspected that the patient had a gonad tumor harboring Y-chromosomal material and secreting hormones such as This patient had elevated β-HCG in peripheral blood, negative imaging examination and nomal β-HCG levels in the CSF which did not support intracranial or extragonadal tumors. These findings suggest that gonads are the primary sites for HCG secretion, and should therefore be studied further. According to monism, HCG-secreting Gb is conceivable. However, HCG-secreting Gb is extremely rare, with only 4 cases reported internationally; therefore, gonad exploration and pathology can explain for the above concerns.E2, and T levels . Laparoscopic examination revealed that the left gonad was of acceptable size ; howeverT levels . The entT levels .Pathological biopsy and immunohistochemistry suggested bilateral Gb . In all After being informed of the pathological results and waiting for another five working days, the family finally consented to a re-surge of the right gonad. Laparoscopic and right gonadectomy was performed on the 26th day after the first operation. Pathologyical results revealed mesosalpinx cyst and a large amount of tubal-like tissue, in addition to the presence of scattered inflammatory cell infiltration and focal multinucleation on the local peripheral serosal surface. Giant cells aggregated, consistent with postoperative inflammatory changes, but there was no tumor or malignant features.After operation, the patient was referred to the Children's Oncology Department of Sun Yat-sen University Affiliated Cancer Hospital for consultation.Since the tumor secreted HCG, four courses of chemotherapy  were administered 3 months after the first operation.After surgery, the rapid increase in the patient's height slowed down , her breE2 and T levels were significantly decreased to below the limit of detection. After surgery, there was a significant decrease in β-HCG levels, which did not return to normal at 68 h (12.9% of the intraoperative percentage), and were below the detection limit 8 days after surgery. At last follow-up (258 days following surgery), peripheral blood E2, T, and β-HCG levels were all below the detection range. There were no tumor recurrence indications  of the testis  along with germ cell neoplasia e testis , 13. Aboe testis . TypicalClinical manifestations of Gb are variable and may include asymptomatic, female phenotype without virilization, female phenotype with virilization, and pure virilization . GonadalE2, P, DHEAs, and androstenedione levels to be elevated. Elevated PRL levels have been reported . In cases of malignant germ cell tumors, some pure germ cell tumors , and other tumors such as liver tumors, pancreatic tumors, combined with elevated β-hCG indicate the presence of trophoblast cells . Two facClinical incidences of Gb-secreting HCG have not been conclusively reported. We agree with Schanne  that, inE2 and T were increased in the effluent of tumor tissue and peripheral blood. In addition, β-HCG levels were elevated, which supports the notion that Gb secretes E2, T, and β-HCG. In our case, due to appearance of the tumor on the left side of the gonads and the cord-like appearance on the right-side during surgery, the tumor was biochemically diagnosed as secreting E2, T, and HCG on both sides, and this diagnosis was pathologically confirmed. Testing for gonad venous blood hormone concentrations will inform the surgeon/endocrinologist on assessment of the tumor lesion to decide on whether or not surgical excision is necessary.Venous blood collection from endocrine glands is commonly used for auxiliary localization of lesions, and despite significant advances in imaging technologies in recent decades, it continues to have a significant diagnostic significance. In a previous report of Gb with secreted PRL , 20, a 4Generally, Gb is considered to be a benign tumor , and successful surgical excision of the diseased gonad is associated with good prognostic outcomes. Morin j  reportedThis patient's pathology was Gb, a premalignant condition that was surgically removed and was in stage I of a childhood ovarian GCT stage . Due to In conclusion, we present the fifth case of HCG-secreting Gb in the world. It is a rare case of 45, X TS with gonad Y chromosome mosaicism. The patient presented with breast enlargement and cystic mammary glands, with virilizing features , and elevated blood β-HCG levels. Even though the patient was a female child, she exhibited masculine characteristics, thus, detection of peripheral blood karyotype was very important. When a TS patient exhibits masculinizing characteristics, it is necessary to investigate Y chromosome material to determine whether there is cellular mosaicism. Additionally, gonadal and adrenal tumors should be explored. Detection of Y chromosomal material in pathological tissues is important for diagnosis of gonadal Y chromosome mosaicism. In diagnosis and treatment of precocious puberty, clinicians should follow the routine of precocious puberty, conduct a comprehensive physical examination, carefully evaluate the examination report, detect abnormalities in a timely manner, and make early diagnosis as well as treatment. Patients with precocious puberty, regardless of gender, must undergo HCG and AFP examination.


Giant ovarian cysts are rare in developed countries due to advanced achievements in medical diagnostics. However, in the midst of the coronavirus disease 2019 (COVID-19) pandemic, patients with non-COVID-19-related illnesses tend to delay their health-seeking attention; thus, they had presented late.A 25-year-old single lady complained of a 3-month worsening abdominal pain and distention. She was initially well but neglected the symptoms due to the COVID-19 situation, yet came to our attention after she developed obstructive symptoms. A computed tomography (CT) scan of the abdomen revealed a huge cystic lesion from the pelvic area, which later was found to be from the right ovary upon urgent laparotomy exploration. The histopathological examination was consistent with mucinous cystadenoma of the ovary.Acute non-COVID-19-related emergencies have decreased, as evidenced by reduced visits to the Emergency Department, and the number of abdominal CT scans. An emergency case like a huge abdominopelvic mass deserves an extensive radiologic examination as clinical assessment alone may not be adequate. Preoperative CT is superior to ultrasonography in getting the extent of the lesion, local infiltration, staging purpose, and surgical intervention. Pathology with a variety of spectrums such as mucinous neoplasm deserves to be investigated, evaluated, and resected even during the COVID-19 pandemic.A giant abdominopelvic cystic mass can present emergency havoc during the COVID-19 pandemic. Urgent surgical intervention is mandatory by using full protection and exercising extreme precaution, regardless of the preoperative screening to avoid unnecessary viral transmissions. •Acute abdomen cases have reduced in numbers during COVID-19 pandemic which can cause delay in diagnosis and management.•Preoperative CT scan can determine the extent of the lesion, local infiltration, staging, and surgical intervention.•During pandemic, urgent surgical intervention is mandatory by using full protection regardless of the preoperative screening to avoid unnecessary viral transmissions. Occasionally, various diagnoses of cystic lesions can be categorised according to their histologic and anatomical origins . Althoug2A 25-year-old single lady presented with complaints of constipation, recurrent vomiting, and abdominal distension. She initially noticed her abdomen becoming distended three months prior, associated with a mild occasional colicky abdominal pain. She was hesitant to seek medical attention during the initial period due to the evolving COVID-19 pandemic. However, as the symptoms gradually progressed during the last 1 week, in addition to the increasing obstructive features, she reluctantly came to the hospital for consultation.Upon the initial presentation, she was considered a well-built, nourished lady with no cachexia or dehydration. She was clinically stable. Physical examination revealed a distended, tense abdomen without any sign of peritonism. Blood investigations were within normal range. In view of the possibility of gynaecologic pathology, tumour markers including serum cancer antigen (CA) 125, lactate dehydrogenase (LDH), and carcinoembryonic antigen (CEA), were performed showing normal results. Simple abdominal radiography revealed an extensive radiopaque lesion involving the abdominopelvic region with no evidence of intestinal obstruction . A compuOn laparotomy, a generous midline incision was made extending from the xiphisternum to the pubic symphysis to allow for a better surgical view and access A. Intrao3The COVID-19 pandemic has created global chaos, especially in the healthcare system . Cases oHuge abdominopelvic mass can be due to various reasons, either from surgical or gynaecological causes. Clinical symptoms and physical examination findings alone may not be adequate in helping elicit the pathology's likely origin. Ultrasound remains the first line of imaging study, especially during a pandemic, as it is readily available at the bedside, widely acceptable, inexpensive, and non-invasive . The risIn view of the tumour size, minimally invasive surgery is technically inappropriate, therefore, laparotomy was chosen as the route to retrieve the mass. Works of literature recommend an intact removal of any hydatid cyst or suspected ovarian mass to avoid any spillage of its content ,16. PercPathologic criteria are crucial in making the correct diagnosis in order not to miss the borderline or invasive components. Mucinous neoplasm represents a variety of spectrums, either benign, borderline, or invasive histologic variants. Thus, a thorough evaluation of the specimen is crucial to get a proper diagnosis. Among benign ovarian neoplasms, mucinous cystadenomas account for approximately less than 15% of all cases . Mucinou4A giant abdominopelvic cystic mass can present emergency havoc during the COVID-19 pandemic. Ultrasound is convenient and safer, but might not be diagnostically accurate compared to a CT scan. In view of the pandemic, urgent surgical intervention is mandatory by using full PPE and exercising extreme precaution, regardless of the preoperative screening to avoid unnecessary viral transmissions.Ethical approval was obtained from the local institution.None.RG - manuscript preparation. AAA - manuscript preparation. FH - final review. VVR - literature search. AOP - data collection. AAW - literature search. NA - literature search. MMAA – data collection. BA - final review.The authors declare that there are no conflicts of interest.No ethical clearance required as it only involves case report.Nornazirah Azizan.Written informed consent was obtained from the patient for publication of this case report and accompanying images. Permission was also obtained from local administrators. A copy of the written consent is available on request.Data sharing is not applicable to this article, as no data sets were generated or analysed during the current study.Not commissioned, externally and internally peer-reviewed.


We present a case of calcific tendinopathy of the rotator cuff with intraosseous migration of the calcification, treated with ultrasound-guided bursal steroid injection and followed up with multiple imaging modalities for a year following the initial presentation. The radiographs, ultrasound, CT, nuclear scintigraphy, and MRI images demonstrate the temporal evolution of the intraosseous migrated calcium and show how this pathology, in its acute phase, can mimic other pathologies like osteoid osteoma. The follow-up imaging also illustrates how the migrated intraosseous focus of calcification took a much longer time to heal compared to its intratendinous counterpart, possibly leading to the protracted course of recovery. This report also highlights a previously undescribed pattern of healing of the intraosseous migrated calcium on multiple imaging modalities. This condition often involves the rotator cuff tendons, especially the supraspinatus tendon, in middle-aged females. Although benign and self-limiting, it can be an excruciatingly painful condition by inciting inflammatory changes. Intraosseous migration of these tendinous calcifications is relatively uncommon but well-documented in the literature.Calcific tendinopathy is a relatively common condition related to the deposition of calcium hydroxyapatite crystals within the tendons. Our case report attempts to bridge this knowledge gap and present the temporal evolution of intraosseous migration of rotator cuff tendinous calcifications on multiple modalities 1 year after initial presentation and following treatment by ultrasound-guided bursal injection of steroid.Although this pathology is evident on radiographs, CT and ultrasonography, MRI is often requested by clinicians in the setting of non-traumatic shoulder pain. The intraosseous manifestations of migration of intratendinous calcification may mimic a bone tumour or infection, especially on MRI. At times, further imaging like bone scintigraphy may also be requested in such a situation, further adding to the diagnostic dilemma. The challenge in making the diagnosis on MRI is exacerbated by the knowledge gap in the temporal evolution of these lesions on various modalities. To our knowledge, there is only one article in the literature describing the evolution of these migrated intraosseous calcium deposits on radiography 1 year after the presentation, with no articles describing the associated bone changes over time on MRI.A 36-year-old, right-hand-dominant lady presented to her general physician with acute onset severe pain in her left shoulder. There was no history of trauma or surgery to the shoulder. She did not respond to a trial of physiotherapy and was referred to an orthopaedic surgeon by her general physician. Physical examination by the surgeon revealed mild weakness in internal rotation of the left shoulder with generalised restriction in shoulder movements due to pain. Her blood counts and serum inflammatory markers were within normal limits.Radiographs of the left shoulder confirmed a 2.1 cm amorphous calcification within the supraspinatus tendon. The calcification was in close relation to the adjacent greater tuberosity. Faint sclerosis with a subtle erosion with sclerosis was seen at the greater tuberosity on the radiographs . There wThe patient was referred for a percutaneous ultrasound-guided lavage of the tendon calcification 2 months after the MRI. The ultrasound evaluation showed a significant reduction in the size of the tendinous calcification, which measured only 8 mm in the largest dimension and was not amenable for a lavage . The ulti.e. 7 months after the first MRI scan), the patient returned to her orthopaedic surgeon, who requested a CT scan of the shoulder. The CT demonstrated a 1 cm osteolytic focus in the region corresponding to the previously demonstrated T1 and T2 low signal focus on MRI and erosion on radiograph and ultrasound (99mTc nuclear bone scan, which was performed 6 weeks later, and showed focal mildly increased bone tracer activity at the site of the osteolytic lesion (The patient only had a mild reduction in her symptoms following this treatment. In addition, she had significant persistent pain limiting her activities, which got worse at night. 5 months later (trasound . The tentrasound . Faint ctrasound . Due to c lesion . HoweverSince the CT and bone scintigraphic findings were not typical of an osteoid osteoma, the patient was started on conservative management and follow-up radiographs and a second CT scan were performed 5 months after the bone scan and almost a year after the initial presentation and the first MRI scan. The radiograph and CT demonstrated the same osteolytic focus within the greater tuberosity of the proximal humerus, which was stable in size but showed interval ossification along its periphery . The preIn summary, the follow-up imaging features ruled out the possibility of a neoplastic bone lesion. The lesion was consistent with a migrated intraosseous calcific tendinopathy, demonstrating features of healing. The patient’s symptoms had also improved with conservative therapy, paralleling the imaging findings and suggesting her persistent symptoms post-percutaneous bursal steroid injection were related to the bone and bursal involvement of the calcific tendinitis.Accounting for almost 7% of all painful shoulder conditions, the presentation of calcific tendinopathy of the rotator cuff may vary from asymptomatic to severe pain. In addition, the symptomatology in calcific tendinopathy does not always correlate with the imaging findings. proposed that calcific tendinitis evolved through three stages: pre-calcific, calcific, and post-calcific. In the pre-calcific stage, the tendon, especially the relatively hypovascular “critical zone”, sustains a hypoxic and mechanical injury resulting in fibrocartilaginous metaplasia. During this stage, the patients are essentially asymptomatic or complain of mild pain and reduced range of motion. The second stage, i.e. the calcific stage, is further divided into formative and resorptive phases. The formative phase is the phase of actual calcium deposition mediated by the chondrocytes, while in the resorptive phase, there is vascular weaving in the affected area followed by macrophages attempting phagocytosis of the calcium deposits. This phase is characterised by increased intratendinous pressure, which leads to acute pain and disability, especially if the calcium leaks into the subacromial–subdeltoid bursa. Finally, the post-calcific stage is characterised by tendon tissue remodelling by fibroblasts forming scar tissue. The pain persists during this phase, although less severe than the resorptive phase. These phases vary in duration, especially the latent period between the formative and resorptive phases.Uhthoff et al A histopathological evaluation performed in a few of these lesions confirmed the intense inflammatory reaction incited by the calcified material in the bone marrow, with one of the authors mentioning histiocytic inflammation with giant cells and decalcified areas.During the resorptive phase, the intratendinous calcification can migrate into the surrounding structures such as bone, subacromial–subdeltoid bursa or even into the adjacent muscles. The exact mechanism of intraosseous migration is not well understood. However, it is postulated that enzymatic action causes lysis of cortical bone of the greater tuberosity, through which calcium salts can penetrate the bone and produce an inflammatory reaction of the adjacent bone marrow. However, the radiographs are frequently poor predictors of intraosseous migration. In our case, the radiograph did show subtle sclerosis at the site of intraosseous migration initially, which became lytic subsequently on follow-up.The radiographic features of intraosseous calcium are often subtle and may appear as cortical erosions or irregularities, while rarely the migrated calcium may appear as a dense or sclerotic focus in the proximal humerus. In our case, the lesion was osteolytic. We believe that the lesion appeared osteosclerotic in the early phase, with the enzymatic processes leading to resorption of the calcification and eventually resulting in a lucent lesion at the site of intraosseous migration. Our patient’s follow-up CT images show that the lesion shows healing by reossification along the periphery. Although healing by ossification is a known phenomenon in treated bone lesions, this pattern of spontaneous healing of intraosseous calcific tendinopathy has not been previously described in the literature to our knowledge.CT detects the signs of intraosseous migration, such as cortical erosions, with much more accuracy. There are varying reports from the literature suggesting that intraosseous calcium may result in an osteosclerotic or an osteolytic lesion within the humeral tuberosity.Ultrasonography is very useful in detecting calcific tendinopathy, appearances of which are well-documented in literature and beyond the scope of this report. Ultrasound appearance of intraosseous migration is intrinsically suboptimal due to lack of bone penetration. However, ultrasound can detect cortical erosions with/without subcortical intraosseous lesions with reasonable success. Establishing continuity between the tendinous calcification and the intraosseous component is essential for establishing a diagnosis. Doppler evaluation may also show hyperemia around the calcification and, in acute stages, around the erosion.When performed due to clinical suspicion of an aggressive bony lesion, bone scintigraphy may show focal increased uptake at the site of intraosseous migration. The specific MRI features of intraosseous migration of tendinous calcifications are:Erosion of the greater tuberosity associated with an intraosseous hypointense focus in multiple sequences, which corresponds to the migrated intraosseous calcium.Inflammatory oedema in the perilesional bone marrow and adjacent soft tissue.Although MRI is considered less sensitive than CT or radiographs to detect calcifications, it is highly sensitive in detecting the reactive inflammatory changes in the soft tissues and the bone due to the calcifications.In our case, the intraosseous focus returned a typical low signal in the initial MRI during the acute stage, when the migrated calcium was dense enough to appear sclerotic on the radiographs. However, on the subsequent MRI scan, the migrated deposit showed a higher signal on T2, suggesting interval resorption of the migrated calcium. The lesion also demonstrated a peripheral rim of fatty signal with overlying bone remodelling, a sign of healing, along with a complete resolution of the bone marrow oedema, which virtually excluded any aggressive bone lesion.Our report shows that a CT scan accurately depicts the intraosseous migration of tendon calcification. Nevertheless, CT features can be misleading, especially once the calcification has been resorbed and the cortical erosion begins to heal. The MRI appearance is also highly variable, depending on when the scan is performed. However, MRI is less sensitive than CT for detecting tendon or intraosseous calcifications.Our patient was treated with percutaneous ultrasound-guided bursal steroid injection since her tendinous calcifications had significantly reduced in size to be amenable for a lavage, partly due to ongoing resorption and partly due to the continued intraosseous and possibly also bursal migration. Despite the injection, she only had a mild reduction in her symptoms. Unsatisfactory results following the percutaneous treatment made the clinician perform additional imaging and raise the suspicion of a possible underlying bone lesion, since there was an improvement in the size and density of the tendinous calcifications while her symptoms persisted. A review of recent literature reveals that the presence of intraosseous migration of calcific rotator cuff tendinopathy is associated with a less satisfactory outcome with percutaneous treatment than an uncomplicated rotator cuff calcific tendinopathy.In conclusion, this case report highlights a previously undescribed evolution in the appearance of intraosseous migrated calcium over time, with the calcium deposit initially appearing dense in the acute phase on radiographs, with corresponding low signal on MRI. Over the next few months, the focus became osteolytic on CT and showed a higher T2 signal on MR. The healing process began from the periphery in the form of a rim of fat signal, surrounding ossification and bony remodelling. In the acute stage, extensive perilesional bone marrow oedema was also identified on MRI, which later resolved. Despite percutaneous treatment for managing the pain due to the calcific tendinopathy, the intraosseous migration took significantly longer to heal. In concordance with the imaging appearance, the patient also had a less satisfactory result following percutaneous intervention for pain management. Awareness of the temporal evolution of intraosseous migration on imaging is essential to make the correct diagnosis, avoid unnecessary aggressive management, and prognosticate the response to percutaneous treatment of calcific tendinopathy.Intraosseous migration of calcific tendinopathy can have a highly variable appearance on imaging based on the duration since the onset of the pathology.The healing process of the migrated intraosseous calcific focus starts along the periphery of the focus, in the form of fatty marrow proliferation followed by ossification.Patients having calcific tendinopathy with intraosseous migration can have a more protracted course of improvement, even with percutaneous interventions.CT most accurately detects intraosseous migration, especially in the early stages. However, the appearances can be confusing once healing sets in, with the onset of calcium resorption.MRI features of intraosseous migration vary depending on when the scan is performed during the course of the disease. MRI is not as sensitive as CT to detect tendon or intraosseous calcifications.


Rectus sheath hematomas (RSH) are increasing in prevalence, presumably correlating with increased use of anticoagulation medications and an aging population. Comorbidities such as blood dyscrasias, atherosclerosis, and hypertension are associated with an increased risk of developing an RSH. Iatrogenic origin of RSH, secondary to treatment of various abdominal pathologies, is not uncommon. Due to its exceptionally non-specific array of clinical signs and symptoms, RSH can be challenging to diagnose in the clinical setting without the aid of radiological images. Abdominal computed tomography (CT) is generally the modality of choice through which the RSH can be successfully identified and characterized. CT imaging can play an important role in the planning of RSH management, as effective management varies depending on the size and position of the RSH. Recurrent bleeding, hypovolemic shock, abdominal compartment syndrome, myonecrosis, and infection have been traditionally considered as the more prominent complications of RSH. However, with more cases occurring, more complications are being described in the literature. The following case presents a previously unreported complication of RSH, that of bowel herniation into a potential space created by a previously treated RSH. Rectus sheath hematomas (RSH), most often the result of bleeding from an epigastric artery or one of its branches within the rectus sheath, are increasing in frequency and severity . An aginOur patient is a 71-year-old female with chronic lymphocytic leukemia on anticoagulation for a history of deep vein thrombosis. She was admitted to the hospital for tachycardia, weakness and diarrhea, and ultimately diagnosed with Clostridium difficile colitis. Several days into her admission she developed right lower quadrant (RLQ) abdominal pain that was initially believed to be due to the colitis. However, over several days her pain worsened and she became hemodynamically unstable, requiring blood transfusions. Contrast enhanced CT demonstrated an RSH with active extravasation from the right inferior epigastric artery . IR decided to perform an inferior epigastric embolization procedure, after which the patient stabilized Figures , 3. Two years later she again developed RLQ pain, and was found to have a small bowel hernia that entered the space created by the prior RSH Figures -6. Mesh RSHs are increasing in frequency and severity, correlating with an aging population and greater use of systemic anticoagulation. As a consequence, complications from RSH will also increase, including more rare complications such as hernia into the resultant potential space . The most common presenting symptom of RSH is abdominal pain. While pain may be focal or diffuse, it has been reported that diffuse pain is more frequent for RSHs greater than 3-5 cm in size . PhysicaRSH generally develops due to tearing of an epigastric artery or one of its branches within the rectus sheath. RSHs are more common below the arcuate line for several reasons. Below the arcuate line, the posterior fascia is less robust, as the internal oblique and transversus abdominis aponeuroses of the rectus sheath instead pass anteriorly to the rectus abdominis muscle, leaving only the transversalis fascia posteriorly. Additionally, there is the potential for communication between the inferior retrorectus space and the prevesicular space of Retzius, which creates a natural dissection plane ,5. ThirdCT is the modality of choice for detection of RSH and its complications ,2,5. IncTreatment depends on presentation, anticoagulation status, and hemodynamics. Because many mild RSHs are self-limited, supportive treatment with pain management, limited activity, and anticoagulation discontinuation can often lead to resolution ,2. AdditRegardless of whether conservative or invasive management is employed, clinicians should consider sequelae of RSH when a patient with a history of RSH presents with abdominal pain. While not likely, such abdominal pain could be due to bowel herniation into the space created by a previous RSH, as was seen in this case. Rectus sheath hernia is a very rare entity, with only a few published cases. Most occur as the result of trauma or surgical weakening, with spontaneous cases much less common . It is oAlthough more common complications, such as recurrent bleeding, infection, or the rarer complication of abdominal compartment syndrome are well known, the delayed complication of abdominal hernia should be considered in patients with abdominal pain and a history of RSH. A review of the literature did not reveal small bowel herniation into the space created by the RSH as a complication. Quality abdominal imaging is the key to ensuring proper diagnosis and management in these individuals. Our hope is to raise awareness of this rare complication. Given that RSH is increasing in prevalence, it stands to reason that this hernia may occur more frequently in this demographic and should be considered highly on the list of differential diagnoses in a patient with abdominal pain and a history of RSH.


Teaching Point: The acute appendicitis in a context of Malone appendicostomy complication is very rare but can occur and may be challenging to diagnose due to its unusual position. Figure 1, red arrow axial image) and enlargement of the appendicostomy due to a large 30 × 10 mm appendicolith  with discrete fat stranding  and local reactional mesenteric lymph nodes. No bowel perforation was detected. The retained diagnosis was acute appendicitis, and the patient was treated conservatively with a satisfactory clinical evolution. Years later, relapsing symptoms led to surgical ablation of the appendicostomy. MA anastomoses the appendix to the deep part of the umbilicus and includes a valve mechanism allowing for antegrade colonic enema flushing without stool leakage in patients with fecal incontinence. Frequent complications of MA include stomal orifice stenosis as well as stomal infection and appendiceal perforation during catheterization [A 33-year-old male patient with a history of Malone appendicostomy (MA) for neonatal ano-rectal malformation presented with fever (40°C), increasing periumbilical pain, diarrhoea and nausea. Clinical examination revealed periumbilical cutaneous inflammation. Bloods showed only discrete increase of CRP. Abdominal computed tomography (CT) examination revealed wall thickening (


PEComa has become a widely accepted entity, and increased recognition has led to descriptions of this tumor in a wide variety of anatomic sites, including the adrenal gland. PEComa (perivascular epithelioid cell tumor) is a mesenchymal tumor composed of perivascular cells, and the most frequent sites of PEComas are the uterus and retroperitoneum. The incidence is <1 per 1,000,000 people. We report a case of adrenal metastatic PEComa in a 63-year-old man discovered by a spontaneous hematoma of the rectus abdominis. In our case, PEComa of the adrenal gland was a significant diagnostic dilemma as the morphologic and immunophenotypic features of this neoplasm may easily be confused with those of other more commonly encountered lesions. PEComa of the adrenal gland may present a significant diagnostic dilemma as the morphologic and immunophenotypic features of this neoplasm may easily be confused with those of other more commonly encountered lesions. PEComa (perivascular epithelioid cell tumor) is a mesenchymal tumor composed of perivascular cells, and the most frequent sites of PEComas are the uterus and retroperitoneum. Since its first description, PEComa has become a widely accepted entity, and increased recognition has led to descriptions of this tumor in a wide variety of anatomic sites ,2. AmongA 63-year-old man with a spontaneous hematoma of the rectus abdominis muscles had an abdominal ultrasound (US), which revealed a 4 cm abdominal mass positioned in the left upper quadrant. Magnetic resonance imaging (MRI) to complete the evaluation of the lesion revealed a 4.1 cm round-shaped adrenal incidentaloma with intracellular fat and no indications of invasion. The patient’s functional activity was systematically assessed by means of endocrine biochemical testing, regardless of the presence or absence of symptoms. Measurement of urinary catecholamines and metanephrines, 24 h urine-free cortisol (UFC) excretion, late-night salivary cortisol (LNSC) levels, and 9 am plasma cortisol following an overnight dexamethasone suppression test resulted negative. Hypokalemia was not demonstrated. Following the examination, the patient was referred to our outpatient endocrine surgery clinic. In anamnesis, the patient presented the following comorbidities: obesity (Body Mass Index = 38), myasthenia gravis, atrial fibrillation with anticoagulant therapy, and previous cardiac surgery for pulmonary valve stenosis. He denied having abdominal pain, and he did not complain about nausea, vomiting, fever, chills, anorexia, or weight loss. Abdominal examination was normal, with no tenderness or evidence of hepatosplenomegaly. The patient also had a DOPA PET scan and an FDG PET scan (fluorodeoxyglucose positron emission tomography), which were both negative.The case was discussed in a multidisciplinary meeting, and a conservative approach was recommended for important comorbidities, including an enhanced MRI (Magnetic Resonance Imaging) of the abdomen at 12 months and biochemical testing. Following a new MRI one year later, the lesion appeared to have grown in size, measuring 5.9 cm in diameter without evidence of malignancy or infiltration. Based on the increase in tumor size, the case was re-discussed, and left laparoscopic adrenalectomy was undertaken with the patient’s consent. The surgical intervention started with a transabdominal lateral laparoscopic approach but, since its beginning, it was complicated with frequent minor hemorrhages from the lesion, necessitating conversion to a subcostal laparotomy. The mass was excised en bloc with the entire capsule. The patient was discharged without complications on POD #5. Histological diagnosis was of adrenocortical adenoma (Weiss Score: 1 point because of a nuclear grade of 3 points according to Fuhrman criteria). No vascular or peritumoral capsular invasions were observed. The mitotic index was <1 × 10 HPF.The patient underwent an annual follow-up for 3 years with imaging (computed tomography—CT or MRI), which was negative for any pathologic features other than muscular relaxation at the site of the laparotomic incision.Three years later, the patient presented to the emergency unit with walk instability and lower back pain that had persisted for fifteen days without any relief despite medications. Neurological examination revealed symmetrical reflexes in the biceps, triceps, and a left prevalence in the knees and ankles. Upright posture could be maintained for a few seconds with double support. The patient had a lumbar spine MRI, which revealed an expansive lesion with medullary compression in D9, as well as a smaller lesion in D11. Emergency neurosurgery was performed on the patient, and a decompressive laminectomy of the D8–D11 vertebra was carried out. The histological report concluded that the patient had epithelioid mesenchymal neoplasia with clear and eosinophilic cells consistent with bone metastases from PEComa. Pathological review of the adrenal mass resulted in a revised diagnosis of adrenal PEComa, with an immunophenotype melan A +, cathepsin K +, synaptophysin −, chromogranin A −, calretinin −, SF1 −, HMB45 −, smooth muscle actin −, and inhibin − .FISH test for the detection of the TFE3 (Xp11.23) rearrangement was negative in both adrenal and bone lesions.A new FDG-PET revealed a round-shaped enhanced mass in the left para-aortic region compatible with lymph node enlargement, multiple areas of elevated SUV in the lumbar spine, and a single 8 mm nodule in the right upper pulmonary lobe .The patient died of cardiac failure one month later.Adrenal incidentaloma is defined as a clinically inapparent adrenal mass (>1 cm in diameter) found during an imaging study performed for a reason unrelated to adrenal disease. This definition excludes patients who are undergoing screening and surveillance because of hereditary syndromes or those with known extra-adrenal cancer who are undergoing imaging for staging or during follow-up after treatment. The prevalence of adrenal incidentaloma has been reported to be 1 to 6% and is higher among older adults (V–VII decades), regardless of gender. According to the literature, 80% of incidentalomas are non-functioning adenomas, 5% are subclinical Cushing’s syndrome, 5% are pheochromocytoma, 2.5% are adrenal metastases, and the remaining are adrenal carcinomas, PGL, myelolipomas, or benign cysts ,4,5. PatAccording to Mantero et al., a non-functional adrenal incidentaloma that is 4 cm or less and has been positively identified in imaging tests should be checked periodically via radiological imaging  and hormone evaluation. Surgical treatment should be performed regardless of tumor size, radiological imaging features, and in all cases of hormone-hypersecreting tumor-associated clinical symptoms ,4,5,6,7.Adrenal PEComa is a very rare pathology with a varying prognosis based on histological features. The variety of therapeutic strategies used with heterogeneous results, as well as the lack of established guidelines, highlights the need for randomized trials. While the optimal course of treatment is debatable, surgical resection remains the cornerstone of therapy.


Type I Neurofibromatosis (NF1) is a dominant autosomal disease. Its prognosis is related to the development of tumors that may evolve to malignancy. It is characterized by multiple café-au-lait spots, skeletal defects, optical gliomas, Lisch nodules and neurofibromas.Plexiform neurofibromas (PN) are one of the many possible findings on patients affected by the disease.This paper aims at reporting on a case of a pediatric patient with cervical plexiform neurofibromas and the difficulties inherent to the treatment.A four months old male patient, with high respiratory discomfort, was diagnosed with a mass in the rhinopharynx that extended all the way to the oropharynx, later described as a plexiform neurofibroma in the pathologist's report.The CT scan of the area revealed a mass located in the left parotid region. The tumor was diverting the internal carotid artery from its original position and compressing the internal jugular vein. (Picture 1)At 16 months of age the patient underwent a tracheotomy to address the respiratory difficulties. At 18 months he was submitted to a partial excision of the tumor as it was infiltrating in the cervical plexus, brachial plexus, and facial nerve. Biopsy findings also pointed to plexiform neurofibroma.The child is being monitored for worsening of compressive symptoms and signs of malignancy.Patients with NF1 have increased chance of developing benign and malignant tumors, which may in some cases infiltrate and lead to compression of vital structures and evident deformities.Images are key for diagnostic purposes, and tissue biopsy is used to confirm the diagnosis.Although most tumors are benign,Surgery is the only effective option to manage plexiform neurofibromas. Success is however limited, as this is a highly infiltrating tumor with elevated relapse rates. Besides, the difficulty in identifying the main nervous plexus during surgery increases postoperative morbidity and incidence of neurological complications.It seems prudent to postpone surgery in symptom-free patients with head and neck PN until clearly obstructive symptoms are present.Neurofibromatosis is an entity to be considered by otolaryngologists when performing the differential diagnosis of cervical tumors.It usually manifests itself in the form of deeply located benign tumors that may compress vital structures. In such cases, surgical management is required.There is consensus that surgery must be postponed until compressive symptoms are present or signs of malignancy have been identified.


Crohn’s disease (CD) is an inflammatory disease that can affect any portion of the gastrointestinal tract (GIT). Although it can present with a number of complications, perianal fistulae are among the most common consequences in patients with CD. In very rare cases, these patients can develop fistula-associated anal adenocarcinoma (FAAA). In this case report, we discuss a 72-year-old man with a long-term history of CD complicated by perianal fistulae, which failed medical and surgical management, ultimately presenting with acute anal pain in the outpatient setting. The physical examination revealed a seton traversing through a fistula surrounded by circumferential granulation tissue suspicious for malignancy. A biopsy of the tissue confirmed grade 3 mucinous-type infiltrating adenocarcinoma of the perianal skin. The patient was diagnosed with an anal verge malignancy associated with a fistula in the context of long-standing CD, and MRI staging demonstrated a T3N1 lesion with potential left inguinal node involvement. He completed neoadjuvant chemo-radiotherapy using capecitabine for five weeks with minimal tumor response, and subsequently, an abdominoperineal resection (APR) was performed with patient discharge on the fifth post-procedure day. Post-operative chemotherapy with oxaliplatin/leucovorin/fluorouracil was administered with minimal complications. Although rare, this report demonstrates the importance of consistent follow-up and mitigation of risk factors in patients with CD, along with the significance of prompt multimodal treatment in the event of developing FAAA. Crohn’s disease (CD) is a relapsing, inflammatory condition of the gastrointestinal tract (GIT) characterized by transmural inflammation that can affect any portion of the GIT, with the terminal ileum being the most commonly involved ,2. ComplA diagnosis of CD puts patients at a greater risk of developing small bowel cancer and colorectal cancer (CRC), while the additional presence of perianal fistulae magnifies the risk of developing anal carcinoma in the long term . In a meIn the following case report, we describe the clinical course of a gentleman presenting with longstanding perianal CD with subsequent malignant degeneration into FAAA.Patient informationThe patient is a 72-year-old male with a past medical history significant for CD initially diagnosed in 1996 and subsequently was lost to follow-up without treatment. The patient did not have any active disease until 2013 when his illness was complicated by the development of recurrent perianal abscesses and a complex posterior midline fistula. Between 2013 and 2019, he was medically treated with occasional antibiotics, while multiple fistulotomies and seton placements had to be performed to manage the perianal fistulizing CD. He was started on azathioprine in October 2018 for his active disease and planned to eventually transition to adalimumab; however, the medication was ultimately never initiated due to social reasons.A prior colonoscopy in 2018 demonstrated fragments of tubular adenoma, colonic polyps, diverticula, and erythematous mucosa in the rectum. He was an active smoker of 0.25 packs per day for about 50 years at presentation and had a history of cured hepatitis C after antiviral therapy.The patient presented acutely with significant anal pain to the colorectal surgery outpatient clinic in early May 2020, after a recent seton placement in January 2020. He reported the anal pain to be associated with defecation but denied any fever, chills, or purulence from the non-healing fistula opening.Clinical findingsAt this outpatient clinic visit, the patient was normotensive with a slightly elevated pulse at 102 beats per minute. His abdomen was soft, non-tender, and non-distended. An anorectal examination revealed a seton in the right posterior position, multiple perianal skin tags, and butterfly-shaped granulation tissue with a firm margin surrounding the seton circumferentially in the perianal area without induration, significant pain, or purulence.TimelineThe firm granulation tissue was biopsied to rule out malignancy; however, the results of the biopsy showed grade 3 infiltrating adenocarcinoma of the perianal skin, mucinous type. The patient was subsequently diagnosed with an anal verge malignancy associated with a fistula in the context of long-standing CD. The MRI staging demonstrated a T3N1 lesion with potential left inguinal node involvement. He completed neoadjuvant chemo-radiotherapy with capecitabine for five weeks. Post-treatment MRI showed a minimal response of the tumor to neoadjuvant therapy. In November 2020, an abdominoperineal resection (APR) was performed. He recovered well postoperatively and was discharged on postoperative day five.Diagnostic assessmentPathological evaluation of the biopsy specimen from the perianal skin biopsy done in the clinic in June 2020 showed invasive tumor nuclei staining positive for MLH1, PMS2, MSH2, and MSH6. Additionally, no loss of the DNA mismatch repair (MMR) protein was noted, indicating a micro-satellite stable (MSS) tumor. The tumor was also negative for mutations in the KRAS, BRAF, and NRAS genes. The tumor was staged at T3N1. The patient's carcinoembryonic antigen (CEA) level was 3.6.Flexible sigmoidoscopy was performed shortly after to evaluate anal and rectal mucosa which revealed normal results.The MRI without contrast of the pelvis described the mass as located in the posterior perianal region with disruption of the internal and external anal sphincters and extension between the Coccyx and Levator Ani. The MRI also demonstrated potential left inguinal involvement, and seton transversal through the tumor was confirmed Figure .Preoperative evaluation with an MRI in October 2020 showed minimal changes relative to the initial diagnostic MRI, other than a minor decrease in left inguinal involvement . Lymphovascular invasion was also not identified.Following surgical intervention, the patient completed 12 cycles of chemotherapy with modified leucovorin/fluorouracil/oxaliplatin (FOLFOX-6) after evaluation by hematology-oncology. Cycle 9 was complicated by an episode of osteomyelitis that resolved with antibiotic treatment and evaluation from wound care.Follow-up and outcomesHis immediate postoperative course was complicated by a wound seroma that was drained and packed. Unfortunately, he was re-hospitalized around one year after the surgical intervention with findings concerning for osteomyelitis. He is being surveilled for recurrence of the neoplasm with no current signs of malignancy.In this case report, we have described the case of a 72-year-old man with CD who was subsequently diagnosed with FAAA and treated with a combination of chemotherapy, radiotherapy, and surgical intervention. His overall therapeutic regimen can be described as successful given the complete removal of the tumor and lack of neoplasm recurrence, and several lessons can be learned for application to future cases.While cases of FAAA have been noted to have increased over the past few decades ,8, reporThe development of carcinoma in the context of perianal fistulae is associated with perianal disease progression for a period longer than 10 years . AlthougWhen comparing the clinical course of this patient to other cases of FAAA, a number of similarities and differences can be noted. In a similar fashion to this patient, the presentation of FAAA in nearly all examined cases were associated with anal pain, a diagnosis of CD more than 20 years prior, and a corresponding long-term history of perianal fistulae. In contrast to other cases, the subject of this case report was noted to be more than a decade older than FAAA patients reported elsewhere in the available literature, at the time of presentation ,7,10. ReWhile our patient has achieved a positive result with no evidence of recurrent disease almost two years after his APR, outcomes have varied among other cases. Results after a local resection were less optimal, with a life expectancy of only around six to 12 months when compared to a life expectancy of up to one to six years after an APR with varying rates of tumor recurrence ,7,10. WeIn summary, our experience treating this patient demonstrates the essential nature of consistent follow-up and monitoring of patients with perianal fistulizing CD concerning the development of FAAA. This case report further demonstrates the importance of prompt intervention with a combination of chemotherapy, radiotherapy, and surgical resection to optimize positive outcomes in these patients. Finally, patients should be encouraged to mitigate potentially modifiable risk factors for the development of these tumors.


Large cervical leiomyomas (≥10cm) are extremely rare. Our case report concerns the surgical treatment of a patient with a large cervical leiomyoma associated with chronic pelvic pain, bilateral hydroureteronephrosis and significant impairment of renal function. A 47-year-old patient of reproductive age with a normal menstrual cycle and a medical history of chronic pelvic pain presented to the gynecology clinic for examination. Clinically, the presence of a large pelvic mass was found, the upper margins of which were palpable at the level of the umbilicus. A preoperative assessment revealed bilateral hydroureteronephrosis due to obstructive uropathy and renal dysfunction. Hydroureteronephrosis, as a consequence of the large pelvic mass, probably originating from the cervix of the uterus, was evaluated as the main cause of renal dysfunction. Tumor markers were negative. The imaging studies confirmed the clinical diagnosis of uterine leiomyoma, and the surgical treatment of the patient with laparotomy was decided. Intraoperatively, the presence of a large uterine cervical fibroid was detected, and a total abdominal hysterectomy and bilateral adnexectomy were performed. Operating was difficult, with significant surgical difficulties. The postoperative course was uneventful, without immediate complications. The patient's symptom relief began gradually, immediately after surgery. Three months after surgery, the patient reported complete relief of her pelvic pain. A re-examination of the urinary tract revealed complete recovery of renal morphology and function. In the paper, after the presentation of the case, a brief review of cervical leiomyomas is attempted based on the literature, mainly regarding the diagnostic and therapeutic approach. Leiomyomas, also known as fibroids, are the most common uterine neoplasms. They are benign estrogen-dependent tumors consisting mainly of myometrial smooth muscle cells. Fibroids usually occur during reproductive age and are more common in women of African descent than white women . The etiThe current case report emphasizes the significant degree of bilateral hydroureteronephrosis with deterioration of renal function and the significant surgical difficulties that may arise when treating rare cases of large leiomyomas originating from the cervix. At the same time, it is pointed out that, despite their rarity, large uterine cervical leiomyomas must be included among other pathological conditions in the differential diagnosis of chronic pelvic pain associated with hydroureteronephrosis, and deterioration of renal function in women of reproductive age, to avoid permanent renal parenchymal disease and to ensure the good health and quality of life of these patients.A 47-year-old patient with a normal menstrual cycle came for a gynecological examination. The patient had two vaginal deliveries in her obstetric history and a medical history of hyperlipidemia and arterial hypertension, well-regulated with medication. From the history, neither chronic kidney disease was reported, nor recurrent urinary tract infections in recent years. From the personal medical history, the presence of pelvic pain during the last two years, accompanied by occasional mild episodes of frequent urination and dysuria, was mainly reported. The clinical examination revealed the presence of a large pelvic mass, the upper margins of which were palpable at the level of the umbilicus. Transabdominal ultrasound disclosed a solid, discrete, echogenic mass occupying the entire pelvic cavity, likely originating from the cervix Figure .Computed tomography confirmed the ultrasound findings but could not rule out the presence of a pedunculated subserosal uterine fibroid or a solid adnexal mass Figure .Intravenous pyelography revealed bilateral dilatation of the pelvicalyceal system, displacement of the ureters, and incomplete filling of the bladder Figure .The laboratory analysis upon patient admission to our clinic found: Ht 39.6%, Hb 13.1gr/dl, PLT 260x103/ml, U 83mg/dl, Cr 1.9mg/dl, Na 142mEq/lt, K 4.2mEq/lt. Inflammatory markers were negative. The urine culture was without evidence of urinary tract infection. Cytology (Test Papanikolaou) of the displaced and partially deformed cervix by the pelvic mass, which took place preoperatively, was negative for malignancy. Tumor markers  were within normal range. The examination by the physicians of the nephrology clinic of our hospital did not find any comorbidity that could be associated with impaired renal function.The clinical diagnosis of uterine leiomyoma was confirmed by imaging, and it was decided to treat the patient surgically with laparotomy after the pre-operative insertion of pigtail catheters. After opening the abdominal wall and peritoneum, the presence of a large cervical fibroid was detected and a total abdominal hysterectomy with bilateral adnexectomy was performed. After a technically difficult surgery accompanied by significant blood loss, intraoperative transfusion with packed red blood cells was deemed necessary. Transfusion with second-packed red blood cells was also assessed as necessary on the first postoperative day to stabilize the patient hemodynamically. Histological examination of the surgical specimen confirmed the intraoperative diagnosis: the body of the uterus was strongly deformed by the presence of a large leiomyoma in the cervix with a maximum diameter of 14cm. Increased cellularity, coagulative necrosis, atypia, or increased number of nucleokinesis was not observed.After a smooth postoperative course and immediate undisputed improvement of renal function (serum creatinine 1.5mg/dl), the patient was discharged from our clinic on the fifth postoperative day. Three months later, the patient was completely free of chronic pelvic pain and its accompanying symptoms.The ultrasound revealed a complete remediation of the renal morphology and function. The kidneys were visualized with normal echogenicity, normal perfusion, and without dilation of the pelvicalyceal system Figures , 5. SeruCervical leiomyomas are located on the cervix. Cervical leiomyomas are divided into two types depending on their localization: the extra cervical type, which is characterized by the growth of the tumor outside the cervix, and the intracervical type (our case), whose fibroids grow inside the cervical lumen ,6. CerviThe clinical diagnosis of uterine cervical fibroids is challenging. These patients, when the fibroids are small, are usually asymptomatic. Abnormal uterine bleeding, chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility are the main clinical manifestations that characterize symptomatic patients with cervical uterine leiomyomas ,11. In mIn contrast to clinical criteria, imaging can be instrumental in delineating the location and quality of various space-occupying lesions originating from the cervix. On its classical ultrasound imaging, cervical leiomyoma corresponds to a round, distinct, well-defined hypoechoic solid mass with a thin hypoechoic circumference that appears to protrude from the cervix. With Doppler ultrasound imaging, the cervical leiomyoma appears with relatively poor perfusion compared to the surrounding normal myometrium. The imaging of a more hyperechogenic mass is usually associated with bleeding and degeneration of the cervical leiomyoma . Also imMagnetic resonance imaging (MRI), due to the higher resolution of soft tissues that characterizes it, is currently the best method for imaging the normal anatomy of the cervix and evaluating cervical lesions. Magnetic resonance imaging is estimated to be of significant help in the challenging differential diagnosis of cervical fibroids from adnexal tumors . On MRI,Surgery is the main treatment option for cervical leiomyomas. Performing hysterectomy or myomectomy with laparotomy or laparoscopy remains the cornerstone of the treatment approach for cervical leiomyomas and should be customized based on symptomatology, tumor size, patient age, and her desire to maintain fertility . SurgicaThe promising interventional radiology techniques in recent years for the treatment of uterine leiomyomas have not had the expected results . UterineLarge leiomyomas of the cervix are extremely uncommon, and their treatment with main laparotomy or laparoscopy surgery presents several difficulties and challenges. Chronic obstructive uropathy secondary to large cervical leiomyoma can result in renal dysfunction with a significantly increased risk of morbidity and mortality. Thorough clinical and imaging preoperative evaluation allows early diagnosis of hydroureteronephrosis and renal dysfunction-related chronic pelvic pain in women with cervical leiomyomas and aims to promptly implement the most appropriate modern available treatment options to avoid permanent renal damage and ensure the good health and quality of life of these patients.


Eccrine poroma is the term that includes benign neoplasms of the terminal duct of the eccrine sweat glands, which may clinically and dermoscopically resemble other melanoma and non-melanoma skin tumors. They are often located on the extremities , presenting as normochromic or erythematous papules and nodules, measuring up to 2 cm. Pigmented variants are uncommon, accounting for less than 20% of cases. This report describes a 37-year-old man who developed a large pigmented eccrine poroma on his right shoulder, causing diagnostic difficulty. Histopathological examination revealed a nodular neoplasm consisting of small, monomorphic, cuboidal cells, with ample, eosinophilic cytoplasm and well-defined borders, in addition to conspicuous intercellular bridges, with melanin deposits diffusely distributed inside them. The absence of cytological atypia, cellular pleomorphism, increased mitotic activity, and necrosis foci corroborated the diagnostic exclusion of porocarcinoma, which can develop from eccrine poroma. Eccrine poromas (EP) are benign neoplasms of the sweat glands consisting of epithelial cells with distal tubular differentiation (acrosyringium), representing approximately 10% of all sweat gland tumors. They are often located on the acral regions, especially the palms and soles, due to the high density of eccrine glands in these areas but can affect any region of the skin.This report describes a young adult patient with an atypical, pigmented EP lesion on the shoulder, clinically resembling other pigmented neoplasms, emphasizing the relevance of histopathological examination for diagnostic confirmation.A 37-year-old dark-skinned male reported that he had a tumor showing progressive growth on the posterior region of the right shoulder, for one year and a half A. ClinicDue to the pandemic (COVID-19), the surgical excision was delayed for one year, leading to lesion growth. Upon reassessment, the patient had a vegetative, erythematous-violaceous tumor with a blackish-brown, infiltrated surface, with a slightly erythematous base, measuring 5 × 4 cm B, which The lesion was submitted to total excision, with a safety margin, under the hypotheses of nodular melanoma, proliferating trichilemmal cyst, pigmented basal cell carcinoma, and pigmented dermatofibrosarcoma protuberans (Bednar's tumor).The histopathological examination revealed a well-defined nodular neoplasm, connected with the epidermis, consisting of small, monomorphic, cuboidal cells, with ample, eosinophilic cytoplasm and well-defined borders, in addition to conspicuous intercellular Bridges. There were melanin deposits diffusely distributed inside the neoplasm. Moreover, intracytoplasmic lumens and ductular formations delineated by cuticles Figs.   were obThe absence of cytological atypia, cellular pleomorphism, increased mitotic activity, and foci of necrosis corroborated the exclusion of porocarcinoma as a diagnostic possibility. Polyclonal CEA (carcinoembryonic antigen) immunostaining was negative .Figure 5The first EP description was reported by Pinkus et al. (1956), who described five cases of benign plantar tumors, whose histological assessment indicated a neoplasm that affected the terminal duct of the sweat glands.cuniculatum), pyogenic granuloma and amelanotic nodular melanoma. Surgical excision with complete removal of the neoplasm is the treatment of choice, which leads to complete healing of the lesion.Histopathologically, EP is a benign tumor that originates in the intraepidermal portion of the sweat duct. Its etiology remains uncertain and it is a slow-growing tumor, with heterogeneous features; however, it is associated with trauma, radiation, and growth over scar tissue.The pigmented variant of EP is uncommon, corresponding to only 17% of cases, and has been previously described in individuals with different phototypes. Its diagnosis is challenging due to its rarity, and because it can be mistaken for other pigmented tumors such as melanoma, seborrheic keratosis, pigmented basal cell carcinoma, and Bednar's tumor.Eccrine porocarcinoma, which can also be pigmented, is the main differential diagnosis on histopathological examination, inasmuch as it has a slow growth, and incisional biopsies may reveal components with apparent benign characteristics, delaying the diagnosis.11Dermatologists should be aware of the diagnosis of slow-growing pigmented tumors, even outside the palms and soles, due to the possibility of a pigmented EP, a tumor with a favorable prognosis after extensive surgical excision.None declared.Melissa de Almeida Corrêa Alfredo: Design and planning of the study; approval of the final version of the manuscript; critical review of the literature; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Mariana Righetto de Ré Lai: Approval of the final version of the manuscript; critical review of the literature; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Luciane Donida Bartoli Miot: Design and planning of the study; approval of the final version of the manuscript; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Gabriela Roncada Haddad: Approval of the final version of the manuscript; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Aline Lutz Garcia: Approval of the final version of the manuscript; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.Hélio Amante Miot: Approval of the final version of the manuscript; critical review of the manuscript.None declared.


Tumefactive demyelinations (TDs) are demyelinating central nervous system lesions that masquerade as neoplastic lesions on radiological images. Brain biopsy is often required for confirmatory diagnosis. Since crush cytology has become a routine practice, a thorough knowledge of the cytomorphologic features of TD is required to prevent misdiagnosis. In this report, we describe the cytomorphological and histomorphological features of a case of TD. Tumefactive demyelinations (TDs) are well-demarcated lesions mimicking neoplasm on radiological images. On magnetic resonance imaging (MRI), these lesions present as space-occupying lesions with irregular infiltrative borders showing peri-lesional edema, and necrosis with cystic degeneration resembling an axial malignancy. Hence, a brain biopsy and histopathological examination are mandatory for diagnosing such lesions . HistomoA 52-year-old female presented with a history of headache and short-term memory disturbance associated with disorientation to space and person which was of insidious onset and progression. She also had intermittent nausea and spells of dizziness. Mild impairment of sensory disturbances in the right upper and lower limb was seen. MRI revealed left frontoparietal well-defined hyperintense lesion measuring 2.9 × 2.7 × 2.5 cm with mild surrounding edema and incomplete peripheral enhancement. MR spectroscopy revealed increased choline/creatine ratio and increased choline/N-acetyl-aspartate (NAA) ratio with lactate peak. The final impression was low-grade glioma. Frontal craniotomy was performed and two tiny biopsy fragments were given for intraoperative diagnosis. The tissues measured 0.8 × 0.5 × 0.2 cm and 0.5 × 0.4 × 0.2 cm each. Tiny bits from different areas of the tissue were taken and crush smears were made. Slides were fixed in 95% ethanol and stained with hematoxylin and eosin stain.Microscopic examination revealed varied cytomorphology on the slides. Few slides studied from the lesion showed scattered neurons embedded in fibrillary matrix, representing the normal gray matter. Slide from the lesional area showed numerous scattered foamy histiocytes and many vascular fragments with perivascular aggregates of mature lymphocytes and histiocytes. Numerous scattered reactive astrocytic cells with moderate nuclear atypia, prominent nucleoli, and moderate eosinophilic cytoplasm with processes were noted. Mitosis and necrosis were absent Figure .The histological sections showed a well-demarcated lesion predominantly involving the white matter. The lesion consisted of sheets of histiocytes, mature lymphocytes, and reactive astrocytes similar to features on crush smears. Perivascular lymphohistiocytic cells were seen Figure .Crush smear cytology is routinely performed for rapid intraoperative diagnosis of central nervous system tumors and the cytomorphological features of these lesions are well known . The proHence, the knowledge of the cytological features of TD will also help to rule out other malignant and infective conditions which are the causes of misdiagnosis on crush cytology. The differential diagnosis for TD on crush smears includes low-grade and high-grade gliomas, lymphoma, infarction, and infections. Low-grade gliomas show cellular smears composed of oval- to spindle-shaped astrocytes with fibrillary cytoplasm and there is the absence of histiocytes and mature lymphocytes ,5. High-A correct diagnosis of TD is a challenge and crush cytology has to be interpreted with a high index of suspicion. Early and prompt treatment of these patients would ensure a remarkable and complete clinical and symptomatic recovery. Awareness about the lesion and a combined diagnostic modality approach between the radiologist, pathologist, and neurologist will ensure prompt and early diagnosis of this lesion. One should consider including this entity in the differential diagnosis of all solitary space-occupying lesions. The presence of numerous histiocytes, reactive lymphocytes, and reactive astrocytes on crush smears should raise a suspicion of TD. Though challenging, crush smear cytology is a useful tool for rapid and cost-effective diagnosis of TD like other CNS neoplasms. Since crush smear cytology has become a routine practice for neuropathologists, a thorough knowledge of the cytological features is mandatory to avoid misdiagnosis.


Omental lipoma is an uncommon abdominal tumor of mature fat cells. Those benign tumors are usually asymptomatic but occasionally can cause signs and symptoms based on their location, size, and presence of complications. Radiological investigations such as Abdominal ultrasonography (USG) and computed tomography (CT) are crucial to evaluate and diagnose intra-abdominal tumors, especially omental lipomas.A 61-year-old male patient presented to our hospital with right iliac fossa pain. Physical examination and laboratory test results were normal. The performed abdominal CT scan revealed a large right-sided intraperitoneal mass measuring about 2.4 × 10 × 20 cm. Then, an ultrasound-guided biopsy was done and the picture was most consistent with lipoma. So, surgical intervention was decided and omental lipoma was completely exteriorized via a laparoscopic approach. The weight of the excised omental mass was 2.45 kg, measuring 23 × 18 × 7 cm. The resected specimens, including omental lipoma and omental lymph nodes, were sent for histopathological studies. The postoperative period was uneventful.Omental lipoma is an unusual entity that occurs often in children and rarely in adults. The clinical features of omental lipomas include abdominal discomfort, abdominal lump, abdominal pain, nausea, and/or weight loss. Diagnosis of the omental lipoma relies on imaging and physical examination, which was normal in the presented case. Abdominal CT provides definitive fat content characterization and its localization within the omentum.Due to the rare etiologic origin of omental lipomas, we report the case of a 61-year-old male with right iliac fossa pain, found to be caused by detected giant omental lipoma. •Omental lipomas are extremely rare soft tissue tumors.•Omental lipomas are uncommon in adults.•The intraoperative detection of a giant omental lipoma is considered an unusual finding.•Both CT and USG provide high diagnostic value for intraabdominal lesions.•The laparoscopic approach is the best treatment option. Physical examination and laboratory test results were all normal. At this point, acute appendicitis was suspected and an abdominal CT scan was suggested to rule it out. An abdominal CT scan revealed a large right-sided intraperitoneal mass measuring about 2.4 × 10 × 20 cm .Fig. 1OmAs a result, an ultrasound-guided biopsy was done. It revealed mature adipose tissue with hemorrhage and no evidence of atypia. The picture was most consistent with lipoma. So, surgical intervention was decided and laparoscopic excision of radiologically detected lipoma was scheduled. The complete dissection of the large omental mass was done laparoscopically. Then, the omental lipoma was exteriorized via an extension of the midline port side incision along with omental lymph nodes were detected during the procedure. The weight of the excised omental mass, which was detected intraoperatively, was 2.45 kg .Fig. 2ImMacroscopically, the omental mass consists of a soft fatty mass measuring 23 × 18 × 7 cm, showing a smooth yellowish outer surface with dark brownish hemorrhagic areas. Whereas, the omental lymph node consists of irregular gray-brown soft fragments measuring 1.5 × 1.3 × 0.6 cm. Then, the omental mass and lymph node specimens were sent for further histopathological studies . The pat3•Large well-defined mixed hypo and hyperdense misty soft-tissue attenuation lesion•The lesion is seen on the right hypochondria and extends to the midline of the abdomen•It measures about 2.4 × 10 × 20 cm•Lesion associated with mass effect compressing the transverse colon inferiorly•No radiological evidence of acute appendicitisAbdominal cavity lipomas can present in the mesentery, omentum, and retroperitoneum, but the omental lipomas are rare The definitive treatment modality of omental lipoma is surgical resection 4Despite the rarity of omental lipomas, they should be considered in unusual abdominal pain or vague non-specific symptoms. Imaging helps to demonstrate the characteristics and localization of the intraabdominal lipomas. To cure omental lipoma, total excision via a laparoscopic approach is a viable treatment option. Our case report emphasizes the diagnostic and surgical challenges of omental lipomas.This report does not contain any personal information that could lead to the identification of the patient.Not commissioned, externally peer-reviewed.No sources of funding are available.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 by the Editor-in-Chief of this journal upon request.AS wrote and edited the manuscript; KA, MH, and AA operate; AS and KA provided the illustrated figures; JA and AA analyzed the data; all authors read, contribute, and approved the final manuscript.This does not apply to our case report, there is no involvement of research here.Athary Saleem, B.Med.Sc., MD; Department of General Surgery, Al Adan Hospital, Kuwait.There is no conflict of interest including any financial or personal relationships with other people or organizations or any work influencers.


Asbestos use started to be gradually banned in Europe from 1991 onwards, and there are currently strict occupational exposure limits for asbestos. However, malignant mesothelioma has a long latency time (in some cases up to 50–60 years), so the risks related to asbestos exposure should not be forgotten. Considering the increased risk of lung cancer following the inhalation of asbestos fibers, lifetime health monitoring should be considered in people occupationally exposed to asbestos, with an emphasis on the respiratory system. An assessment of their occupational history should be performed rigorously, especially in the areas with a history of asbestos production/use, as this is a key element for an early diagnosis and appropriate treatment. This case report presents a near-missed case of occupational pleural malignant mesothelioma. The latency time between the first asbestos exposure and the diagnosis of occupational pleural malignant mesothelioma was 49 years. The accurate diagnosis was made two years after the first symptoms appeared. Malignant mesothelioma is a rare and aggressive form of cancer, with a world standardized incidence rate (WSIR) per 100,000 persons in Europe of 1.7 for males and 0.4 for females. Malignant mesothelioma is most frequently located at the pleural level, with approximately 60–70% of cases, followed by the peritoneal 30%) and pericardial 1–2%) localization [% localiz0% and peThe etiology of malignant mesothelioma is related to exposure to mineral fibers, especially asbestos fibers . AsbestoThe period of latency between exposure and the appearance of the disease is, on average, 40 years , and thuA 68-year-old non-smoking female patient with a history of essential hypertension, dyslipidemia, and hypothyroidism, was admitted in February 2022 to the Colentina Occupational Medicine Clinic due to dyspnea, asthenia, loss of appetite, weight loss, and pain in the left thoracic area. Clinical examination revealed severe skin and mucous membrane pallor, a postoperative scar in the left thoracic region, pleural rubs in the left pulmonary base, dullness in the lower base of the right thoracic area, an abolished vesicular murmur in the right pulmonary base, 92% oxygen saturation at rest.In 2019, the patient was admitted to a local hospital in the respiratory department for dyspnea on exertion during moderate physical activity. A clinical evaluation and thoracic computed tomography (CT) revealed the presence of pleural effusion in the left hemithorax a. The reBetween 2019 and 2021, the dyspnea progressively accentuated, and it was accompanied by chest pain and weight loss. In September 2021, the patient was admitted to a thoracic surgery department. A thoracic CT showed pleural effusion b. ThoracIn October 2021, a left thoracotomy and decortication of the pleura were performed. The histopathological examination showed diffuse biphasic mesothelioma (with 60% sarcomatous elements and 40% epithelioid elements) with pulmonary invasion. In the epithelioid areas, the cells were arranged in tubulopapillary and trabecular structures, while in the sarcomatous areas, the cells had a transitional morphology. Areas of necrosis, moderate atypia, and mitosis were also identified. Immunohistochemical tests were carried out, and the results were positive for Calretinin, Wilms tumor 1, and D 24–0 supporting the diagnosis of mesothelioma. The results of the immunohistochemical tests are presented in To assess the extension of the lesions, a positron emission tomography (PET-CT) was performed. The results showed the thickening of the left pleura from the top to the base. No metastases or invasion of the chest wall, mediastinum, or diaphragm were noted .The patient completed five sessions of radiotherapy with modular intensity and image-guided radiotherapy and followed chemotherapy (cisplatin 100 mg and pemetrexed 750 mg).In January 2022, the patient’s condition worsened, and the patient reported dyspnea at rest and orthopnea. A thoracic CT showed right pleural effusion c. ThoracA detailed occupational history was taken on admission to the Occupational Medicine Clinic in February 2022. The patient completed a total of 36 years of work, with a history of 1 year and 10 months of occupational exposure to asbestos in the period from 1973 to 1975. During that period, the patient worked in a factory that produced asbestos-cement plates using chrysotile in the production process. The patient worked as a quality control specialist, and her duties were to check if the thickness of the asbestos-cement boards complied with the technical specifications. From 1975, she worked for 34 years as a teacher in a middle school. The patient retired in 2014.In February 2022, the patient was diagnosed with malignant pleural mesothelioma following occupational exposure to asbestos and right pleurisy.The evolution was not favorable contralateral pleurisy appeared with the aggravation of the general condition. In June 2022, the patient started radiotherapy treatment.Because the use of asbestos has been banned in Europe for many years now, the exposure to asbestos and its associated risks are many times overlooked by doctors and patients; however, the risks associated with asbestos exposure should not be neglected because malignant mesothelioma occurs after a period of over 40 years from exposure.Malignant mesothelioma is a rare and aggressive form of cancer, with a higher incidence rate in males compared to females . MesothePleural malignant mesothelioma is an aggressive type of cancer of the pleural surface associated with previous asbestos exposure, with a very long latency time and poor prognosis . ClinicaRegarding imaging investigations, chest X-rays are usually the first investigation to be performed, and it shows unilateral pleural effusion in 30–80% of cases. Computed tomography with contrast material is mandatory even for the initial evaluation and plays a leading role in staging, tracking the evolution, and establishing the therapeutic protocol . PET-CT A certain diagnosis is established by pleural biopsy under tomographic guidance or by biopsy performed with video-assisted thoracotomy .From an anatomopathological point of view, pleural mesothelioma is a heterogeneous tumor including three main histological types: epithelioid (60–80%), sarcomatoid (<10%), and biphasic or mixed (10–15%), and others less common desmoplastic, with small cells and lymphocyticoid. Identifying the histopathological type is a useful tool for therapeutic conduct and provides information on survival analysis. The epithelioid form is less aggressive compared to the sarcomatoid form, as it is associated with higher sensitivity, a better response to chemotherapy, and a better survival rate compared to sarcomatoid or biphasic types . In the Immunohistochemical tests have an essential role in positive and differential diagnoses. Typically, BAP1 and p16FIH are negative in malignant mesothelioma, and they are used in differential diagnosis to identify benign diseases . On the Currently, the treatment of malignant mesothelioma includes chemotherapy, radiotherapy, and the surgical decortication of the pleura. First-line chemotherapy consists of a combination of cisplatin and pemetrexed or raltitrexed. The cisplatin and pemetrexed combination was reported to be associated with a median survival of 13.3 months, compared with 12.7 months which were reported following the administration of cisplatin alone . PatientThe surgical treatment of pleural mesothelioma remains controversial. The selection of the patient is difficult due to the advanced stage of the disease, older age, and comorbidities. In addition, the surgery on the pleura must be radical. The form of the sarcomatous tumor is excluded from the surgical treatment, and the therapeutic opinions in the case of biphasic mesothelioma are different .The third treatment method, postoperative radiation therapy, is performed in doses of up to 54–60 Gray, and it is administered with new techniques such as intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT) .Even if the current treatment options for pleural mesothelioma seem to be encouraging, the survival rate and the quality of life are not substantially improved yet. Unfortunately, there are no clinical signs in the early phase of this deadly disease, so diagnosis is made in a late stage. The currently available chemotherapy or surgery options are not providing a significant improvement in survival rate if applied in the early stages of the disease ,23,24. TThis case report presents an occupational pleural malignant mesothelioma in a patient exposed to asbestos for 1 year and 10 months. For the present case, the latency time between the first asbestos exposure and the diagnosis of occupational pleural malignant mesothelioma was 49 years. This long latency could be attributed to the short (1 year and 10 months) and/or low exposure . The accurate diagnosis was made 2 years after the first symptoms appeared; the late diagnosis can be explained by the lack of doctor experience in this rare disease. The treatment included the decortication of the left pleura, radiotherapy, and chemotherapy (with cisplatin and pemetrexed). Unfortunately, the evolution was not favorable. After the third course of chemotherapy, contralateral pleurisy appeared with the aggravation of the general condition.The asbestos exposure of this patient happened in the 70s in a Romanian factory with approximately 300 employees. The work was conducted in an asbestos processing plant, where all operations were carried out in a single large room. The protective equipment did not ensure respiratory protection, so exposure to asbestos was possible even for the personnel from the quality control department. No determinations of asbestos fibers were made at the workplace during that period. The health monitoring of these asbestos-exposed workers was carried out yearly, as requested by the local legislation, by the occupational medicine physician but only during asbestos exposure; no health monitoring was conducted after retirement or after changing occupation. There are no data available related to post-exposure medical follow-ups/surveillance of the workers from this factory.Statistical data related to workers exposed to asbestos in Romania are insufficient. The data provided by the Public Health Institute show that 1200 people exposed to asbestos were registered in Romania in 2006.In January 2007, the production, sale, and the use of asbestos was banned in Romania. However, the current national guidelines allow the treatment and disposal of products which result from the demolition and removal of asbestos . A guideThe present case reiterates the information provided by the literature data that mesothelioma is related to occupational exposure to asbestos and that it has a long latency time, sometimes longer than 40 years.The latency time was longer when the exposure duration or intensity to asbestos was short. Therefore, lifetime health monitoring with screening for mesothelioma and other asbestos-related diseases should be considered in people occupationally exposed to asbestos. In addition, rigorous occupational health records should be taken, especially in areas with a history of asbestos production/use.Insidious debut and nonspecific clinical manifestations of malignant pleural mesothelioma contribute to the late diagnosis associated with the advanced stage of the disease and low survival rate.In the present case, the patient was not aware of the risk related to asbestos exposure, and no health monitoring was conducted. Asbestos exposure was overlooked for 2 years. The treatment included the decortication of the left pleura, radiotherapy, and chemotherapy (with cisplatin and pemetrexed). The standard therapeutic protocols were applied, and none of the newly approved or novel medicines were used. Unfortunately, the evolution was not favorable. After the third course of chemotherapy, contralateral pleurisy appeared with the aggravation of the general condition.Occupational asbestos exposure may be overlooked, especially in cases of short-term exposure and long latency until the onset of the malignant mesothelioma.There is a need to increase awareness of the risks associated with asbestos exposure among current and former workers involved with asbestos-related work.Lifetime monitoring of the persons exposed to asbestos with screening for mesothelioma and other asbestos-related diseases should be recommended.A rigorous occupational history is essential for an early accurate diagnosis that might be associated with a better prognosis in the case of malignant pleural mesothelioma.


In severe blunt trauma, multiple organ injuries are often observed. Patients with a ruptured diaphragm and pericardium are referred to as having pericardio-diaphragmatic rupture. However, few studies have reported a narrowly defined case of connected rupture of the diaphragm and pericardium via their congenitally fused site along with an abdominal visceral herniation and cardiac luxation into the thoracic cavity.A 78-year-old man presented to our hospital with left chest pain caused by a traffic accident. Contrast-enhanced computed tomography revealed a left diaphragmatic rupture and an intestinal herniation into the thoracic cavity. Surgical repair of the diaphragm was performed, and pericardial rupture was noted during surgery. It was considered that the laceration had spread via the congenitally fused site of the diaphragm and pericardium. The diaphragm was sutured, but the pericardium was left open because the laceration was large and the risk of cardiac incarceration was thought to be low. One year after the operation, no recurrence of diaphragmatic hernia was observed and any circulatory symptoms were not occurred.In cases of diaphragmatic laceration extending to the fused site of the pericardium, connected pericardial rupture should also be considered. It would be challenging to detect without intraoperative findings, and it is desirable to observe both the thoracic and abdominal cavities. In severe blunt trauma, multiple organ injuries are often observed. Excessive pressure in the abdominal cavity can cause diaphragmatic rupture. Most cases occur on the left side because the liver offers some protection to the right side . When thA 78-year-old man presented to our hospital with left chest pain caused by a traffic accident. Three hours before emergency transport, he had driven a car and had a car accident that hit a wall at 40 km/h and then returned home by taxi. The chest pain persisted and worsened, and he was referred to the emergency department.2 89% in ambient air). He was conscious  and could speak normally. He complained of left chest pain; however, no superficial wounds were detected. Electrocardiography showed incomplete right bundle branch brock, prolonged QTc interval, and no axial deviation; it was not seemed to be specific to any traumatic abnormalities.Upon arrival at the hospital, his vital signs demonstrated hypoxia  revealed left diaphragm hernia, right traumatic lung cyst, sternum fracture, bilateral multiple rib fractures, 11th thoracic vertebral fracture, and multiple lumbar vertebral fractures. Herniation of the stomach, small intestine, and colon into the left thoracic cavity and compressed lung was observed, and no ischemic lesions were detected  5. On POD 12, the patient was infected with coronavirus disease due to the institutional cluster, and dexamethasone was required for worsening respiratory status. However, the patient recovered without any obvious sequelae and was discharged. One year after the operation, no recurrence of diaphragmatic hernia was observed and any circulatory symptoms were not occurred.We report a rare case of the diaphragm and pericardium rupture in which the laceration had spread via the congenitally fused site of the diaphragm and pericardium, and an abdominal visceral hernia and cardiac luxation were observed. This case may be referred to as a case of pericardio-diaphragmatic rupture, which has become relatively commonly mentioned in the literature, although the word is actually refers to a disease with many different pathologies.Diaphragmatic rupture from blunt thoracoabdominal trauma has been previously reported. Among those cases, abdominal viscera herniation into the pericardial cavity, or intrapericardial hernia, is relatively rare, and it is occasionally described as pericardio-diaphragmatic rupture because of a rupture of the congenitally fused diaphragmatic pericardium . AdditioHowever, so few studies have been published, pericardio-diaphragmatic rupture may not be a rare disease. The diagnosis of a large diaphragmatic rupture is relatively easy on CT  because In our case, the pericardial rupture was not closed because the large laceration was thought to have little risk of causing cardiac incarceration. Whether and how to close the pericardium after cardiac dislocation remains controversial, even in elective operations . However