The rate of iatrogenic endometriosis after gynecologic surgeries due to benign uterine disease is 1–2%. Laparoscopic supracervical hysterectomy is also a part of frequently used surgical treatment of apical pelvic organ prolapse, which is followed by sacrocervicopexy. However, there are no data about iatrogenic endometriosis after apical prolapse surgery in the current literature. Herein, we present a case report of a patient diagnosed with A 46-year-old parous Slavic woman who underwent laparoscopic supracervical hysterectomy and sacrocervicopexy secondary to grade 3 symptomatic apical prolapse 1 year earlier was admitted to the same clinic with pelvic pain that had started 6 months following surgery. Deep vaginal palpation was painful. Transvaginal ultrasonography revealed an area with hypervascularization on the sacral promontory. She was scheduled for diagnostic laparoscopy. A 2 × 2-cm solid, wine-colored, hypervascular hemorrhagic lesion was seen on the sacral promontory. The lesion and the peritoneal layer behind it were totally excised. The patient was discharged on the first postoperative day, without any complications. Pathologic examination revealed foci of endometriosis comprising endometrial glands and stroma within the connective tissue, along with hemosiderin-laden macrophages. The symptoms of the patient resolved after the surgery, and no further adjuvant treatment was needed.Although the rate of iatrogenic endometriosis is low after laparoscopic supracervical hysterectomy and sacrocervicopexy, the possibility of the occurrence of iatrogenic endometriosis should be discussed with patients who are diagnosed with apical prolapse to determine the type of surgical intervention. Iatrogenic endometriosis should be kept in mind for differential diagnosis in case of pain after laparoscopic supracervical hysterectomy and sacrocervicopexy. To the best of our knowledge, this is the first such case report in the literature.Iatrogenic endometriosis (IE) is the presence of endometrial glands and stroma out of the uterus following certain surgical interventions, such as total or supracervical hysterectomy, myomectomy, and cesarean section . The mosA 46-year-old parous Slavic woman who underwent LASH secondary to grade 3 symptomatic apical prolapse 1 year ago was admitted to our clinic with pelvic pain that had started 6 months following surgery. It worsened with sexual intercourse and was not relieved with oral analgesic drugs. She had no complaints of urinary incontinence or prolapse. She did not have any remarkable bladder or bowel symptoms. On physical examination with vaginal speculum, pain upon deep vaginal palpation was detected, but there was no sign of erosion on the cervix and vaginal wall. Transvaginal ultrasonography (US) revealed a hypoechogenic and hypervascular solid area with irregular contours sized 3 × 2 cm in diameter on the sacral promontory. Transabdominal US showed normal kidneys and ureters with normal peristalsis. A flexible cystoscopy and office-based rectosigmoidoscopy was performed to exclude any reason for pelvic pain. No further abnormal findings were observed in the bladder and rectosigmoid area. The patient was reluctant to undergo further diagnostic imaging such as pelvic magnetic resonance imaging (MRI) because of her insurance status. After discussing the diagnostic possibilities with the patient, she was scheduled for diagnostic laparoscopy.An informed consent was obtained from the patient preoperatively. After administration of general anesthesia and antibiotic prophylaxis, the patient was placed in Trendelenburg position. A Veress needle was used to achieve pneumoperitoneum. Previous trocar sites were used for laparoscopic port placement; a 12-mm port was placed at the inferior margin of the umbilicus, and 5-mm ports were placed medially to iliac spine on both sides. After the port placement, adhesions secondary to the previous surgery were excised. The position of the mesh under peritoneum from promontory to cervical uteri was totally normal. No abnormalities were detected regarding ureters.The only pathologic finding was detected on the peritoneum covering the sacral promontory: a 2 × 2-cm, solid, wine-colored, hypervascular hemorrhagic lesion, which macroscopically resembled endometriosis Fig. . The lesPathologic examination revealed foci of endometriosis comprising endometrial glands and stroma within the connective tissue, along with hemosiderin-laden macrophages. The patient was classified as having stage 1 disease  according to the American Society for Reproductive Medicine and category 1  according to the Endometriosis Foundation of America. The symptoms of the patient resolved, and no adjuvant treatment was needed up to 1 year after surgery. A clinical visit including physical examination and US assessment was planned for every 6 months as follow-up.Endometriosis has been known since its first description by Sampson in 1924 as the presence of functional endometrial tissues out of the uterine cavity . Howeveret al. [et al., 32 different publications were evaluated, and among 66 patients who underwent reoperation after hysterectomy, 4 with IE were identified [of IE may be the limited number of cases in which reoperation is needed following total/subtotal hysterectomy, myomectomy, and LASH.The rate of IE was reported to be 1.4% in a case-control study by Schuster et al. . Among 4et al. suggested that in the presence of endometriosis and adenomyosis at the time of previous surgery, retrograde flow from resting endometrial tissues in the cervix is a reason for IE after supracervical hysterectomy [et al. emphasized direct endometrial tissue implantation and seeding on pathogenesis of IE, especially after cesarean section surgery and the morcellation of uteri [Hilger erectomy . Stefanoof uteri . We viewet al. first described electric morcellation of the uterus for laparoscopic hysterectomy in 1993 [et al. reported morcellator-related injuries in 55 cases and deaths in 6 cases [et al. described pathogenesis of parasitic leiomyomas and disseminated peritoneal leiomyomas secondary to morcellation [et al. described cancer tissue spreading to the peritoneal cavity in a case with occult malignancy in the uterus after use of a morcellator [et al. suggested using a confined morcellator with a specimen bag. They stated that leakage from the bag and increase in operation time were problems [Steiner  in 1993 . Althoug 6 cases . Tulandiellation . Pereiracellator . After tproblems .In our practice, we routinely check patients in terms of uterine malignancies and use nonconfined morcellation preoperatively. We did not experience any injury or death related to morcellator use, and also no occult uterine malignancies were detected. However, after our present patient’s case, we can argue that unless the specimen bag is damaged, confined morcellation with a bag can be a beneficial option to avoid IE. Also removing the specimen via an incision to avoid IE can be discussed with the patient preoperatively.et al. suggested that the most common symptoms of endometriosis are pain, dyspareunia, local mass effects, and bleeding [et al. stated that USG and MRI are the first-line diagnostic tools for endometriosis [Kill bleeding . In our etriosis . Howeveretriosis . We deteet al., it was suggested that the treatment of endometriosis aims at pain relief, preserving fertility, and preventing obstruction [In a review by Kızılay truction . Oral cotruction . Surgicatruction . When ittruction –5. In acly implantation and seeding of endometrial tissue. IE can also be diagnosed secondary to laparoscopic supracervical hysterectomy and electrical morcellation of the uterus as a part of POP surgery. With the wide application of these procedures, an increase in the rates of IE following POP surgeries may be detected in the future. Although the rate of IE is low after LASH surgery, the possibility for the occurrence of IE should be discussed with patients who are diagnosed with apical prolapse to determine the type of surgical intervention. IE should be kept in mind for differential diagnosis in case of pain after LASH surgery. Laparoscopic intervention may provide the diagnosis and further the excision of IE. Further studies are needed to determine the real rates and proper treatment modalities of IE and eligible surgical maneuvers to avoid IE during prolapse surgery.IE is a rare complication of total or supracervical hysterectomies for benign uterine diseases. The pathogenesis can be explained by the presence of endometriosis or adenomyosis at the time of previous surgery, retrograde flow from the rest of endometrial tissues, and direct


The term desmoplastic infantile ganglioglioma was coined by VandenBerg et al in 1987. In their first report these authors referred to a rare, distinct brain tumor. About 60 cases of desmoplastic infantile ganglioglioma have been described in the literature since its first description. We report a case of a 6-year-old girl who was admitted for seizure without family history. Magnetic resonance imaging scan showed a hypodense area in the right temporal region. A right temporal craniotomy was performed and the tumor was excised. The pathologic examination revealed the diagnosis of desmoplastic infantile ganglioglioma. The term desmoplastic infantile ganglioglioma (DIG) was coined by VandenBerg et al in 1987 . In thisA 6-year-old girl was admitted for seizure without family history. Neurological examination was normal. Magnetic resonance imaging scan showed a hypodense area in the right temporal region, with contrast enhancing solid as well as large cystic components . A rightDIG is a supratentorial brain tumor occurring before 2 years. It has similar clinical and neuroimaging features with desmoplastic infantile astrocytoma (DIA), including a favourable prognosis, but DIA lacks ganglion cells. DIG and DIA have been categorized together as desmoplastic infantile astrocytoma/ganglioglioma in the last editions of the WHO classification. They are WHO grade 1 tumors . The maiDIA and DIG are tumors of the same family. They occur in children under 2-year-old. Their diagnosis should be rendered only after correlation between neuropathologic, clinical and neuroimaging features. They have favorable prognosis if completely resected.The authors declare no competing interest.


Central nervous system tuberculosis is a major cause of morbidity and mortality in developing countries. Intracranial tuberculoma is rare and is one of the most severe cases of tuberculosis. We present two cases. The first one is about a girl of 7 years, followed for 5 months for lymph nodes tuberculosis on anti-TB treatment that presents generalized tonic-clonic seizures associated with progressive intracranial hypertension syndrome. Brain MRI has objectified necrotic nodules in left hemisphere. The surgical approach of the lesions was direct with complete excision. The diagnosis of tuberculoma was confirmed by anatomopathological examination. The second case is about a 6-year-old girl with no particular medical history, which presents for three months progressive and treatment-resistant cervico-occipital headaches associated with walking difficulties. The MRI objectified left cerebellar tumor process interpreted preoperatively as medulloblastoma. The patient was operated on intraoperative, appearance was that of a nodular lesion. Anatomopathological examination confirmed the diagnosis. The intracranial tuberculoma is an unusual variety of the central nervous system tuberculosis and remains a topical issue in Morocco. The prognosis depends on prompt diagnosis, quality of surgical resection and anti-TB treatment. The diagnostic confirmation is histological and should therefore be evoked infront of any intracranial process mimicking a brain tumor. Tuberculomas represents with leptomeningitis the most common tuberculous lesions. They are responsible of 10-30% of the intracranial expansive processes in endemic countries. In tuberculous meningitis, the incidence of tuberculomas is estimated to be between 4 and 28%. It is probably underestimated since 50% of the subjects are asymptomatic.Case 1: a seven-year-old girl, followed for 5 months for lymph nodes tuberculosis on anti-TB treatment, which was revealed by suppurating then fistulated jugular-carotid and supraclavicular lymph nodes and confirmed by ganglionic biopsy which objectified a tuberculous granuloma. Clinical evolution was marked by the appearance of generalized tonic-clonic seizures with intracranial hypertension syndrome made of treatment-resistant headaches and vomiting, all evolving in a context of fever and alteration of the general state. On admission, she was febrile (39°C), had lost 6kg in 5 months and had small cervical lymphadenopathies. Cerebral MRI objectified necrotic nodules in left hemisphere with edema and meningeal granulations (ulations . BiologiCase 2: a six-year-old girl, with no particular medical history, hospitalized for occipitocervical headaches, resistant to analgesic treatment, associated with vomiting and walking disorders, without fever or other associated signs, all evolving in a context of weight loss of 5kg. The clinical examination found a statokinetic cerebellar syndrome. Brain MRI objectified an expansive process of the left cerebellar hemisphere with isosignal on T1, low signal intensity on T2, enhancing annularly after injection of gadolinuim and responsible for a mass effect on vermis and V4 with upstream hydrocephalus (cephalus . The radcephalus .Tuberculosis is a major public health problem in developing countries, particularly in Morocco, where an annual incidence of 30,000 new cases/year is found, all localizations combined . The manRadiological aspects of the cerebral tuberculoma are not specific. The brain scan reveals the tuberculoma as an isodense or hyperdense lesion in the calcified forms with ring enhancement after contrast injection . The preCerebral tuberculoma is a rare but serious form of extrapulmonary tuberculosis. It's characterized by clinical polymorphism often leading to delayed diagnosis. MRI is the examination of choice for diagnosis, especially for small tuberculomas and those located in the brain stem. Its prognosis remains guarded despite the improvement of its management.The authors declare no competing interests.


Sclerosing stromal tumor (SST) of the ovary is rare. We describe the first case of ovarian SST with estrogen excess with both clinical and serological evidence in a postmenopausal woman.A 70-year-old female who referred menopause 14 years ago was admitted with postmenopausal bleeding for 3 months. Ultrasonography revealed thickened endometrium of 6 mm and no adnexal masses. An elevated serum estradiol level of 49.78 ng/L was revealed in laboratory examination with normal ranges less than 27.25 ng/L in postmenopausal women.The final histology diagnosis is SST of left ovary and endometrial hyperplasia with polyps.Laparoscopic hysterectomy and bilateral salpingo-oophorectomy were performed and a solid tumor with a diameter of 3 cm × 2 cm from the left ovary was found intraoperatively.Three days after removal of the tumor, the serum estrogen level was decreased to normal which indicated the estrogen activity of the tumor.To the best of our knowledge, it is the first reported case of ovarian SST with estrogen excess with both clinical and serological evidence. The present case illustrates the necessity to consider the rare possibility of ovarian SST as a cause for estrogen excess leading to postmenopausal bleeding. Hormonal evaluation  should be considered in women with postmenopausal bleeding regardless of imaging examination. A few reports demonstrated that it was associated with higher serum androgens and cause virilization. Rarely, it was shown to be related to estrogen activity; however, no case of ovarian SST has been reported for elevated serum estrogen level with serological confirmation. In the present manuscript, details of a rare case study including an ovarian SST in a postmenopausal female with estrogen excess are described. To the best of our knowledge, it is the first reported case of ovarian SST with estrogen excess with both clinical and serological evidence.Sclerosing stromal tumor (SST) of the ovary is rare and predominantly observed in young women of the second and third decades. Most patients with SST present with menstrual irregularities, pelvic pain, and nonspecific symptoms associated with presence of a pelvic mass (mean diameter of about 10 cm).2In July 2017, a 70-year-old Chinese woman presented at the Shandong Provincial Qianfoshan Hospital, China with postmenopausal bleeding (PMB) for 3 months. She referred menopause 14 years ago. Following admission, ultrasonography revealed thickened endometrium of 6 mm and no adnexal masses. Cervical smear test result was normal. An elevated serum estradiol level of 49.78 ng/L was revealed in laboratory examination with normal ranges less than 27.25 ng/L in postmenopausal women. Serum testosterone, progesterone, calcium 125, liver function, and thyrotropin were all normal. No virilization was observed. She denied any chronic disease or any use of hormonal replacement therapy.Owing to the postmenopausal status of the patient and her unwillingness of keeping uterus and bilateral accessories, laparoscopic hysterectomy and bilateral salpingo-oophorectomy were performed as therapy for a hidden ovarian tumor and presumed endometrial malignancy. Intraoperatively, a solid tumor with a diameter of 3 cm × 2 cm from left ovary was found. The frozen section was reported as benign, suggestive of a sex cord stromal tumor of the left ovary and endometrial hyperplasia with polyps. The immunohistochemistry result included positive staining for alpha-inhibin and negative staining for CD10 of the left ovary tumor. The final histology diagnosis is SST of left ovary and endometrial hyperplasia with polyps  should be considered in women with PMB for excluding ovarian tumors with hormone activity regardless of imaging examination.PMB is defined as uterine bleeding occurring after at least 12 months of amenorrhea. It is a common clinical condition with an incidence of 10%. Women with PMB have a 10% to 15% risk of having endometrial carcinoma and approximately 90% of patients with endometrial carcinoma presents with PMB as the only complaint. Surgical removal of the tumor is curative, and no local or distant recurrences have been reported until now.Ovarian SST is considered to be benign except for 1 case with low grade malignancy reported.In conclusion, we presented the first case of ovarian SST with estrogen excess with both clinical and serological evidence in a postmenopausal woman. The present case illustrates the necessity to consider the rare possibility of ovarian SST as a cause for estrogen excess leading to PMB. And hormonal evaluation  should be considered in women with PMB for excluding ovarian tumors with hormone activity regardless of imaging examination.Investigation: Hongtao Lv, Hongtao Liu.Writing – original draft: Zhiyi Zhao, Li Yan.Writing – review and editing: Zhiyi Zhao, Fengnian Rong.


Primary gastric squamous cell carcinoma is a very rare disease. A 53-year-old male with history of hypertension, alcoholism, and nicotine abuse presented to the hospital after a syncopal episode. He complained of bloating abdominal pain, early satiety, and poor appetite. A CT of his abdomen and pelvis revealed a gastric mass with diffuse hepatic metastasis. A gastric mass was seen on upper endoscopy and biopsies revealed gastric squamous cell carcinoma. There was no involvement of the esophagus. This case should add to the limited literature and serve as a reminder that while this is a rare malignancy, it must be considered when evaluating a gastric mass. Primary gastric squamous cell carcinoma (PGSCC) accounts for less than 0.2% of all primary gastric carcinomas . The preA 53-year-old white male with hypertension, chronic alcoholism, and tobacco abuse presented to the emergency department for syncope while standing outside. Review of systems was positive for four weeks of abdominal discomfort and poor oral intake due to increased abdominal pressure. He denied any changes in weight, melena, hematochezia, hematemesis, or dysphagia.Physical examination revealed a soft, moderately distended abdomen with mild epigastric and right upper quadrant tenderness with guarding. Bowel sounds were hypoactive. There was no supraclavicular lymphadenopathy, and the rest of the exam was unremarkable.Initial work-up found the patient to be hyponatremic at 118 mmol/L (136–144 mmol/L), Aspartate Aminotransferase (AST) of 184 U/L (15–41 U/L), Alkaline Phosphatase 390 U/L (40–129 U/L). Gamma-Glutamyltransferase (GGT) was 1080 U/L (7–50 U/L), total bilirubin 1.7 mg/dL (0.3–1.2 mg/dL) with direct bilirubin of 0.9 mg/dL (0.1–0.5 mg/dL). Alanine Aminotransferase (ALT) was within normal limits at 53 U/L (17–63 U/L). Complete blood count (CBC) revealed a leukocytosis of 15.3 K/cmm (4.0–11.0 K/cmm), Hemoglobin 10.9 g/dL (12–17.3 g/dL), Hematocrit 32.3% (36–53%), and a platelet count of 384 K/cmm (140–440 K/cmm). CT of the abdomen and pelvis with IV contrast revealed a 6.1 cm mass lesion in the lesser curvature of the stomach contiguous with the gastrohepatic ligament, as well as extensive hepatic metastatic lesions, with the largest measuring 9.5 cm . Serum CUpper endoscopy revealed a large necrotic mass of approximately 6 cm in the lesser curvature with ulceration in the gastric cardia without extension into the esophagus . BiopsieInitially, gastric primary was thought to be less likely initially due to the evidence of keratinization; however, outpatient PET scan showed a 6.5 cm hyper metabolic ulcerative gastric mass and no additional source for a primary tumor. The liver metastasis was appreciated once again, as well as hypermetabolic metastatic adenopathy in the abdomen . A liverAt this time, he has completed six rounds of systemic chemotherapy including IV Carboplatin and IV Paclitaxel for Stage IV PGSCC with diffuse liver metastasis and gastric lymphadenopathy. He has developed chemotherapy induced thrombocytopenia with platelets of 22,600 K/cmm, and neuropathy treated with gabapentin. Report of the PET scan after 6 months of therapy revealed an enlarging gastric mass, increased adenopathy, and worsening hepatic metastasis.PGSCC is considerably rare, with incidence reported at 0.2% of all gastric carcinomas –6.Adenocarcinoma accounts for 95% of all gastric malignancies. PGSCC occurs more commonly in middle-aged men .Because many gastric masses, which are initially thought to be PGSCC, ultimately turn out to be of a different cell origin , or from a different location , criteria developed by Parks et al. exclude any such cases: Originates in the gastric cardia, extends into the esophageal mucosa, or the presence of squamous cell carcinoma from any other site must be ruled out , 3. PrioIn respect to these diagnostic criteria, our patient's findings of gastric mass originating in the lesser curvature without extension into the esophagus , PET imaP63 tumor marker has been shown to be positive in 81% of squamous cell carcinomas  Figure . MoreoveThe presentation is variable and non-specific. Symptoms include abdominal discomfort, dysphagia, melena, hematochezia, and weight loss. SIADH has not been reported in a PGSCC previously; however, it has been seen in other sites of squamous cell carcinomas . A hyponGiven its rarity, the etiology is still not well understood. Several theories exist: gastric mucosal stem cells, ectopic squamous epithelium in the gastric mucosa, squamous differentiation of preexisting adenocarcinoma, origin from endothelium of gastric vessels, and squamous metaplasia of glandular epithelium induced by noxious agents . Given oWhen disease is local, radical resection is the therapy of choice. The benefit of adjuvant chemotherapy remains uncertain . Due to While PGSCC is a rare disease, it is vital to keep this in mind when evaluating gastric pathology. With surgical resection being the recommended therapeutic approach, prompt identification with attention to the strict diagnostic criteria is essential.


Gallbladder volvulus (GV) is an axial twisting of the gallbladder (GB). If not treated on time, this condition has a mortality up to 6%. It is usually diagnosed intraoperatively, because it can mimic a typical acute cholecystitis. An 81-year-old female patient presented with an acute onset of right upper quadrant pain accompanied with nausea. The patient was admitted to receive treatment for acute cholecystitis after the findings of ultrasound imaging. Robotic-assisted cholecystectomy was the approach chosen. GV was diagnosed after initial diagnostic laparoscopy. Cholecystectomy was performed uneventfully. Indocyanine green fluorescence was used to assess the biliary anatomy. The postoperatory course went uneventful. The patient was discharged home on postoperatory day 2. Management of acute cholecystitis has been proven to be safe in the minimally invasive setting, even for elderly patients . NeverthGV is defined as an axial twisting of the gallbladder (GB), with subsequent interruption of the vascular and biliary flow . As a cost case of GV managed with this novel surgical approach.Robotic-assisted surgery has had an exponential growth in the last two decades, but its use in the acute setting has still to be fully explored , 6. HereThis 81-year-old female presented to the emergency room with an acute onset of nonradiating and sharp right upper quadrant (RUQ) pain, primed by food intake and associated with nausea and fever (38.8°C). Past medical history was significant for hypertension, allergic sinusitis, and multiple abdominal surgeries . Labs were unremarkable; WBC and liver function parameters were within normal limits. Abdominal and pelvic CT scans showed a dilated GB with large (5.4 cm) stone without signs of cholecystitis . RUQ ultShortly thereafter, the patient developed atrial fibrillation with rapid ventricular response, which required consultation and treatment by the cardiology consultant.Surgical consultation was then requested, and the patient was brought to the operating room for an urgent robotic-assisted cholecystectomy.Under general anesthesia, the patient was positioned supine, with tucked arms and intermittent compression devices in lower extremities. Pneumoperitoneum was achieved with a Veress needle placed at Palmer's point .A 5 mm skin incision was performed over the right flank to place the laparoscopic camera. The initial diagnostic laparoscopy showed numerous omental and intestinal adhesions to the abdominal wall. Two additional 5 mm trocars were placed cephalad and caudal to the prior. Successful and uneventful adhesiolysis was carried out. The robotic trocars were then placed according to standard configuration for robotic cholecystectomy . The patrd arm; the organ was untwisted  was used to facilitate the assessment of the biliary anatomy as shown in The postoperatory course went uneventful; the patient was discharged on postoperatory day 2, with anticoagulation treatment for atrial fibrillation, ambulating, and with resolved pain. The pathology report informed gangrenous cholecystitis.GV is a rare condition that occurs after the GB twists around its mesentery . It mostAccording to the classification by Gross , free flClinical symptoms are nonspecific, usually mimicking an acute cholecystitis . This is the reason why a high level of suspicion is a key. The low frequency of fever and jaundice, associated with a poor response to antibiotic therapy, may contribute to the differential diagnosis from acute cholecystitis . If surgPreoperative diagnosis of GV can be challenging, and most images may be interpreted as acute cholecystitis, especially if lithiasis is present . UltrasoSurgical management must not be delayed if diagnosis is made preoperatively. A minimally invasive approach should be the first choice . DespiteRobotic surgery is on the rise. This novel technology is now used not only for routine but also for complex procedures , 19. DesThe magnified 3D vision, the finer dissection facilitated by instruments with Endowrist® , and the real-time assessment of biliary anatomy using ICG-aided cholangiography were perceived by the surgical team as added benefits to the more traditional laparoscopic approach. However, further evidence is necessary to show an obvious advantage of the robotic approach in the management of this rare and acute condition in comparison to the widely accepted laparoscopy.


Candida albicans fungal balls and emphysematous pyelonephritis. Awareness about the various imaging findings of this rare clinical entity and a high index of suspicion in high-risk individuals will help in overcoming the challenges in early diagnosis and, thereby, institution of proper treatment.Fungal ball or fungal bezoar is the saprophytic colonization of a pre-formed cavity by a conglomerate of fungal mycelia without invasion of the adjacent tissue. Fungal bezoar is seen commonly in immunocompromised individuals. We describe the cross-sectional imaging characteristics of two cases of renal fungal ball, a rare clinical entity. The first case is that of a 36-year-old female with diabetes who presented with a single fungal ball that caused ballooning of the renal pelvis by coelomycetes, a rare species of fungi. The second case is that of a 45-year-old immunosuppressed male with diabetes who presented with multiple  Candida albicans fungal balls and emphysematous pyelonephritis (EPN). Awareness about the various imaging findings of this rare clinical entity and a high index of suspicion in high-risk individuals will help in overcoming the challenges in early diagnosis and, thereby, institution of proper treatment.Fungal ball or fungal bezoar is the saprophytic colonization of a pre-formed cavity by a conglomerate of fungal mycelia without invasion of the adjacent tissue. Fungal bezoar is seen commonly in immunocompromised individuals. We describe the cross-sectional imaging characteristics of two cases of renal fungal ball, a rare clinical entity. The first case is that of a 36-year-old female with diabetes who presented with a single fungal ball that caused ballooning of the renal pelvis by coelomyecetes, a rare species of fungi. The second case is that of a 45-year-old immunosuppressed male with diabetes who presented with multiple A 36-year-old female patient with diabetes was admitted with complaints of increased frequency of urine for 1 week, fever, vomiting, right loin pain for 2 weeks, and nocturnal incontinence and urgency for 3 months.The patient had a history of right renal calculus, for which extracorporeal shock wave lithotripsy and double J stenting were performed 4 years back. 10 years back, she underwent right mastectomy for carcinoma of the breast that was followed by chemotherapy.Enterococcus and Pseudomonas, sensitive to amikacin.Routine urine analysis showed 2–4 pus cells and 2–3 red blood cells. Urine culture showed species of Provisional clinical diagnosis on admission was pelviureteric junctional calculus and an associated bacterial infection.The patient was referred for ultrasonogram (USG) of the abdomen, which showed a predominantly hypoechoic lesion in the dilated right renal pelvis with specks of echogenic foci in the periphery . It did Plain CT imaging of the abdomen  confirmeT2 sequence  outlining the lesion.The presence of tiny peripheral calcifications (areas of high attenuation) can be owing to encrustations.T2 or short tau inversion-recovery sequence). The renal pelvic wall is seen separately as an outer isointense margin separate from the lesion.On MRI, the lesion appears isointense, surrounded by a rim of urine (hyperintense line all around the lesion in With the increasing number of patients with immunosuppression, diabetes and posturinary procedure follow-ups, renal fungal bezoar should be considered as one of the differentials. While knowing the imaging characteristics helps in timely identification, confirmation helps in starting correct treatment.Written informed consent was obtained from the patient for publication of this case report, including accompanying images.


Chondromas are benign cartilaginous tumors that occur very rarely in the spine. Moreover, chondromas of the extraskeletal origin are also very rare. In this case report, we describe an extremely rare case of chondroma arising from the ligamentum flavum in the cervical spine. A 67-year-old man presented to our clinic with acute-onset spastic quadriparesis. We performed emergent magnetic resonance imaging and found an epidural mass in the right ligamentum flavum at C4-C5. The acute-onset presentation was suspicious for intraligamentous hematoma in the ligamentum flavum at this level. We performed emergency decompression surgery and en bloc removal of the epidural mass with the right C4 and C5 lamina. The lesion had the appearance of cartilaginous tissue rather than hematoma. Based on the histological investigation, the final diagnosis was intraligamentous chondroma of the cervical spine. The quadriparesis improved postoperatively, as did the results of manual muscle testing in the affected area, and he was able to resume walking independently with a cane. At the one-year follow-up, the manual muscle testing results were almost normal. Surgeons should keep in mind the possibility of benign tumors including chondroma of the cervical spine when a patient presents with acute-onset quadriparesis. Soft-tissue chondroma is a benign mesenchymal neoplasm that contains cells with a chondrocyte phenotype, secretes cartilage matrix, and arises in extraosseous and extrasynovial tissues . AlthougMost chondromas are solitary and present as a painless mass in the soft tissue around tendons and joints. Chondromas arising from ligamentous tissue are rare, with only one case report involving the knee reported in the literature . In thisA 67-year-old man presented to our clinic with acute-onset spastic quadriparesis. During the previous 2 years, he had been under follow-up at 3-month intervals in our clinic following decompressive laminectomy for lumbar spinal canal stenosis and fusion surgery for ossification of the ligamentum flavum of the thoracic spine. In April 2016, he suddenly noticed quadriparesis. He could not stand or walk, but did not present to our clinic until his scheduled follow-up visit 2 weeks later. Manual muscle testing (MMT) confirmed right-dominant quadriparesis . PatellaEmergent magnetic resonance imaging (MRI) revealed an epidural mass in the right ligamentum flavum at the C4-C5 level Figures . The masSoft tissue  chondroma is a rare benign tumor. We searched “extraskeletal chondroma” in PubMed and there are 42 English papers. The location was various, hand and forearm –24, footWe have described a very rare case of chondroma in the ligamentum flavum at the level of the cervical spine. A literature search in 2018 by Inoue et al. . TherefoIn our patient, the symptoms had an acute onset and the tumor was located in the ligamentum flavum. We initially suspected that the mass was an intraligamentous hematoma. Tamura et al.  had prevIt is unclear how chondroma can arise in a ligament or other soft tissue. It is well known that mesenchymal stem cells can differentiate to chondrocytes in vitro , 50. The


Spontaneous flexor pollicis longus (FPL) tendon rupture is rarely reported. Although there are several studies investigating spontaneous FPL tendon rupture, the exact etiology of spontaneous rupture is unclear. Here, we present a case of unusual spontaneous FPL tendon rupture due to tendolipomatosis.A 64-year-old right-handed retired male teacher was referred to our clinic with an inability to flex the interphalangeal joint of his left thumb.Magnetic resonance imaging (MRI) revealed complete FPL tendon rupture at the level of the distal one-third of the proximal phalanx.With the patient under general anesthesia, the FPL tendon was explored through a volar zig-zag incision. During the operation, the FPL tendon was found to be ruptured completely. Gross examination revealed a slightly yellowish denaturated tissue at the distal end of the ruptured tendon. We excised the denaturated tissue from the distal end of the ruptured tendon and sent it for histological examination. FPL tendon was repaired primarily via modified Becker method. Histopathological examination revealed normal vasculature in the tendon tissue and degenerative changes associated with lipid deposits in the tendon tissue.At 12-month follow-up, the patient was completely asymptomatic and had excellent IP joint range of motion (0° to 40°) in his left thumb. The wrist grip strength was 30 kg (28 kg in the Rt.) and the thumb pinch strength was 5.7 kg (4.7 kg in the Rt.). The Quick DASH score was 0.Spontaneous rupture of the FPL tendon, attributed to degenerative changes caused by tendolipomatosis, is the first report of its kind, in the authors’ opinion. Hence we recommend to perform the histopathological examination of the debrided tissue from the ends of the ruptured tendon, if the physicians couldn’t know the exact cause of the spontaneous intratendinous rupture of the FPL. And early diagnosis followed by debridement and primary tendon repair provides an effective outcome. Ethical approval of this study was waived by the ethics committee of Chonbuk National University Hospital because it was a case report and there were fewer than 3 patients.3A 64-year-old right-handed retired male teacher was referred to our clinic with an inability to flex the interphalangeal (IP) joint of his left thumb. One week previously, he was gardening. He had flexed his thumb around the stem of a firmly embedded weed, and as he pulled hard, he felt a sudden pop in his left thumb and found he could not flex his left thumb. Although he often played saxophone, he could not recall any specific episode of pain or discomfort within the left thumb. There was no evidence of any history of rheumatoid or other inflammatory arthritis and his rheumatoid serology was normal.Upon examination, no specific painful swelling in the left thumb was detected. However, the patient was unable to actively flex his thumb at the IP joint Fig. . He had Initial plain left thumb radiographs revealed no bony abnormalities resulting in secondary tendon rupture. Magnetic resonance imaging (MRI) revealed complete FPL tendon rupture at the level of the distal one-third of the proximal phalanx and the proximal end of the ruptured tendon was retracted to the level of the metacarpophalangeal (MP) joint Fig. .With the patient under general anesthesia, the FPL tendon was explored through a volar zig-zag incision. During the operation, the FPL tendon was found to be ruptured completely. Gross examination revealed a slightly yellowish denaturated tissue at the distal end of the ruptured tendon and the gap of the ruptured ends was interposed by a fibrous tissue Fig. . No bonyPostoperatively, the left thumb was immobilized in a below-elbow plaster splint with extension block for 1 week, followed by dynamic splinting recommended for another 6 weeks and unrestricted full active motion at week 7.At 12-month follow-up, the patient was completely asymptomatic and had excellent IP joint range of motion (0°–40°) in his left thumb. The wrist grip strength was 30 kg (28 kg in the Rt.) and the thumb pinch strength was 5.7 kg (4.7 kg in the Rt.). The Quick DASH score was 0 Fig. .4 Although the etiology of spontaneous flexor tendon ruptures in the hand is unknown, repetitive impact forces sustained by the hand alone or in conjunction with tendon loading have been implicated in flexor tendon rupture.Spontaneous intratendinous rupture is difficult to define. However, usually, it is associated with intrinsic or extrinsic pathological processes in the tendons. evaluated tendon specimens obtained from 5 different sites after spontaneous rupture in 891 patients. They found pathological changes in all spontaneously ruptured tendons with characteristic hisopathological patterns. Most (97%) of the pathological changes were degenerative, including hypoxic degenerative tendinopathy, mucoid degeneration, tendo-lipomatosis, and calcifying tendinopathy. The most common lesion was hypoxic degenerative tendinopathy (44%).In 1991, Kannus and Jozsa investigated the vascularity of the FPL tendon and noted that the FPL was supplied by the 4 separate vascular systems with an area approximately 10 mm in length in the relatively avascular MP joint. O’Dwyer and Jefferiss reported that 2 of 3 FPL tendons spontaneously ruptured in this avascular area in their case analysis. On the basis of these findings, it was suggested that the blood supply of the FPL tendon was disturbed and resulted in relative ischemia of the tendon and rupture. These findings were supported by hypoxic degenerative tendinopathy described by Kannus and Jozsa.In 1980, Hergenroede et al Tendolipomatosis was first described by Jozsa et al. Although the etiology of tendolipomatosis is unknown, similar to invasive soft tissue tumor, the lipid cells spread deep in the tendon between the collagen fibers, disrupting the integrity of the collagen eventually. Therefore, in our case, we believe that the FPL tendon rupture occurred due to a longitudinal traction force on the contracted FPL muscle that was exerted on the thumb to pull the weed out in a weakened state by tendolipomatosis. Tendolipomatosis has not been reported to occur predominantly in any particular tendon. However, it was mainly reported in the quadriceps tendon or patellar ligament, and there was no report in the FPL tendon.However, in our case, the tendon rupture site was not in the avascular zone. However, it was observed in the distal one-third of the proximal phalanx and normal blood vessels were seen in histopathological examination, which was not due to hypoxic degenerative tendinopathy. In addition, many lipid cells were deposited in the tendon tissue, which was consistent with tendolipomatosis tendinopathy, according to Kannus and Jozsa.5Spontaneous intratendinous rupture of the FPL tendon is rarely reported. Spontaneous rupture of the FPL tendon, attributed to degenerative changes caused by tendolipomatosis, is the first report of its kind, in the authors’ opinion. Hence, we recommend to perform the histopathological examination of the debrided tissue from the ends of the ruptured tendon, if the physicians could not know the exact cause of the spontaneous intratendinous rupture of the FPL. And early diagnosis followed by debridement and primary tendon repair provides an effective outcome.Software: Malrey Lee.Supervision: Young-Keun Lee.Writing – original draft: Young Keun Lee, Malrey LeeWriting – review & editing: Young Keun Lee, Malrey Lee


The patient was operated via the pterional approach but resection had been halted due to severe haemorrhage and only tumour biopsy could be obtained. The diagnosis of cavernous sinus haemangioma was established by histopathology and confirmed by subsequent digital subtraction angiography. The patient refused second surgery or adjuvant radiosurgery and the treatment strategy was observation and follow-up. Retrospectively, we included the key radiographic features of cavernous sinus haemangioma which would facilitate pre-operative diagnosis and avoid unforeseen operative complications. Diagnostic radiographic features include a well-defined mass in the cavernous sinus which shows isodense to slightly hyperdense attenuation on non-contrast CT scan with possible adjacent pressure bone remodelling. On MRI, it shows remarkable high T2 signal; intense homogenous enhancement or characteristic progressive contrast enhancement on sequential enhanced images. On digital subtraction angiography, it may demonstrate a vascular blush.Cavernous haemangioma of the cavernous sinus is a rare vascular malformation. It's often confused with other parasellar masses. Here, we report a case of a female with a left parasellar mass which was misdiagnosed as schwannoma  A 48-year-old female presented with a history of progressive headache and blurring of vision of 1 year duration. Her physical and neurological examinations were unremarkable. Routine laboratory investigations and pituitary hormonal profile were all normal.Non-contrast CT scan of the brain revealed a large extra axial mass at the sellar and left parasellar regions. It appears homogeneous and shows isodense to slightly hyperdense attenuation relative to the adjacent brain parenchyma. No internal calcifications or necrosis. The lesion effaces the prepontine cistern. Examination of the bone window showed smooth bone remodelling and erosion of the medial part of the sphenoid wing. No evidence of bone hyperostosis. T1 weighted images and remarkable high signal on T2 weighted images  vascular spaces lined by flat endothelial lining. Some vascular spaces were empty but most spaces were filled with blood cells ; a pictuFollowing surgery, digital subtraction angiography was performed and showed a tumour blush at the lateral projection during the late arterial and venous phases supplied from small meningeal branches of the internal carotid artery . It alsoPost-operative neurological examination revealed paralysis of the left third cranial nerve with ptosis in the left eye and loss of light reflex; however, it gradually improved. The patient refused second surgery for total excision of the lesion or adjuvant radiosurgery and preferred the strategy of follow up and observation.1,2 Cavernous haemangioma is one of the four most common types of cerebral vascular malformations.2 They commonly occur intra axially within cerebral parenchyma1,3 ; however, they can also occur within extra axial spaces and when they occur extra axially they have the propensity to develop at the cavernous sinus.4 Extra axial haemangiomas have the same histologic features as intra axial lesions but have a different clinical picture, radiologic findings, and management.3Cavernous haemangiomas, also known as cavernous angiomas or cavernomas, are defined as vascular malformations formed of abnormal dilated vascular spaces with no intervening neural tissue.5 as in our case. Cavernous sinus haemangioma has not been reported before in the Egyptian population; however, several cases were documented in Japan.1,4,6,7 The clinical presentation is insidious and patients usually suffer from headache and dysfunction of the cranial nerves passing through the cavernous sinus, presenting by ptosis, diplopia or facial neuralgia. Optic chiasm may be compressed in large masses and patients may thus present with decreased visual acuity.5Cavernous sinus haemangioma has a predilection to middle-aged females7,8Cavernous sinus haemangiomas are divided pathologically into three types. Type A is a sponge-like lesion with intact pseudocapsule which consists of thin-walled vascular sinusoids with scanty intervening connective tissue; this type usually demonstrates homogeneous contrast enhancement on MRI. Type B is a mulberry-like lesion with absent or incomplete pseudocapsule which contains ample solid parenchyma with well-formed vasculature and connective tissue, and Type C which has both Type A and Type B compositions. Types B and C usually demonstrate heterogeneous contrast enhancement on contrast enhanced MRI studies.7,8 Jinhu and colleagues retrospectively reported MRI features of 21 surgically confirmed cavernous haemangiomas of the cavernous sinus. Most of the cases presented with a well-demarcated dumbbell-shaped appearance at the parasellar region extending to the middle cranial fossa laterally and sellar regions medially. Similar to our case, the cavernous haemangioma usually encircles the cavernous segment of the internal carotid artery without occluding it.7 Non-contrast CT shows a well-demarcated lesion of similar density or slightly higher density to the brain parenchyma . It also shows intense homogeneous post-contrast enhancement. Calcifications are not common in haemangiomas however adjacent bony remodeling and erosion may happen.2 MRI reveals mass which elicits isointense or hypointense signal on T1 weighted images and remarkably hyperintense (CSF like) signal on T2 weighted images with homogeneous post-contrast enhancement.1 Some studies observed heterogeneous enhancement on the first contrast-enhanced series and subsequent homogeneous contrast enhancement or progressive “filling in” enhancement on subsequent contrast-enhanced series especially in histopathological types B and C.7 Unlike intra-axial cavernous angiomas, cavernous sinus haemangioma does not demonstrate T2 hypointense margin or blooming effect on gradient-echo sequences secondary to scanty hemosiderin deposition.9 Angiographically, haemangiomas exhibit a high degree of vascularity and a vascular blush has been reported5 ; however, they may be angiographically subtle.2 Tc-99m tagged red blood cell (RBC) imaging was recently recommended for the diagnosis of cavernous sinus haemangioma in the setting of nondiagnostic surgical biopsy.8,9Radiological imaging is essential for the prediction of cavernous sinus haemangioma and differentiation of haemangioma from similar intracavernous sinus masses. CT, MRI and digital subtraction angiography are helpful for diagnosis of cavernous sinus haemangioma.2 Our case was similar to meningiomas as it elicited homogeneous signal on T1 and T2 weighted images and was similar to trigeminal schwannomas as it elicited high T2 signal and caused widening of the ipsilateral foramen ovale; however, unlike meningiomas and schwannomas; the mass elicited characteristic remarkably high (CSF like) signal on T2 weighted images. Cartilaginous masses such as chondrosarcomas or chordomas are also hard to differentiate from cavernous sinus haemangiomas because they elicit high signal on T2 weighted images and demonstrate intense contrast enhancement; however, they are usually associated with calcifications and adjacent bone destruction.10 A characteristic MR feature of the lesion in our case was its dynamic enhancement pattern. Following contrast administration, the lesion showed early heterogeneous contrast enhancement on the initial axial images that changed to homogeneous enhancement on the subsequent coronal and sagittal post-contrast images. This progression of contrast enhancement took only the acquisition time for obtaining the contrast enhanced T1 weighted sequences (about 2 min per sequence); this can be explained by the pathological nature of the lesion being composed of thick-walled vascular sinusoids which caused this short delay to achieve homogeneous contrast enhancement. This rapid increase in the degree of contrast enhancement is characteristic for cavernous sinus hemangioma as it is not seen in other lesions7 ; angioblastic meningiomas, neurilemomas, and chondrosarcomas may display heterogeneous enhancement however they usually lack progressive “filling in” enhancement pattern or delayed homogeneous enhancement on subsequent sequences.7The differential diagnosis includes similar cavernous sinus masses.11 However, the reported perioperative mortality rate was high due to uncontrollable severe bleeding.12 Therefore the pre-operative diagnosis is important because it requires the surgeon to be ready to tackle such pathology with low surface bipolar coagulation with no attempt to debulk the lesion without complete coagulation and shrinkage. Thus, the surgeon mindset should be delivered to that pathology.1,2 Also, piecemeal removal can be performed after the main feeding arteries are interrupted.4 Stereotactic radiosurgery or radiation therapy has been proposed as primary therapy for patients with inoperable lesions, for those that undergo limited subtotal resection as adjuvant therapy or as a pre-treatment for direct surgical excision as it suppresses tumour growth and decreases vascularity of the mass.13,14Treatment of choice is surgical excision.Cavernous sinus cavernous haemangioma is a rare vascular malformation and an uncommon cause of cavernous sinus masses.Differentiation of cavernous sinus haemangioma from similar intracavernous sinus masses like meningiomas and schwannomas is often challenging.Preoperative diagnosis is crucial as it requires a different surgical technique to avoid intraoperative profuse bleeding.MRI, CT and angiography studies can help to predict the diagnosis and to differentiate cavernous sinus haemangioma from similar cavernous sinus masses.Cavernous sinus haemangioma on non-contrast CT scan appears as a mass in the cavernous sinus which shows isodense to slightly hyperdense attenuation with intense homogeneous contrast enhancement and possible adjacent smooth bone remodeling and erosion.T2 signal; intense homogenous enhancement or characteristic progressive contrast enhancement on sequential enhanced images.Cavernous sinus haemangioma has characteristic MRI features of remarkably high Angiographically, cavernous haemangiomas may show vascular blush as they exhibit a high degree of vascularity but sometimes they might be angiographically subtle.


Background: Solid pseudopapillary neoplasm of pancreas is a rare tumor with a low potential for metastasis and recurrence. Long-term outcomes after surgical resection are excellent and recurrences after an R0 resection are extremely rare.Case Presentation: We present an unusual case of a 42-year-old man who had a recurrence of his solid pseudopapillary tumor 4 years after undergoing a distal pancreatectomy and splenectomy and then again a year after his reresection.Conclusions: The lack of histological features deemed to be suggestive of a malignant variant and the aggressive clinical course seen in this case is remarkable. It underscores the fact that despite the low incidence, recurrences of solid pseudopapillary neoplasms of the pancreas do occur and it can be very difficult to predict malignant potential based on radiological or histopathological features. SPNP have a low malignant potential but local invasion can be present and metastatic spread has been reported with liver and peritoneum being the most common sites. Surgical resection affords long-term cure and the reported recurrence rate after resection ranges from 3% to 9%.2 We hereby present a case of SPNP recurrence in the resection bed with involvement of accessory splenic tissue, diaphragm, stomach, and omentum. The late presentation, male gender, and lack of histological features suggestive of a malignant variant and aggressive growth pattern of the recurrent tumor highlight the unique aspects of this case.Solid pseudopapillary neoplasms of the pancreas (SPNP) are relatively rare tumors comprising around 0.13–2.7% of all pancreatic tumors and 10–15% of all pancreatic cystic neoplasms.pos nuclear β-cateninpos chromograninneg and synaptophysinneg). Margins were negative without any lymphovascular or perineural invasion. The patient was discharged home after an uneventful period of convalescence in the hospital.A 42-year-old man presented to our pancreas multidisciplinary clinic after a computed tomography (CT) scan , prompteFour years later, he was referred back to our clinic after discovery of a biopsy-proven recurrence in the splenic fossa . The bulFinal pathology report confirmed the presence of recurrent metastatic SPNP in omentum, diaphragm, accessory spleen tissue, and the gastric fundus. The patient recovered well from his surgery and was discharged home. He underwent CT surveillance at 3-month intervals per his medical oncologist and his first three scans showed stable postoperative changes without any evidence of local recurrence or metastatic spread. However, his next scan showed enlarged retroperitoneal paraaortic nodes that were found to be fluorodeoxyglucose (FDG) avid. He was started on capecitabine with stable disease on recent repeat imaging in April 2018.3 Intra- or peritumoral calcifications and intravenous contrast enhancement within the mass may sometimes be present. This corresponds well with the CT findings in the case described. Histological appearance of SPNP is marked by the presence of solid, pseudopapillary, or hemorrhagical pseudocysts in varying proportions4  were associated with an aggressive clinical course. Marchegiani et al.1 found expansive growth pattern, pancreatic parenchymal invasion, and capsular invasion to have a statistically significant association with recurrence of SPNP, whereas angiovascular or perineural invasion, nodal/liver metastasis, and margin status did not. Only 2 out of 131 patients included had a recurrence.1 One had a local recurrence in the pancreatic remnant with peritoneal metastasis 72 months after the initial pancreaticoduodenectomy, whereas the other patient developed liver and peritoneal metastasis 56 months after the initial distal pancreatectomy with splenectomy. Histological analysis showed pancreatic parenchymal invasion in both.Tang et al.10 Local, vascular, or perineural invasion was not reported to be predictive of recurrence or overall survival. Irtan et al. reviewed all pediatric SPNP cases in France for a 20-year period and found that the only significant risk factors for recurrence were younger age (<13.5 years) at diagnosis and positive surgical margins at the initial resection.11 Nishihara et al. compared 19 nonaggressive SPNs with 3 aggressive SPNs and proposed that venous invasion, nuclear grade, and prominent necrotic areas were predictive of a more aggressive phenotype.12 In their case series of 71 SPNs, Yang et al. showed that vascular invasion, extrapancreatic invasion, nodal metastasis, and Ki67 index >4% were predictors of recurrence.13Strikingly, Memorial Sloan Kettering Cancer Center (MSKCC) reported a total absence of recurrence after an R0 resection in node-negative tumors.Despite the remarkably typical appearance without any areas of necrosis or hemorrhage, the tumor described in this report had a clinically aggressive course with extensive local invasion. No significant nuclear pleomorphism or foci of sarcomatoid change were observed. It had a more diffuse growth pattern, and the mitotic activity was 6/10 high power field . The onl14 Similarly, Maffuz et al. utilized seven cycles of gemcitabine in conjunction with radiation to downsize a locally advanced SPNP of head of the pancreas with extension to mesocolon, porta hepatis, and gastrocolic ligament.15 Machado et al. treated local recurrence in a patient with chemotherapy and the patient was reported alive 39 months from the index surgery. In their experience with treating metastatic SPNPs, Czarnecka et al. observed a partial response with FolFox-4 for 17 months until drug toxicity forced a switch to FOLFIRI, which unfortunately failed to curtail disease progression.16 Radiation alone was successfully used by Fried et al. and Zauls et al. to manage an unresectable SPNP.18 The case series by Law et al. describes 35 patients with SPNPs who received adjuvant chemotherapy and/or radiotherapy. Among these 24 had long-term follow-up, of which, 6 died of their disease, whereas 18 were alive at a mean interval of 51.1 months.2Since SPNPs have a tendency to displace the surrounding structures rather than invading them, recurrences are usually resectable. There is paucity of data on the role of chemotherapy or radiation in either neoadjuvant or adjuvant setting and the limited data available are predominantly anecdotal. Strauss et al. described regression of an SPNP invading superior mesenteric vein with neoadjuvant cis-platinum and 5-fluorouracil, which was substantial enough to facilitate a surgical resection.19–22 These reports notwithstanding, it bears reiteration that surgical resection is the definitive treatment. A better understanding of the factors associated with recurrence/metastasis would help determine the appropriate surveillance or adjuvant treatment if any are warranted.Other treatment modalities that have been implemented for treating recurrent, metastatic, or nonresectable disease with some reported degree of success include radiofrequency ablation, transcatheter arterial embolization, transcatheter arterial chemoembolization, selective internal radiotherapy, and hyperthermic intraperitoneal chemotherapy.


Primary testicular lymphoma (PTL) is a rare form of non-Hodgkin’s lymphoma more prevalent in males aged over 60 years old. PTL has a tendency to disseminate to systemic extranodal sites, however there has been a rare continuous spread involving the gonadal vein and spermatic cord. This method of dissemination has been described in 3 previous cases, and this case report presents another such case where such spread was noted, in a patient with a previous history of seminoma. Knowledge of this method of spread may increase the index of suspicion of PTL on cross-sectional imaging. This was noted approximately 6 weeks prior to his presentation; and although not particularly painful, had increased in size. His background history, aside from hypertension and eczema, included a history of a right sided orchidectomy and chemotherapy for a testicular seminoma approximately 25 years ago.On examination he had a large left hemi-scrotal swelling, with the left testis being impalpable.−1, normal inflammatory markers, lactate dehydrogenase (LDH) of 743 iu l−1 (raised), alpha-fetoprotein (AFP) of 4 ku/L  and a beta human chorionic growth hormone (β-hCG) of 3 iu l−1 .A baseline set of blood tests which showed a haemoglobin of 131 g lAn ultrasound scan of his testis was requested initially, which demonstrated a grossly enlarged testicle with a heterogenous sonographic appearance. The normal testicular architecture was not perceptible , and colFollowing a multidisciplinary team discussion, a contrast enhanced staging CT of his thorax, abdomen and pelvis was performed. This CT demonstrated a soft tissue mass within the left testicle extending through the left spermatic cord and forming a continuous soft tissue column, most likely within the left gonadal vein. This extended to the level of the left kidney, and a further large soft tissue suprarenal mass was noted .After further discussion, a biopsy to obtain a tissue sample and a fluorodeoxyglucose positron emission tomography (FDG-PET) scan for further staging were both arranged. The FDG-PET scan demonstrated the left testicular mass which was FDG avid. The soft tissue noted extending from the testicular mass was also FDG avid along with the left suprarenal mass. .Initial CT guided biopsy from the left suprarenal mass was arranged, however, it was felt at the time that it was inaccessible. Therefore, after discussion with the referring team, an ultrasound guided core biopsy from the left testicular mass was performed instead. The tissue cores were found to show features highly suspicious of a high grade diffuse large B cell Non-Hodgkin’s lymphoma of non-follicle centre type (ABC).Following the histological analysis from the biopsy, our patient proceeded to have a radical left orchidectomy. The histopathological analysis confirmed the presence of the lymphoma as described above, with invasion of the tunica albuginea, tunica vaginalis, epididymis, spermatic cord and the vascular space.He has since been referred to our haematology team for further treatment.This particular case presented interesting diagnostic challenges. Perhaps the biggest confounding factor was out patient’s history of previous right seminoma operated on 25 years ago.1 Thus, in our patient the probability of recurrence was unlikely. The other differentials given the ultrasound findings alone would be of other non-seminomatous germ cell testicular malignancies; but given our patient’s age these would be unlikely.1Given our patient’s clinical presentation, following the initial ultrasound, the possibility of seminoma recurrence could be considered. However, the risk of this occurring is 2–5% in the first 15 years of treatment and higher in patients under the age of 30.2 However, given the nature of the spread: contiguous along the left gonadal vein3,4 and the clinical presentation of our patient (painless testicular swelling in the absence of B-symptoms), PTL was the likely diagnosis.Once the cross-sectional imaging had been performed, it was evident that our patient had more advanced disease. This would mean distinguishing PTL from a lymphoma arising from another site with secondary testicular involvement; which would be difficult based on imaging alone.5,6 The presentation is usually a unilateral mass within the testicle, and the presence of constitutional symptoms at diagnosis are uncommon; but may indicate the presence of systemic disease if present.6 The main risk factor for developing PTL is in patients infected with the human immunodeficiency virus (HIV), where the incidence is increased and the age of occurrence is often younger.7Primary testicular non-Hodgkin’s lymphoma is a rare form of testicular cancer accounting for approximately 5% of all testicular cancers.5–7In addition to diffuse large B-cell lymphoma, there are other subtypes which may be found on histological analysis including Burkitt and follicular lymphoma3,6 The closest differential would be of testicular seminoma; however, the important discriminator is patient age.3,5,6 Following the initial sonography, a CT scan would be indicated for staging and to aid further work-up. The finding of continuous infiltration of the gonadal vein is in keeping with PTL given its propensity for haematogenous spread2 and has only been described in 3 cases to our knowledge.3,4 If an FDG-PET study is carried out; the main findings are usually asymmetric, focal, increased uptake in the affected testicle; and also, may include abnormal increased uptake within inguinal and retroperitoneal lymph nodes particularly at the renal hilum.8 It is worth mentioning that physiological FDG accumulation within the testes can vary significantly and can be asymmetric hence mimic disease.8 With our patient this was not an issue given his previous history of orchidectomy.With regards to initial radiological appearances, sonography of the affected testis may appear as a diffusely hypoechoic but hyperaemic testicle or a focal testicular mass with increased blood flow.9 Specific to PTL, the findings on ultrasound would usually suggest the diagnosis,10 with the homogenous mass lesion replacing the affected testis manifesting on MRI as hypo-intense on 1T weighted sequences and iso- to hypo- intense on 2T weighted sequences relative to the unaffected testis.3,10 In addition, moderate to strong diffusion restriction may be seen3 and low-level enhancement relative to the normal testis following contrast administration.10 Due to the aggressive nature of PTL, extension out of the testis and involvement of the epididymis may be seen on MRI.5,10 With our patient, MRI was not performed in part due to local protocols, and also following discussion at the urology MDT, the decision was made to obtain a histological sample given the imaging findings on ultrasound and CT to help guide further management.The use of MRI has also been shown to further characterise testicular masses particularly where initial ultrasound evaluation is inconclusive about the classification of a lesion; with one study reporting a sensitivity of 100% and specificity of 97% in classifying malignant lesions.5–7 Serum biochemical markers particularly the LDH is useful to gauge how aggressive the tumour is, and later, to monitor the response to therapy.7Staging the disease is mostly based on the Ann Arbor system, with particular analysis of the CNS  and the contralateral testis.11 This would be followed by either chemotherapy, radiotherapy or a combination of the two,2,11 with the precise regimen based on the stage of the disease.7 Unfortunately, PTL are very aggressive malignancies, and most patients with Stage I/II disease will experience relapse.5 Most relapses occur within the first 2 years of follow-up, but late relapses have been also reported mainly affecting the CNS and the contralateral testis, the former being more common.6,11 This has raised the need for CNS prophylaxis to prevent recurrence, however the method of delivery  remains controversial.6,7The treatment usually consists of performing and orchidectomy initially which would be a therapeutic intervention (to relieve the tumour burden) and also diagnostic .In older patients presenting with unilateral testicular enlargement with no constitutional symptoms , PTL is to be considered in the differential diagnosis.Spread of a testicular tumour through the spermatic cord and the gonadal veins is considered pathognomonic for Primary Testicular B-cell Lymphoma.Initial ultrasound imaging of a scrotal lump may suggest PTL as a differential, however if there is still uncertainty regarding the nature of a testicular lesion, MR imaging may be considered for further accurate characterisation.Unfortunately, due to the aggressive nature of PTL, there is a high propensity of relapse which would most commonly affect the CNS.


Middle ear adenomatous neuroendocrine tumor (MEANT) poses a diagnostic challenge. Clinical symptoms are nonspecific. Definite diagnosis is made by histopathological analysis of the tumor after a complete surgical resection based on an extensive computed tomography/magnetic resonance imaging (CT/MRI). Controversial terminology of the neoplasm arises from the differentiation of this tumor composed of both endocrine and exocrine glands. Middle ear (ME) localization is rare and less aggressive than gastrointestinal tract or lung localizations. Nevertheless, clinical and CT/MRI analyses are necessary follow-ups for preventing or detecting recurrence or metastasis. A case of a female patient aged 26 with recurrent middle ear neuroendocrine adenoma is presented herein. Known for about 40 years , 2, MEANClinical symptoms are nonspecific and include hearing loss, aural fullness, tinnitus, otalgia, facial weakness, and the like –9.Anatomical imaging CT and MRI are not specific enough and sufficient for an accurate localization before surgery. Functional imaging (octreoscan™) targets somatostatin receptors, especially SSR2 and SSR5 located on the cell membrane of the tumor, and is much more sensitive , 11. To Definite diagnosis relies on combined histopathology and immunohistochemistry. The authors discuss the controversial terminology of these tumors based on different degrees of glandular or neuroendocrine differentiation , 12, 13.In February 2008, a 26-year-old female patient consulted us for a second opinion before surgery on a suspected ME cholesteatoma. She had been complaining for several months about right aural fullness and otalgia.The otoscopy revealed a posterosuperior reddish retrotympanic mass without retraction pockets accompanied by a subnormal audiometry. The well-defined soft tissue mass density observed on the CT scan close to the ossicles but without any bone erosion did not support a diagnosis of cholesteatoma cf. . A surgiHistological examination revealed an epithelial proliferation with architecture sometimes trabecular, sometimes glandular, embedded in a dense fibrous stroma. The tumor was composed of uniform cuboidal or cylindrical cells with round to oval nuclei and a plasmacytoid morphology. No necrosis or mitotic activity was identified cf. . PeriodiImmunohistochemical staining was strongly positive for synaptophysin cf. , focally111Indium-pentetreotide scintigraphy showed an intense activity in the right ME  and/or neuroendocrine differentiation. Immunoreactivity is variously positive for keratin antibodies  and neuroendocrine markers  , 12. DivCoexistence of cells derived embryologically from both endoderm and mesoderm  led some authors to claim either that uncommitted epithelial  cells would develop neuroendocrine features, or that uncommitted neural crest cells would acquire exocrine and epithelial characteristics .Most cases of ME localization in literature are described in case reports with local malignancy. Recurrence rate of insufficiently resected tumors occurs between 15 and 22% according to the authors , 15. EveThe best treatment is surgery, and the extent of resection depends on the staging, from intact canal wall tympanomastoïdectomy to a subtotal petrosectomy.Saliba and Evrard  reviewedMore recently, Marinelli et al.  proposedMEANTs are listed in the 2017 WHO classification as “middle ear adenoma,” arguing that it is always appropriate to designate them as adenomas with neuroendocrine features [111In-pentetreotide scintigraphy in the diagnosis and the management of 145 patients with NE tumors . The authors noted that cross-sectional CT/MRI detected 60% of primary or recurrent tumors and suggested that scintigraphy should be reserved for patients with biochemical diagnosis of NE tumor with silent CT/MRI.Shaverdian et al.  studied MEANT is a rare, slow-growing, and low-grade malignancy tumor with nonspecific clinical symptoms. Radical surgery treatment prevents 22% recurrence. Clinical combined with CT/MRI remains actually the best available method for controlling recurrence. Octreotide scintigraphy will be performed in case of doubt. NE neoplasm behavior, however, still remains unpredictable, and a lifelong follow-up is necessary.


Dieulafoy disease of the bronchus is a rare vascular deformity. To the best of our knowledge, reports of these involving both lung vascular are hitherto absent.A 67-year-old male was admitted to our department due to agnogenic hemoptysis.Bronchoscopy was performed and some smooth, pulsatile nodular lesions were found in the middle and lower lobes, Computed tomography angiography of the bronchial artery confirmed a left bronchial artery arising from the aortic arch at T4 level, and both bronchial arteries were dilated and tortuous.Bronchial artery embolization was performed successfully.The patient was discharged with no hemoptysis. In addition, patient is under follow-up until today without any further incidents.This case reminds us that Dieulafoy disease of the bronchus could be a potential etiology for unexplained hemoptysis. The clinician should be aware of this disease when bronchoscopy revealed multiple some smooth, pulsatile nodular lesions, thereafter, bronchoscope biopsy should be avoided, as it could lead to fatal hemoptysis. Here, we present the case of a 67-year-old male who was diagnosed to have Dieulafoy disease of the bronchus, computed tomography angiography of the bronchial artery confirmed a left bronchial artery arising from the aortic arch at T4 level, and both bronchial arteries were dilated and tortuous.Dieulafoy disease is a rare vascular anomaly characterized by dilated, tortuous arteries in the submucosa. It was observed to occur commonly in the gastrointestinal tract and was described for the first time by Dieulafoy in 1898. Dieulafoy disease of the bronchus is rarely seen, which could be presented with recurrent and unexplained massive hemoptysis or with asymptomatic. To our knowledge, 29 cases have been reported since it was first reported by Sweets in 1995,2A 67-year-old nonsmoking man was admitted with productive cough and hemoptysis. He had been hospitalized 8 months earlier because of the same symptom and coughed up approximately 10 ml of fresh blood. After cessation of bleeding, there was no hemoptysis during the period before this hospitalization. One day before the current admission to our hospital, he developed recurrent hemoptysis and coughed up fresh blood (about 100 ml) without any clots.Physical examination of the head, neck, chest, and abdomen was within normal limits. Laboratory tests including white blood cell count, hemoglobin level, platelet count, hematocrit, prothrombin time, partial thromboplastin time (PT), and international normalized ratio (INR) did not reveal any obvious abnormal findings.Computed tomography angiography showed a left bronchial artery arising from the aortic arch at T4 level, from which a branch supplied the pulmonary circulation, and both bronchial arteries were dilated and tortuous Fig. A, B.Bronchoscopy was performed and some smooth, pulsatile nodular lesions were found in the middle and lower lobes; 2 cone-shaped endobronchial protrusions covered by a smooth mucosa were noticed in the right upper lobe Fig. C, D, andThen, bronchial angiography was performed and it showed bilateral bronchial arteries were dilated and tortuous Fig. F, G. The3Massive hemoptysis is a common critical disease in respiratory medicine. There are many causes of hemoptysis, such as bronchiectasis, tuberculosis, or neoplasm. Dieulafoy disease of the bronchus is a rare clinical entity. It appears to occur throughout the gastrointestinal tract. Since Dieulafoy disease of the bronchus was first reported by Sweerts et al in 1995, multiple similar cases have been reported in the literature.–23 However, the pathogenesis of this vascular anomaly is unclear. Herein, we present a case of Dieulafoy disease of the bronchus and then we identified 23 published reports with a total of 29 cases and summarized the clinical features of all the cases in Table Dieulafoy disease is a rare vascular anomaly characterized by dilated, tortuous arteries in the submucosa. Most patients had no history of smoking (21/30) or existing respiratory diseases (25/30). Dieulafoy disease of the bronchus should be suspected if a patient is suffering from recurrent and unexplained episodes of hemoptysis. However, the clinical manifestations are non-typical, comprising productive cough, chest pain, recurrent pneumonia, or exacerbation of bronchiectasis.Studies show that this condition is associated with bronchial pulmonary congenital dysplasia, chronic airway inflammation, or injury. In our study, we found that CT angiography have been performed on only 6 cases of 30 patients which revealed bronchial artery malformation. The examination revealed the presence of a dilated, tortuous bronchial artery and bronchial-pulmonary artery fistula. According to the literature, the dysplastic artery appears in the right (23/30) lung more than it does in the left side (5/30), and bilateral vascular lesions are rarer (1/30). The incidence of lesions seems higher on the right side, but in our case, the lesions were bilateral vascular involvement. According to the observations from the pathological examination of dissection specimens, these dilated or deformed arteries pass the bronchial wall and travel through the submucosa. Besides, abnormal vessels arise more from the systemic than the pulmonary circulation. At present, bronchial arteriography is a useful method for making a definite diagnosis.In most cases, only inflammatory change was observed, with atelectasis or a non-significant abnormality on routine imaging examination, either on a chest X-ray image or chest CT scan. Only 3 cases presented with an intraluminal nodular lesion and 2 cases showed consolidation on chest CT scan. However, CT angiography is a useful diagnostic tool to detect and locate the origin of abnormal arteries and bleeding. Among the 30 cases in this study, 8 patients underwent a biopsy, 6 cases presented massive hemorrhage and 4 patients died. Therefore, we do not recommend bronchoscopic biopsy once the disease is suspected.Through bronchoscopy, mucosal abnormalities are expressed as small (about 2–7 mm in diameter), non-pulsatile, and smooth nodular lesions with a white cap (18/30), with active hemorrhage (8/30) and blood clot in the bronchus (5/30). Nevertheless, the diagnosis depends on pathological examination; however, biopsy should be considered carefully because of the risk of fatal hemorrhage.,26 Narrow band imaging (NBI) can aid in visualizing the superficial mucosa to detect vascular lesions by using 2 different ranges of wavelengths: 390 to 445 nm and 530 to 550 nm. Vascular lesions in the submucosa appear blue-green under NBI; the color blue indicates that the vessel is at a shallow location, while green indicates that the location is at a deeper location. Endobronchial ultrasound scan is also a useful tool to detect vascular abnormalities which are usually hypoechoic or anechoic with hyperechoic or echogenic walls.,25 Combining these 2 technologies can help to define the property of intraluminal nodular lesions.When bronchoscopy is performed in a patient presenting with hemoptysis, it is important to identify the characteristics of the intraluminal nodular lesions, thus reducing the risk of fatal hemorrhage. With the use of a conventional white light bronchoscope alone, up to 29% of the vascular anomalies and dysplastic mucosal and dysplastic mucosal lesions may not be detected.Up till now, selective bronchial artery embolization has been an effective and safe procedure for controlling hemoptysis. This procedure offers an alternative method for patients who cannot undergo lobectomy owing to compromised general health status or simply do not want to undergo surgery and demonstrates a good curative effect (10/18). Despite this, 8 cases presented with recurrent hemoptysis, which may have been associated with malformed vessels originating from the pulmonary circulation rather than systemic circulation. In addition, revascularization, neovascularization, and drop of the embolus dropping could also have caused failed embolization.If the malformed vessels are originating from the pulmonary circulation, embolization is often ineffective, and lobectomy can be an alternative option for cure. Lobectomy should be considered when the patient develops massive hemoptysis or embolization is unsatisfactory.To the best of our knowledge, reports of these involving both lung vascular are hitherto absent. We present the first case report of recurrent hemoptysis resulting from dilated and tortuous bilateral bronchial arteries causing Dieulafoy disease. Our patient had a short-term history of slight hemoptysis. Moreover, the time of his first episode compared to others was relatively late. The bronchial angiography and CT angiography revealed the same features, that is, dilated and tortuous bilateral bronchial arteries; however, this is an infrequent situation within clinical practice. Then, the patient showed satisfactory curative effect through bronchial artery embolization.In summary, this case we reported and those reviewed support that Dieulafoy disease of the bronchus should be considered if a patient presents with recurrent and unexplained hemoptysis. Combining narrow band imaging and endobronchial ultrasound scan can help to identify the characteristics of an intraluminal nodular lesions before biopsy, thus reducing the risk of fatal hemorrhage. Bronchial arteriography and selective bronchial artery embolization should be performed in time to reduce the risk of life threatening hemoptysis. Lobectomy could be considered as a radical intervention.Conceptualization: Zaichun Deng.Data curation: Pan Tang, Chengna Lv.Formal analysis: Chaofen Li.Funding acquisition: Qunli Ding.Investigation: Tingting Wu.Methodology: Jing Huang.Project administration: Qunli Ding.Writing – original draft: Pan Tang.Qunli Ding orcid: 0000-0002-6181-4548.


Abdominal cocoon is a rare peritoneal lesion and is difficult to diagnose because of its lack of special clinical manifestations. Until now, there is no case report of abdominal cocoon combined with cryptorchidism and seminoma.A case of abdominal cocoon with cryptorchidism and seminoma was diagnosed and treated in our hospital. The patient had no symptoms except occasional abdominal pain. He underwent laparoscopy because of bilateral cryptorchidism and seminoma in the right testis. During the surgery, he was diagnosed with abdominal cocoon due to the thick fibrous tissues which was tightly adhered and encased part of intestine like a cocoon. Enterolysis and bilateral cryptochiectomy were performed after the diagnosis and nutritional and symptomatic support was provided after the surgery. The patient recovered well and was discharged soon. The postoperative pathological examination confirmed the presence of bilateral cryptorchidism and seminoma in the patient’s right testis.There are only a handful of cases where a patient has both abdominal cocoon and cryptorchidism. Since the etiologies of both diseases remain unknown, further research is required to investigate effective diagnosis and treatment for the diseases and explore the potential connection between the two diseases. Abdominal cocoon is a rare peritoneal lesion characterized by a layer of dense and pale abnormal fibro-collagenous membrane that encases part or all of intestine like a cocoon. The most common symptoms of the disease are abdominal pain, abdominal distension, vomiting, nausea, and abdominal mass, all of which are, however, not specific to abdominal cocoon. The first case of abdominal cocoon was reported by Owtschinnikow in 1907 when he referred the disease as ‘peritonitis chronica fibrosa incapsulata’ . CryptorA 28-year-old male patient was admitted to the Minimally Invasive Urology Center of Shandong Provincial Hospital. The patient complained of bilateral scrotal vacuity which had been bothered him since his childhood. Two years ago when he was diagnosed with cryptorchid nodules in his right testis. He has been constantly bothered by symptoms such as occasional abdominal pain, nausea, and vomiting for 10 years. He had a history of syphilis for 2 years, which had been treated with penicillin. Laboratory examinations including the routine blood test, liver function tests, coagulation analysis, urinalysis, and tumor biomarker tests such as alpha fetoprotein(AFP), carcinoembryonic antigen(CEA) and Human Chorionic Gonadotropin(HCG) were showing no abnormality. His syphilis was confirmed in the present study by a positive gelatin agglutination test result and the result of rapid plasma reactivity (1:2). The sex hormone assay demonstrated an increase of follicular stimulating hormone , luteinizing hormone , and prolactin  and a decrease of the estrogen . However, the testosterone(T) was confirmed to be at a normal level (5.23 ng/ml).The ultrasonography showed bilateral cryptorchidism and cryptorchid nodules Fig. a and b. Laparoscopy was performed in our hospital in August 2018 to proceed with further diagnosis. During the operation, we found adhesions between the patient’s bowel loops and peritoneum. In addition, fibrous tissues were detected between small intestines, which fixed the intestines and made it hard to separate them Fig. .Fig. 2IAbdominal cocoon is also known as primary sclerosing peritonitis, idiopathic sclerosing peritonitis or sclerosing encapsulating peritonitis . MedicinSo far, the preoperative diagnosis of abdominal cocoon is still difficult, and most patients are diagnosed by finding fibrous capsule shaped like silkworm chrysalis during laparotomy exploration . The lacAbdominal X-ray may show dilated bowels with air-fluid levels in a case of abdominal cocoon. A Barium meal can demonstrate that the bowels gather in the center of the abdomen in the shape of a large cauliflower. Ultrasonography can be employed to reveal the dilated intestinal loops surrounded by a thick hypoechoic fibrous membrane . ComputeCryptorchidism can be diagnosed by physical examinations and ultrasonography. Currently, laparoscopy is the gold standard for the diagnosis of cryptorchidism. In the present study, the imaging examination did not find the exact position of the left cryptorchid testis in the abdominal cavity nor obvious imaging characteristics of abdominal cocoon. However, during the laparoscopic exploration, we detected severe abdominal cavity adhesions and fixed intestinal loops gathered which were attached to fibrous tissues. The left ectopic testis was identified during the operation. The patient had no diseases other than syphilis. As he was born with bilateral scrotal vacuity, the diagnosis was idiopathic abdominal cocoon complicated with bilateral congenital cryptorchidism and seminoma in the right testis.The treatment of abdominal cocoon includes conservative treatment and surgical treatment. Patients with mild symptoms can receive conservative treatments such as nutritional support, gastrointestinal decompression, and medications. Corticosteroids, colchicine, immunosuppressive agents  can inhibit the inflammatory response, and tamoxifen has antifibrotic effects, all of which can be employed to treat abdominal cocoon . SurgicaTreatment of adult cryptorchidism includes cryptorchidectomy and orchidopexy. As the incidence of malignant tumors in adult cryptorchid testes is extremely high, cryptorchidectomy is the most recommended treatment. There are cases when a patient chooses orchidopexy to retain the function of secreting sex hormones. Preoperative and postoperative adjuvant hormone therapy may reduce surgical difficulties and improve fertility in patients with undescended testes. Spinelli et al. reported that testicular volume increased significantly after 5 years of follow-up in patients with a normalized testicular atrophy index (TAIn) > 20% receiving gonadotropin releasing hormone analog (GnRHa) before and after surgery . BesidesTesticular seminoma is the most common malignant tumor in testes which has low malignancy and grows slowly. There are three clinical stages of testicular seminoma:I stage is limited to the testicles with no lymph node metastasis; II stage includes regional lymph node metastasis; III stage has distant lymph node metastasis or lung metastasis.Of a single morphological structure and a uniform size, classic seminoma cells are often arranged in the form of nests or sheets and separated by fibrous tissues with a large number of infiltrating lymphocytes. From the perspective of immunohistochemistry, most seminoma could express placental alkaline phosphatase (PLAP) tumor marker, especially in seminoma and ovarian cancer. It has also been verified by Kemmer et al. that 82% of seminoma can express CD117 [Radical orchiectomy is generally recommended for testicular tumors. Approximately 80 to 85% of patients with seminoma of clinical stage I can be cured by the surgery . StandarIn the present study, the testicular seminoma with which the patient was diagnosed was identified as clinical stage I since no tumors were found in other parts of his body in the preoperative examination. As the patient suffered from intestinal damage during the operation, he was given a diet ban for 2 weeks to prevent intestinal fistula, while receiving parenteral nutrition and other symptomatically supportive treatment at the same time. The patient recovered well and was discharged 23 days after the surgery. During the follow-up, no tumor recurrence. The patient’s intestinal obstruction recurred 6 months after the operation, and improved after conservative treatment.Even though there are only a few cases of idiopathic abdominal cocoon complicated with cryptorchidism, it is still worth exploring since there is a possible connection between the two diseases both of which are related to the abnormal embryonic development. A sensible assumption could be that the intestine loops enclosed by the dense fibrous membrane may be responsible for keeping the cryptorchid testis from descending into the scrotum. However, a precise determination of their relationship is still yet to be made and thus calls for further research in this regard. Patients diagnosed with cryptorchidism should be alert to the possibility of abdominal cocoon in order to avoid missed diagnosis and misdiagnosis and reduce the incidence of surgical complications.


Atraumatic splenic rupture is rarely encountered in clinical practice compared to traumatic rupture. General risk factors include hematological, infectious, or malignant splenic diseases, uremic coagulopathy, use of heparin, hypertension, and immune-compromised status. Spontaneous splenic rupture following colorectal surgery has never been reported. Maintaining a high index of suspicion in patients presenting with left upper quadrant pain and tenderness is crucial. Diagnosis can be made with the aid of an ultrasound or CT scan. The management plan should be tailored to the patient's clinical conditions. The authors present a case of spontaneous splenic rupture in a patient following colectomy for cancer and undergoing postoperative hemodialysis and discuss the possible etiological factors. The spleen is the second most commonly injured organ following abdominal trauma . Unlike Spontaneous splenic rupture in patients undergoing colorectal surgery has never been described. In the reported case, postoperative hemodialysis is deemed to have been the precipitating cause with only few cases reported in the literature. Although the exact etiology is still unclear, the use of heparin during hemodialysis, uremic coagulopathy, amyloidosis, infections, and splenic infarction could represent significant risk factors . A high A 61-year-old woman was referred by another institution with a diagnosis of distal transverse colon invasive adenocarcinoma and resectable liver metastases. Her past medical history revealed type 2 diabetes mellitus, hypertension, and chronic kidney disease. No relevant family history was noted. The case was discussed at the multidisciplinary tumor board meeting, and the decision was taken for the patient to undergo surgery for the primary tumor and subsequently address the treatment of liver metastases. A laparoscopic-assisted transverse colectomy with primary anastomosis was performed with no intraoperative complications. On the fourth postoperative day, she developed tachypnea, fever, and leukocytosis. A CT scan of the chest and abdomen with contrast was carried out. This showed a right middle lobe opacification consistent with pneumonia. A small <5 cm localized pelvic collection was noted; otherwise, the intra-abdominal organs including the spleen were unremarkable . Blood c9/L (4-11), platelet count 517 × 109/L (150-400), blood urea nitrogen 12.9 mmol/L (2.7-7.2), and creatinine 342 μmol/L (53-97)). Liver function tests showed an albumin of 14 g/L (34-50), alkaline phosphatase of 225 μ/L (54-144), prothrombin time of 16.1 (9.6-12.6), partial thromboplastin time of 36 sec. (24.3-30.2), and international normalized ratio of 1.5 (0.8-1.2).Laboratory investigations showed normochromic normocytic anemia (hemoglobin 8.7 g/dL (12-17), white cell count 20.8 × 102 of 27 mmHg (36-46), HCO3 of 18.5 mmol/L (21-28), lactate of 1.5 mmol/L (0.5-1), and anion gap of 24.2.Blood gases revealed a pH of 7.15 (7.3-7.4), pCOA CT scan of the abdomen and pelvis showed a large subcapsular splenic hematoma with gas formation. There was no evidence of bowel perforation or obstruction .An emergency laparotomy was performed, and this showed a ruptured splenic hematoma. Peritoneal lavage and splenectomy were performed. Histology showed a necrotic spleen with fibrin and focal fat necrosis with no evidence of malignancy.The patient made a slow but uneventful recovery and was eventually transferred to the nephrology unit to continue treatment for renal failure.The most common cause of splenic rupture is abdominal trauma . SpontanEarly diagnosis and management is crucial as it is a life-threatening condition with a mortality up to 12% . DiagnosFew cases have been reported in the literature of spontaneous splenic rupture in hemodialysis patients , 7, 8. TPatients on dialysis are likely to have an abnormal coagulation profile. This may be evident in the form of prolonged bleeding time, platelet dysfunction, impaired platelet aggregation, decreased activity of platelet factor III, and impaired prothrombin consumption , 9. PatiSplenic artery calcification that can be secondary to uremia and can alter arterial stability has been considered a risk factor for splenic rupture .As most of the cases reported, our patient received anticoagulation during hemodialysis and had evident uremic coagulopathy. There were no other risk factors such as trauma, malignancy, or amyloid deposition. It is possible that pneumonia might have been a contributing factor; however, blood cultures were unremarkable. A first postoperative CT scan had shown a normal spleen ruling out possibility of inadvertent injury during the laparoscopic procedure for cancer. A conservative approach in the patient was deemed inappropriate in view of her instability and evidence of infection with a gas forming organism on preoperative scan.Spontaneous splenic rupture is a rare entity that can be associated with many clinical conditions including malignant, hematological, and infectious causes. It is a fatal condition that can be missed easily especially in the absence of trauma. Prompt diagnosis and management is essential for better patient outcome. Clinicians should have a high index of suspicion in patients with uremia and hemodialysis when presenting with left upper abdominal pain and tenderness, even in the postoperative period. The decision of conservative or operative management should depend on the benefit-risk analysis for each single case.