Small bowel evisceration after vaginal cuff rupture is a seldom seen surgical emergency. We report on a case of rupture seen in the emergency department in a patient eight weeks post hysterectomy. She presented to the emergency department by ambulance in the early morning hours with the complaint of acute severe abdominal pain along with nausea and vomiting. Diagnosis of this condition was confirmed after a thorough physical exam. Following manual reduction in the emergency department and immediate transfer for surgical repair helped the patient avoid the morbidity and mortality associated with this complication. This allowed her to be discharged home later the same day. Small bowel evisceration after vaginal cuff rupture is a rare complication following hysterectomy. Historically, it is often seen as an early surgical complication after hysterectomy with increased mortality in patients following cuff rupture. We report a subacute case of post-operative vaginal cuff rupture in a patient presented to the emergency department with acute onset of severe abdominal pain.A 45-year-old female presented to the emergency department in the early morning hours with the complaint of acute severe abdominal pain with nausea and vomiting. The patient reported consuming a few glasses of wine prior to going to sleep earlier that night and awoke in the middle of the night with upper abdominal pain. She reported going to her bathroom and experienced retching without vomiting. The patient had previously experienced inability to vomit following gastric sleeve placement approximately 10 years prior. Following the “retching” episodes where she was unable to vomit, she continued to have cramping abdominal pain. She noted that with the continued abdominal pain she also experienced what she thought was an episode of urinary incontinence. Concerned, the patient sat on her toilet and felt a protrusion from her vagina which she presumed to be her bladder.The patient’s past medical history was significant for an abnormal cervical pap smear leading to a total laparoscopic hysterectomy, performed eight weeks prior to this emergency department presentation. Her obstetric history was significant for G4P2022. On review of systems, the patient reported a minor amount of vaginal spotting occurring in the few days following the surgery that resolved without intervention. The patient followed up at four weeks with the operative surgeon and was found to be healing appropriately without any noted complications.The patient was transported by ambulance to the emergency department; she appeared uncomfortable and was experiencing a significant amount of pain. Ondansetron 4 mg and Fentanyl 250 mcg were given intravenously by paramedics en route to the hospital.The physical examination, specifically pelvic exam, was remarkable for a protrusion of small bowel loops from the vagina. Active peristalsis of the bowel was visible on external exam. No areas of ischemic bowel were noted Video .After urgent consultation with gynecology, it was recommended the bowel be immediately reduced and the patient prepared for emergent surgical repair. Subsequently, the bowel was covered with warm, sterile saline moistened gauze, and the bowel was reduced with gentle manual pressure back into the abdominal cavity after administration of intramuscular Midazolam for procedural sedation. Based on this, the bowel was covered in warm sterile saline moistened gauze.After successful reduction, the patient was emergently transferred to a facility with the capability to surgically repair her vaginal cuff. She was transported in reverse Trendelenburg by ambulance and asked not to perform any Valsalva maneuvers.The operative report revealed that there was an open vaginal cuff with loops of small bowel in the upper vagina. Purulent exudative tissue was found along the margins of the previous vaginal cuff suture lines. No serosal tears were noted along the inspected areas of small bowel. Transvaginal approach was used to repair the vaginal cuff.Vaginal cuff dehiscence with bowel evisceration is a rare but emergent indication for immediate surgical intervention and repair. First report dates back to 1864, and approximately 100 reports exist of this complication since that time. Rates are hard to determine due to the rarity, but literature shows a rate of between 0.032 and 1.2% of hysterectomies. Mortality increases with small bowel evisceration [Pap smears are screening exams used to test for precancerous and cancerous cells of the cervix. Cervical intraepithelial neoplasia (CIN) is the term given to precancerous cells abnormally growing on the cervix following an infection of human papillomavirus. CIN is graded on a scale between 1 and 3, with 3 being the most dysplastic cells along with undifferentiated neoplastic cells. Indications for hysterectomy following identification of cervical neoplasia are multifactorial and have a wide distribution based on shared decision-making between patients and their surgeon.Treatment of CIN varies, though higher grades of CIN require excision and ablation of the cells. Incomplete treatments that have left remaining neoplastic or dysplastic cells may require hysterectomy.Incidence of vaginal cuff dehiscence following hysterectomy varies with approach. Studies have shown that following the increased use of minimally invasive and robotic surgeries , there has been a corresponding increase in rates of dehiscence. Case reports have shown occurrence of rupture ranging three days to 30 years following surgery .According to a recent report by American Journal of Gynecology, hysterectomy is the second most common surgical procedure performed on women, with cesarean sections being the most commonly performed procedure . HystereCommon events triggering dehiscence have been identified, and include sexual intercourse, defecation, increased abdominal pressure with Valsalva maneuvers or vomiting has also been a precipitating factor. Spontaneous rupture is also common . No assoDehiscence varies with surgical approach. Total transvaginal hysterectomies have less cuff dehiscence complications when compared with other less invasive approaches such as robotic assisted hysterectomy. Repair of vaginal cuff dehiscence requires emergent gynecological surgical intervention to repair cuff and to prevent ischemic changes to eviscerated bowel .Initial management must include antibiotic coverage and protection of the protruding small bowel from ischemia and perforation. Warm soaked gauze should be placed on top of protruding bowel contents. Emergency stabilization with attention to prevent patient discomfort is required to keep patient calm and comfortable for transport to definitive surgical care.Vaginal cuff dehiscence is a rare and serious post surgical complication following hysterectomy. A thorough history must be taken in patients present with acute onset of abdominal pain associated with a rush of fluid, vaginal bleeding, and acute onset of abdominal pain.Upon rupture of the vaginal cuff, vaginal flora can easily be transferred to the abdominal cavity leading to serious complications. Abdominal peritonitis along with septicemia is possible complication following rupture.The differential diagnosis of acute onset abdominal pain is wide. A detailed history, along with thorough past surgical history that is significant for recent hysterectomy, should raise concerns for vaginal cuff dehiscence if patients present to the emergency department with sudden onset pain and rush of fluids. Prompt surgical consultation along with precautions for prevention of bowel ischemia should be emergently performed.


Congenital prepubic sinus (CPS) is a rare congenital anomaly and widely thought to be a variant of urethral duplication. Histological examination of this case gives a clue to this theory. CPS with dorsal penile curvature has been reported in previous publications, but their procedures to correct the curvature are different from this case.A 10-year-old boy complained of the pain in the dorsal base of the penis. Physical examination revealed an accessory meatus located in the midline of the dorsal proximal penis and moderate dorsal penile curvature with deficient dorsal foreskin. Imaging examination showed that the meatus did not communicate with either normal urethra or urinary bladder, and ended blindly at the level of the symphysis pubis. The intact 4-cm-long sinus was completely separated and excised. Penile curvature was corrected after the dorsal proximal fibrous cord was detached. Histological examination confirmed the diagnosis of urethral duplication.The histological result of this case supports the theory that CPS is a variant of the dorsal urethra. Moreover, this case indicates that the curvature in patients with CPS may be caused by the dorsal fibrous cord at the beginning and the operation should be conducted at an early age to avoid further development of the curvature during puberty. Urethral duplication is an infrequent congenital lower urinary tract anomaly and generally classified into three types, including incomplete type 1), complete (type 2) and coronal type 3) [, complet , compl. CPS repA 10-year-old Chinese boy was admitted to our hospital with the chief complaint of the pain in the dorsal base of the penis. He presented with occasional discharge from an accessory meatus located in the midline of the dorsal proximal penis, combined with dorsal penile curvature  showed that the epispadiac tract did not communicate with either normal urethra or urinary bladder, and ended blindly at the level of the symphysis pubis Fig. d. Thus, Methylthionine chloride was injected into the sinus through the dorsal opening at the initiation of the procedure, and the intact 4-cm-long sinus was completely separated and excised Fig. e, f. TheHistological examination showed that the lining epithelium inside sinus was transitional epithelium, and a few smooth muscle bundles were identified around the sinus Fig. i. These CPS is an extremely rare congenital anomaly. Two theories have been proposed to illustrate its etiology, including a variant of dorsal urethral duplication and an abdominal wall closure defect. In this case, the histological result supports the theory that CPS is a variant of the dorsal urethra duplication, which is consistent with other studies , 5. CPS CPS with dorsal penile curvature has been reported in previous publications , 7. Two Retrograde urethrogram, retrograde sinogram, and CT were all conducted in this case. However, CT seems not to provide additional information compared to retrograde urethrogram plus retrograde sinogram in terms of the relationship between CPS and lower urinary tract. Thus, we suggest performing ultrasound rather than CT to investigate the upper urinary tract, which makes much less radiation exposure to the patients.


Ewing's sarcoma (ES) is an extremely rare bone malignancy observed in otorhinolaryngeal practice. In otorhinolaryngology, it sometimes involves the facial bones and cervical vertebrae. In children, ES is the second most common primary malignancy of bone after osteosarcoma. Extraskeletal Ewing’s sarcoma (EES) is an extremely rare malignancy of mesenchymal cell origin. The EES is observed in the trunk and lower extremities. The neck is an extremely rare primary site for EES.A 3-year-old female child referred with a rapidly enlarging right-sided neck swelling since 2 months ago. Physical examination and preoperative investigations suggested the diagnosis of a carotid body tumor and histopathological findings were similar. However, the results of immunohistochemistry revealed a confirmatory diagnosis of ES.Hereby, we presented a case of EES of the neck in a child, which was completely misdiagnosed preoperatively due to its rare incidence. The incidence of EES in the head and neck region can be successfully managed with radical excision and radiotherapy.  Ewing's sarcoma (ES) is a locally aggressive bone malignancy that is observed more commonly in males, compared to females in the first three decades of life . The ES A 3-year-old female child was referred to our Head and Neck Department complaining about right-sided neck swelling since 2 months ago. The case had no pain in swelling, fever, trauma, dysphagia, and dyspnoea. Physical examination revealed a palpable mass of 4×3 cm in the right side carotid triangle that was firmly consistent, as well as nontender and nonfluctuant in nature. There was no evidence indicating the movement of swelling on deglutition. Overlying skin was reported to be normal. In addition, there were no signs of inflammation. Cervical lymph nodes were normal and systemic examination was unremarkable.Applied Examinations No abnormality was observed in the results of haemogram, chest X-ray, and blood chemistries. Computed tomography scan showed a well-circumscribed, isodense, and nonenhancing soft tissue mass with a size of 46×40 mm along the carotid space on right side. Bilateral thyroid gland appeared to be normal in size, shape, and echogenicity. Bilateral submandibular glands, parotid glands, and carotid arteries appeared normal. Laryngeal and parapharyngeal structures were also normal. The diagnosis was carotid body tumor and fine-needle aspiration cytology was not performed. Procedure:The patient was subjected to excision of the cervical mass. She underwent the surgery under general anesthesia with orotracheal intubation. A horizontal incision was carried out on the right side of the neck from the posterior border of right sternomastoid to the midline. The subplatysmal flap was elevated. After dissecting the fibers of strap muscles, the swelling was discovered encasing the right common carotid artery from which it was carefully dissected and separated . The masGross Examination: The excised mass was greyish white, 4x3x1 cm in size, as well as soft and cystic. In the incised section, the cystic cavity was noted at one end, along with papillary projections.Histological examination: Histopathological examination showed that the tumor consisted of large round to oval cells having vesicular nuclei with prominent nucleoli and scanty eosinophilic cytoplasm. The tumor cells were observed in zellballen pattern. Intervening fibrocollagenous stroma was infiltrated by mononuclear cells and congested blood vessels. Microscopic features were also suggestive of carotid body tumor.The results of immunohistochemistry showed immunoreactivity to Mi-2 protein (CD99), vimentin with paranuclear immunopositivity for pancytokeratin. The tumor is immunonegative for leukocyte common antigen (LCA/CD45), S100 protein, desmin, myogenin, synaptophysin, cluster of differentiation 31, ETS-related gene, and transducin-like enhancer of split-1. Immunohistochemical findings were confirmatory for ES -8. The rThe ES comprises about 4% to 6% of all primary bone malignancies ,5. The EThe EES is an infrequent malignancy of mesenchymal cell origin. The EES generally occurs in the soft tissues of the trunk and lower extremities. The head and neck region is an uncommon primary site for EES. Chao et al. described only 5 out of 118 cases of EES localized in the head and neck region (The individuals within the age range of 10-30 years are predominantly affected ,9. Most The management of Ewing's sarcoma consists of surgical removal of the tumor followed by radiotherapy and chemotherapy. Radiotherapy exclusively has high chances of local recurrences; consequently, a radical surgical removal is necessary to reduce the chances of recurrence. The neck tumors have a better survival ratio in comparison to other anatomic locations . Five-yeDespite the fact that ES of the head and neck region is very rare, it must be considered as an important differential diagnosis. Preoperative investigations require a high index of suspicion. It is recommended to perform a complete surgical resection. Even though ES has a poor prognosis, it was concluded that ES of the head and neck region can be successfully treated with adequate excision and radiotherapy.


Cystic lesion around knee usually presents as painless swelling and diagnosed incidentally by imaging for any internal derangement of the knee. Few cases presented with pain. Intra-tendinous patellar ganglion is very rare in location for the disease. Ganglionic cyst usually treated by aspiration followed by steroid and surgical excision in some cases. We reported a case with anterior knee pain due to patellar intra-tendinous ganglion cyst which treated conservatively with no recurrence even after one year. A ganglion is a benign cystic mass containing clear high-viscosity mucinous fluid with a dense fibrous connective tissue capsule lined by flat spindle-shaped cells that is rich in hyaluronic acid and other mucopolysaccharides , 2. GangA 39-year-old boy presented to us with complaints of dull anterior knee pain for three months. He had visited several general practitioners for which he was given symptomatic analgesics. On examination, there was minimal swelling in form of the fullness of paratendon area and slight extensor lag with quadriceps muscle wasting 1 cm) without any instability with active range of motion 150-1200  confirmed a moving well-defined echogenic lesion within the patellar tendon with approximate 1.2 ml volume. The radiological diagnosis was an intratendinous patellar ganglion (ITPG) cyst. The patient was explained regarding treatment option like aspiration and anti-inflammatory injections/surgery if conservative therapy fails, but he chooses to observe and follow up. Even after one-year follow-up the patient is doing well with no recurrence of symptom.Ganglia arise from the mucoid degeneration and occurs in tendon sheath though they can occur in bones, joints and even other soft tissues . HistoloThe intra-tendinous patellar ganglion is a rare location for the disease but should be kept as one of the differential diagnosis for anterior knee pain. Imaging study is key to diagnosis in an unusual location.


A 34-year old male patient, victim of motorcycle accident at about 56 miles/hour, was brought into emergency care with a cervical collar. He was hemodynamically stable, with no respiratory or neurological impairment, complaining of diffuse moderate intensity abdominal pain during the physical examination. During secondary evaluation, abrasions were identified on the abdominal wall in the right flank area.Due to high energy trauma, he underwent a whole body computed tomography (CT) that showed an hematoma in the mesenteric fat planes of the abdomen, and also filling defects in branches of the middle colic artery   . The prThe patient was taken to the operating room and laparoscopy confirmed tomographic findings of mesenteric hematoma and acute ischemic colitis resulting from traumatic mesentery lesion. Right hemicolectomy, was performed   . In most cases, there is solid viscera involvement, especially spleen and liver; and isolated lesions of the mesentery are rare.Blunt abdominal trauma is a frequently found event in the context of emergencies, in which three fourths of cases result from automobile accidents.1 In mIt is believed that these cases result from deceleration forces, which lead to vascular strain, with rupture or mesenteric thrombosis and subsequent intestinal ischemia.3(-)The symptoms are generally non-specific, and not always reliable within the context of trauma. The diagnosis depends on whole body CT. The main findings can be divided into intestinal alterations resulting from ischemia, such as parietal thickening, decreased parietal enhancement, pneumatosis, and/or direct observation of the mesenteric injury, including filling defects, leakage of the contrast medium, mesenteric hematomas, and densification of adipose layers. Other findings also include intra-abdominal fluid collections and pneumoperitoneum.-7This case illustrates a rare vascular lesion in trauma. Although clinical signs are nonspecific and imaging findings subtle, is highly lethal if not promptly identified and treated. Whole body computed tomography with intravenous contrast is the gold standard in the evaluation of lesions related to trauma, including visceral and vascular lesions.


Frequent metastatic sites include the local lymph nodes, skin, spleen, liver and bone marrow. The thorax is rarely affected by metastatic disease and no such cases have been reported in dogs.Mast cell tumours are the most common cutaneous neoplasms in dogs. Other primary sites include visceral organs, such as the gastrointestinal tract, liver, or spleenMast cell tumours are usually not considered as a differential diagnosis for lung and intrathoracic chest wall masses in dogs. Chest wall tumours can be primary tumours of the ribs and sternum, an invasion of adjacent tumours into the chest wall, and metastasis from distant tumours.A German Shepherd dog presented with a history of persistent cough and a large mass involving the thoracic wall and a small round pulmonary mass. The dog had a history of mammary tumours that were surgically excised. Thoracoscopy revealed a thoracic wall mass involving the internal intercostal muscle and a small mass in the left cranial lung lobe. Cytology and histopathology of the intrathoracic mass confirmed the large mass as a mast cell tumour and the small mass as a carcinoma. Cytology of the sternal lymph nodes showed no involvement. The dog received toceranib for 3 months, which failed to alleviate persistent cough. Radiology indicated that the large mass had a partial response to toceranib. The dog was euthanasied., and a large mass involving the left caudal lung lobe. Cytology and histopathology of mass confirmed a mast cell tumour. The dog received toceranib for 2 months. Radiology indicated that the large mass had no response to toceranib. The dog was euthanasied. Confirmation of lungs mast cell tumour and the absence of any other Mast cell tumour was achieved by postmortem examination.A Maltese dog presented with a history of chronic regurgitation and coughThe cases discussed are two unusual presentations of intrathoracic mast cell tumours, in the absence of cutaneous mast cell tumours, in dogs. Mast cell tumours (MCTs) are not usually considered a differential diagnosis for solitary intrathoracic chest wall masses in dogs. Chest wall tumours can be metastases from distant tumours, adjacent tumours invading into the chest wall or primary tumours of the ribs and sternum. Primary rib tumours are the most common tumours of the chest wall and are frequently malignant sarcomas  –5.MCTs are the most common cutaneous neoplasms in dogs, accounting for 16–21% of all canine skin malignancies . Other pAnother case of a dog with a pulmonary and splenic MCT had been described without cutaneous involvement . PrimaryWe found no reference to canine primary intrathoracic MCTs. In all reported cases of intrathoracic MCT, the mast cell disease always spreads to extrathoracic organs , 6, 7, 9The Case 1 is a 9- year- old, 34.1- kg (body condition score 6/9), female, neutered German Shepherd presented with lethargy, weight loss, exercise intolerance and mild dyspnoea. The medical history of the dog included a mammary carcinoma 19 months earlier, with complete clinical resolution following mastectomy. Upon presentation, the dog was hyperthermic (39.2 °C), apathetic and approximately 5% dehydrated. She was tachycardic (150 beats/min) but had a normal auscultation, a soft abdominal palpation and no palpable external masses.Blood analysis and supportive therapy were initially performed. All results were within reference limits.The dog received intravenous crystalloid fluid therapy and was medicated with amoxicillin and clavulanic acid  and ranitidine .Occasional episodes of productive cough and vomiting were observed during hospitalisation. The dog also received maropitant .Thoracic radiographs revealed a large mass of soft-tissue density in the left cranial chest wall involving intercostal spaces 1–7 and a small round pulmonary mass in the cranial lobe of the left lung  during the postoperative period, meloxicam  and lidocaine local injection (4 mg/kg).Cytology and histopathology of the intrathoracic mass confirmed the large mass as a MCT Fig.  and the During hospitalisation, the dog received toceranib . After 41 days, her breathing worsened. New thoracic radiographs revealed that the large mass had shrunk, showing a partial response, but the small mass had increased in size, and a new mass was visible in the lung close to the spine , female, neutered Maltese dog presented with lethargy, weight loss, cough and dyspnoea. Upon presentation, the dog was hyperthermic (39.6 °C), apathetic and approximately 6% dehydrated. She was tachycardic (168 beats/min), a soft abdominal palpation and no palpable external masses.Blood analysis and supportive therapy were initially performed. A complete blood cell count, serum biochemistry profiling and analyses of venous blood gases and electrolytes were performed. All results were within reference limits.The dog received intravenous crystalloid fluid therapy and was medicated with amoxicillin and clavulanic acid and ranitidine.Occasional episodes of productive cough and regurgitation were observed during hospitalization. Thoracic radiographs revealed a large mass of soft-tissue density in the caudal lobe of the left lung involving intercostal spaces 5–8 Fig. .Fig. 5ThThe second step was cytology of lung mass, which indicated a possible MCT. The owner was informed of the diagnosis of a possible MCT, with systemic signs caused by the partial blockage of the esophagus. A thoracoscopic biopsy was obtained from the mass. No further masses were detected. Histopathology of the intrathoracic mass confirmed a MCT. Cytology of the liver and spleen showed no involvement. The dog received toceranib and, after 56 days, her breathing worsened. New thoracic radiographs revealed that the large mass had increased in size, and new masses were visible in the lungs and cranial medastinal lymph node Fig. . The ownIn this report, we described a presumptive primary intrathoracic chest wall MCT and a presumptive primary lung MCT without a previous history of cutaneous MCT in two dogs.Cytology is very important in the diagnosis of MCT and is often more sensitive than histopathology . A cytolThe sensitivity of cytopathological analysis has been reported to be higher than that of ultrasonography for the detection of mast cell infiltration in the spleen and liver . CytologThe clinical staging of Case 1 showed intrathoracic mast cell disease. Thus, it can be presumed that this is the first reported case of canine primary intrathoracic chest wall MCT. A limitation of this case study was the lack of post-mortem examination, bone marrow biopsy and buffy coat smear. A post-mortem examination and a bone marrow examination could have showed additional lesions corresponding to mast cell disease at non-pulmonary sites. However, a buffy coat smear has low sensitivity and specificity for the detection of circulating malignant mast cells .The clinical staging of Case 2 showed intrathoracic mast cell disease. Thus, it can be presumed that this is one of the first reported cases of canine primary lung MCT. In this case, the post-mortem examination confirmed the diagnostic. A limitation of this case was the lack of bone marrow biopsy and buffy coat smear. A bone marrow examination could have showed additional lesions corresponding to mast cell disease at non-pulmonary sites.Furthermore, flow cytometry or lymphocyte immunochemistry markers could have been used to exclude a possible mast cell hyperplastic condition secondary to a lymphoproliferative cause. Similarly, flow cytometry and immunochemistry could have excluded round cell neoplasia, confirming the diagnosis of MCT . In thesIn the Case 1, the staining pattern for the KIT protein and the c-kit gene mutational status were evaluated and were positive. In the last decade, tyrosine kinase inhibitors, such as toceranib and masitinib, have been developed to treat canine MCT via the inhibition of KIT signalling. The large mass demonstrated a partial response to toceranib, but the small mass grew, and a new mass appeared in the last radiograph.Cytoplasmic secretory granules of mast cells  can lead to gastrointestinal ulceration via stimulation of hydrochloric acid production . Plasma In conclusion, the dog discussed in the Case 1 presented with a large intrathoracic chest wall MCT with no evidence of either pre-existing or concurrent cutaneous MCT. The dog discussed in the Case 2 presented with a large intrathoracic lung MCT with no evidence of either pre-existing or concurrent cutaneous MCT. They were very unusual presentations of canine MCT. However, the incidence of four presumptive primary intrathoracic MCTs is not sufficient to support a statistically significant phenomenon. A well-controlled study is thus necessary to confirm that MCTs should be included in the differential diagnosis of intrathoracic tumours.


Intestinal hematoma is usually observed after an abdominal trauma or in patients treated with anticoagulant therapy. Conversely, idiopathic bowel hematoma is very rare, being colon involvement sporadic with few reports in the Literature.The Authors report a case of idiopathic spontaneous large bowel hematoma. A 48-year-old man was admitted for a thoraco-abdominal pain and signs of acute abdomen and fever. After ruling out heart diseases, a CT scan revealed a marked thickening of the ascending colon wall, obstructing the bowel lumen. Leukocytosis was observed. In an emergency setting, an explorative laparotomy was performed. Hemoperitoneum and a large hematoma involving the caecum and the ascending colon were detected, together with intramesenteric and retroperitoneal blood effusion. A right hemicolectomy was accomplished. Histopathology confirmed the diagnosis of large bowel hematoma. Post-operative molecular diagnostic testing for coagulative disorders failed to demonstrate any genetic variation associate with hemorrhagic predisposition.In the post-operative course, the patient experienced a left basal bronco-pneumonia with increased unilateral pleural effusion, successfully treated by a thoracic drain and antibiotic therapy.The reported case and Literature data show that diagnosis of idiopathic colon intramural hematoma is challenging, especially in the emergency setting. Although conservative therapy is the first line treatment, surgery still has an important role when the diagnosis is uncertain, medical treatment fails or a complication, such untreatable bleeding, perforation or occlusion occur.The Authors report a very rare case of spontaneous intramural hematoma of the right colon. Surgery still has a role in selected cases. Radiologic imaging may be misleading . FurtherThe work has been reported in line with the SCARE criteria .23 /μL) and PCR >500 mg/L, an intra-abdominal infection was suspected and the patient was at this time referred to surgery for urgent abdominal exploration.A 48–year–old–man was admitted to the hospital in an emergency setting because of thoracic and abdominal pain. No other significant relevant past medical or mental illness was reported. At the admission, an X-ray showed a right pleural effusion. A ST elevation myocardial infarction (STEMI) was suspected at ECG, but a myocardial ischemia was ruled out on a coronary angiography. The day after the hospitalization, the patient developed signs and symptoms of acute abdomen, intestinal occlusion and fever. Because of a palpable mass in the right quadrants of the abdomen, a CT scan was performed a. A markA midline laparotomy was accomplished. At initial exploration, hemoperitoneum was observed. Intramesenteric and retroperitoneal hemorrhagic effusion was also evident. The right-colon was involved by a massive intramural hematoma , which dHistopathology findings of the surgical specimen showed a transmural hematoma without any other underlying macro- or microscopic alterations. Post-operative molecular diagnostic testing for coagulative disorders failed to demonstrate any genetic variation associated with hemorrhagic predisposition, revealing only genetic variations and polymorphism associated with predisposition to thrombophilia.In the postoperative course, the patient experienced a left basal bronco-pneumonia with increased unilateral pleural effusion that required a thoracic drain. Treated with antibiotic therapy, the patient was discharged and healed on postoperative day 12.3The first report of an intestinal hematoma was published in 1838  by McLauIdiopathic cases, with unknown or uncertain origin, have also been described but their occurrence has been reported in less than 5% of cases . IntramuMost patients with intestinal hematoma complaint of abdominal discomfort or pain for several days before developing symptoms of intestinal obstruction, which is the most frequent clinical picture of intestinal hematoma at the time of diagnosis . In AbbaLaboratory tests may reveal anemia and leukocytosis. Abba et al. observed leukocytosis in 13 out of 13 patients observed with intestinal hematoma . In HughDiagnosis of intestinal hematoma may be challenging. In the emergency setting, when symptoms of obstruction or perforation are suspected, a plain abdominal X-ray is helpful. It may reveal typical patterns of bowel obstruction or signs of intestinal perforation. Colonoscopy performed by an experienced endoscopist in not complicated cases may be useful but not diriment, showing blue round and/or erythematous formations in the submucosal layer with a submucosal mass obstructing the luminal space ,16,28. BIn past reports of intestinal hematoma, surgery has been commonly performed for abdominal diagnostic exploration with resection or bypass of the intestinal involved segment. Nowadays, for diagnosis of bowel hematoma explorative laparotomy is seldom needed, since radiologic imaging studies usually are accurate . When abNozu et al. reported a very rare case of idiopathic intramural hematoma of the colon in an 82-year-old man who did not have history of trauma or anticoagulant intake. He presented abdominal discomfort and constipation, slight anemia and laboratory findings of inflammation. In this case, enhanced CT scan was not diriment and colonoscopy could not detect the lesion. Laparotomy was performed since a neoplastic disease could not be ruled out .It has to be noted that diagnosis is even more difficult to achieve in the emergency setting. In this situation, explorative laparotomy remains strongly indicated not only for diagnosis, but also for treatment. In the patient we report, preoperative diagnostic work-up was not diriment and an intra-abdominal infection with reactive pleural effusion was suspected. Surgery was performed anyway to treat the obstruction of uncertain etiology.It should be emphasized that today if a definitive diagnosis of colon intramural hematoma is performed in patients with anticoagulant therapy, and symptoms and clinic signs showing urgent surgery are absent, surgery is not routinely indicated and conservative therapy must be accomplished . DiscontFernandes et al. reported a case of spontaneous intramural hematoma treated conservatively. Suspension of anticoagulant therapy and complete healing within one month of a descending colon hematoma was observed in a 73-year-old male patient who was taking warfarin and aspirin for cardiac pathology .Liu et al. admitted a 57-year-old male patient with an intramural hematoma of the sigmoid colon, diagnosed at enhanced CT scan. A conservative treatment by means of total parenteral nutrition, blood transfusion and nose-gastric suction was performed, and the patient healed within 3 weeks .Kwon et al. reported a case where a 62-year-old woman in treatment with warfarin and ticlopidine because of artificial cardiac valves, presented with bloody stools and lower abdominal cramping. The physical examination revealed mild tenderness in the left lower abdominal quadrant without peritoneal irritation. She was successfully treated conservatively by means of heparin and fasting . Lobo etSurgery still may have a role if conservative therapy fails and the lesions do not spontaneously heal within a few week. It can be performed either by open or laparoscopic approach . Some AuThomas et al. described a case of colonic obstruction caused by intramural hematoma in a 74-year-old woman with intake of warfarin. Warfarin was stopped, but because of worsening abdominal signs and symptoms, right hemicolectomy was performed. The patient died subsequently because of pneumonia .Sakamoto et al. reported a 35-year-old man with a CT scan diagnosis of a large hematoma in the ascending colon. After an initial conservative treatment, a new CT scan performed for worsening of clinical conditions showed an intestinal perforation. An urgent laparotomy with right hemicolectomy was performed. Histologic examination showed an intramural bleeding that caused wall ischemia and subsequent perforation .Yu et al. reported a case where a 70-year-old woman with abdominal tenderness at the left lower quadrant 3 days after coronaric stent implantation, a CT scan allowed the diagnosis of submucosal hematoma. After two days of conservative treatment, abdominal pain and distention along with signs of peritoneal irritation get worse. Urgent sigmoidectomy was performed. Pathological examination showed colonic hemorrhage with necrosis .Zhou et al. reported a case of a 70-year-old woman who developed a bleeding submucosal hematoma at the sigmoid colon. Conservative treatment failed to stop the bleeding and a left hemicolectomy was finally performed .In conclusion, our reported case and Literature data show that diagnosis of colic intramural hematoma is challenging when a clinical history with trauma or anticoagulant therapy cannot be demonstrated. Furthermore, diagnosis of intestinal hematoma is difficult to achieve in an emergency setting, since in this condition it is challenging to rule out other obstructing or perforated colon diseases. Conservative treatment is the first choice. However, surgery still has an important role when the diagnosis is uncertain, medical treatment fails or a complication, such as intractable bleeding, perforation or occlusion occur.There is no conflict of interest.There are no sources of funding.The study is exempt from ethical approval in our Hospital in Italy.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.All the Authors  contributed to conceptualization, data curation, investigation, methodology and writing.Vecchio R and Intagliata E, in addition, supervised and reviewed the manuscript.None.Dr. Eva Intagliata.Not commissioned, externally peer-reviewed.


Introduction. Splenic artery aneurisms (SAA) are the third most common aneurysms, with reported incidences up to 10.4%. There is a higher prevalence in women, and most are incidental findings on imaging studies. Symptomatic or SAA larger than 20 mm and aneurysms in pregnant or in women of childbearing age are indications for surgery, because of the increased risk of rupture. Treatment options include endovascular, laparoscopic, and open surgical approaches. Presentation of Case. A 50-year-old female patient with nonspecific abdominal pain performed a computed tomography scan and angiography, which revealed a 24 × 20 × 19 mm SAA. After a multidisciplinary discussion, selective laparoscopic excision of the aneurysm was performed, with spleen preservation. Perioperative course was uneventful, and the patient remained asymptomatic. Discussion. A multidisciplinary discussion is of major importance in guaranteeing the optimal treatment for any given visceral aneurysm. Not all SAA are amenable to endovascular treatment, and laparoscopic surgery has mostly replaced open procedures. Laparoscopic ligation and resection of the SAA with splenic preservation offers permanent treatment, with a low morbidity and short hospital stay.  Selective laparoscopic aneurysm resection is a safe and effective approach, with good short- and long-term results, allowing permanent treatment of SAA while maintaining splenic function. The splenic artery is the most common visceral artery affected by aneurysms and pseudoaneurysms, and only less frequent than aortic and iliac aneurysms, with reported incidences between 0.02% and 10.4% in the general population. Most splenic artery aneurysms (SAA) are asymptomatic and incidental findings on imaging studies [SAA are typically saccular and mostly located in the distal third of the artery, followed by the medial third, and only rarely in the proximal third or intrasplenic . They coCT angiography is highly accurate for the diagnosis and characterization of SAA, and 3D reconstructions are usually required to differentiate the false positive of normal vessel tortuosity and atherosclerotic changes.Indications for SAA treatment remain controversial. Symptomatic SAA, SAA discovered during pregnancy, which have an increased risk of rupture, or in patients of childbearing age, and SAA in liver transplant recipients are indications for treatment, regardless of the size. Most agree that aneurysms larger than 20 mm and enlarging are at an increased risk of rupture and should be treated in all patients with reasonable operative risk and with a life expectancy of 2 years , 3, 4.Treatment options depend primarily on aneurism characteristics, surgical experience and patients' age, operative risk, and comorbidities. Endovascular treatment is currently the preferred approach to SAA with favourable anatomy . Open suWe report a case of a successful selective laparoscopic resection of a SAA. This case report has been reported in accordance with the SCARE criteria.A 50-year-old Caucasian female patient was referred by the family physician to the Hepatobiliopancreatic and Splenic (HBPS) Surgery Consult due to a 20 mm SAA. The patient had been complaining of a nonspecific pain in the upper quadrants of the abdomen for months. No other complaints were recorded. Past medical history revealed arterial hypertension and dyslipidaemia, medicated with an angiotensin-converting enzyme inhibitor and with a statin. She had no smoking or relevant alcoholic habits, and she had no past surgical interventions. Family history was irrelevant. No abnormalities in the laboratory studies were identified. She had been previously submitted to an upper endoscopy, which revealed no abnormalities.After careful patient examination and exam reviewing, we conducted an angioCT scan which revealed a SAA with 24 × 20 × 19mm in size, with two branches of the splenic artery originating in the aneurysmal sac . No otheThe procedure was performed under general anaesthesia. The patient was placed in the supine position. The positioning of the trocars was as follows: 12 mm trocar at the umbilicus for the camera, a 5 mm trocar in the epigastric area, a 5 mm trocar in the right upper abdomen, and a 12 mm trocar in the left lower abdomen. A pneumoperitoneum of 12 mmHg was created and maintained.th postoperative day. Postoperative amylase levels were within the normal range, and there were no clinical signs of pancreatitis nor pancreatic leak. Anatomopathological study of the resected aneurysm confirmed the diagnosis, revealing a saccular aneurysm with 28 × 22 × 19 mm, with mural thrombus (A monopolar laparoscopic hook and ultrasonic energy were used for dissection. First, the gastrocolic ligament was divided, and the stomach lifted to expose the anterior pancreatic surface. Special care was taken not to interrupt the short gastric vessels while opening the lesser sac, as this collateral circulation is of major importance in maintaining spleen perfusion. The superior border of the pancreas was approached, and the splenic artery was identified near its origin. This vessel was dissected and looped with an umbilical tape to gain vascular control of the splenic artery proximal to the aneurysm. After dissection of the splenic artery, the aneurysmal sac was isolated. One afferent branch and two efferent branches were identified and ligated with hemolocks. Aneurysmectomy was performed. A few minutes after, the superior pole of the spleen appeared dusky but returned to normal colour at the end of the procedure. It was decided not to pursue with splenectomy. Haemostasis was evaluated, and a multitubular drain was placed. The wounds of the abdominal incisions were closed. Operating time was approximately 120 minutes, and the estimated blood loss was 120 ml. Postoperative course was uneventful, with drain removal on the second postoperative day. The patient was discharged home on the 4thrombus .The patient was asymptomatic at the first month follow-up consultation, and laboratory studies revealed no abnormalities. The postoperative abdominal CT scan revealed a 40 × 40 mm area of infarction in the superior pole of the spleen, representing less than a third of the total parenchyma volume . At the There are several surgical approaches described for SAA, but few published cases of SAA ligation and resection with spleen preservation.Due to technical advances and liberal use of CT imaging, SAA incidence is increasing . This paDespite its low incidence and mostly asymptomatic course, SAA rupture can be fatal . There iSeveral laparoscopic approaches have been described . A tangeWe proposed laparoscopic ligation and resection of the SAA, with splenic preservation. To our knowledge, few cases of aneurysmectomy with spleen preservation have been published , 12. AdvThe risk of pancreatic injury during laparoscopic dissection may be decreased compared to open surgery, by avoiding retractors and direct manipulation of the pancreas. Also, the pancreas and splenic artery are generally separate, and a plane of dissection can usually be found between the two.Laparoscopic ultrasonography with Doppler function is not indispensable but may be useful to evaluate splenic arterial flow signs before and after SAA exclusion . In partSAA have been increasingly diagnosed with the liberal use of imaging studies. Currently, there are no treatment guidelines nor consensus for SAA. A multidisciplinary approach is of major importance in the management of all visceral aneurysms. A predominantly distal location and splenic artery tortuosity make SAA not always amenable to endovascular treatment. Surgery is an important treatment modality, and several laparoscopic approaches have been described. Selective laparoscopic ligation and resection of SAA with spleen preservation is a safe treatment modality for selected cases, with good short- and long-term results, allowing permanent treatment of SAA while maintaining splenic function.


We report the case of a 56-year-old man who presented with locally advanced giant condyloma acuminatum (Buschke-Löwenstein tumor) after approximately 15 years of neglect due to hospital phobia. Clinical examination showed an extensive, erosive, exophytic and cauliflower-like growth involving his suprapubic, external genitalia and perianal region. No inguinal or supraclavicular lymphadenopathy was detected clinically. Histological study revealed a papillomatous and acanthotic epithelium with ortho and parakeratosis and koilocyte cells suggestive of HPV infection. No signs of malignant transformation were noted. Radiological investigations consisted of a thoracic-abdominal-pelvic computed tomography scan which showed the localization of this tumor in the external genitalia, perineal and suprapubic region without any lymph nodes or distant metastases. The results of biochemical and serological investigations including HIV test were normal. After discussion among the oncologist, radiotherapist, pathologist and surgeon, the patient initially received chemoradiotherapy, followed by extensive local excision with average outcome. Buschke-Lowenstein tumor is a relatively rare sexually transmitted disease. It is a neoplasm of the anogenital region which has benign appearance on histopathology. It often grows over years in immunocompetent patients and can be highly destructive to local tissue. It carries a high recurrence rate and a significant potential for malignant transformation. Human papilloma virus (types 6 and 11) has been implicated as an etiologic agent for this tumor. Since this disease is rare and no controlled studies exist, radical excision of this anogenital lesion is generally recommended as the first line therapy and close vigilance and follow up are essential.


Intraosseous hibernoma is a rare finding that has only recently come to light in the literature. We report a case of intraosseous hibernoma in the sacrum identified as an incidental finding in a 40 year-old female with chronic lower back pain. The tumor was characterized with all routine imaging modalities. In the review of the literature we correlate the imaging findings with previously reported cases. With increasing number of radiologic investigations it is expected to discover more intraosseous hibernomas and the radiologists should consider intraosseous hibernoma as differential diagnosis of the sclerotic bone lesion. It was first described by MerkelWe report a case of an intraosseous hibernoma found as an incidental finding in the sacrum of a 40-year-old Caucasian female with chronic lower back pain. All routine imaging modalities were performed to characterize the tumour. In the review of the literature, we correlate the imaging findings with previously reported cases. Furthermore, we show that the intraosseous hibernoma has similar features on all routine imaging modalities, except on post-contrast MRI, where the most common pattern appears to be a moderate enhancement throughout the tumour and in the peripheral rim.T1 weighted image showed a 21-mm round, homogeneous lesion of low signal intensity interforaminally in the left S2 segment of the sacrum. The axial short tau inversion-recovery image showed a well-defined lesion with an inhomogeneous signal intensity throughout the lesion with high peripheral rim intensity. The axial T1 image with fat saturation after contrast media injection showed moderate enhancement throughout the lesion and in the peripheral rim  and make a final diagnosis, a biopsy needs to be performed. Typical histopathological findings include multivacuolated, foamy fat cells with small eccentric nuclei that do not show any features of malignancy. Foamy cells are distributed in small groups among the thickened bone trabecula where they replace the normally present white fat and bone marrow cells. Immunohistochemical investigations have revealed that the foamy cells are positive for S100 protein and negative for cytokeratin AE1/AE3, CD68 and barchyury.T1 hypointense to the subcutaneous fat and T2 hyperintense to the skeletal muscle. However, in correlation with previous reports, the reported lesions show different characteristics of enhancement on post-contrast MRI. We divided the post-contrast MRI characteristics into three groups (All routine imaging modalities were performed on our patient to try and characterize the lesion. In only one previous case had a plain radiograph been taken and it showed a well-defined sclerotic lesion in the left ischiopubic ramus. However, no lesion could be identified on the plain radiograph of our patient. This can be attributed to the location of the lesion in the sacrum, with overprojecting surrounding structures. The tumour was sclerotic on the CT scan of our patient and all the previously reported cases . The tume groups . In our e groups .10,12 9 were the first to describe a case of incidental finding of brown fat tissue in the bone marrow during a biopsy in 2008. Although only six articles have been published since then, the recent report by Bonar et al,3 with a case series of five intraosseous hibernomas, suggests that the tumour might not be as rare as originally thought. In the recent years, PET scans have identified that the presence of brown fat is more frequent than previously thought.5 Bonar et al3 even suggested the possibility that intraosseous brown tissue is a physiological phenomenon and proposed that the term “intraosseous brown-fat associated sclerosis” should be used instead of “intraosseous hibernoma”. Further studies are needed to confirm this; however, with the increasing number of radiological investigations, we can expect more cases of intraosseous hibernoma being discovered. Bearing this in mind, we concur with Bonar et al3 that this diagnosis should be added to the differential diagnosis of a sclerotic bone lesion.Thorns et alIntraosseous hibernoma is a rare benign intraosseous neoplasm composed of brown tissue.The majority of intraosseous hibernomas are discovered as an incidental finding.The appearance of an intraosseous hibernoma on the CT scan is similar to a sclerotic bone lesion.Intraosseous hibernoma has similar features on all routine imaging modalities except on post-contrast MRI, where the most common pattern appears to be a moderate enhancement throughout the tumour with an enhancing peripheral rim.For immunohistochemical confirmation of intraosseous hibernoma, it is critical that brown fat cells test positive for S100 protein and negative for cytokeratin AE1/AE3, CD68 and barchyury.


Gastroblastoma (GB) is a rare gastric epithelial-mesenchymal neoplasm, first described by Miettinen et al. So far, all reported cases described the tumor in children or young adults, and similarities with other childhood blastomas have been postulated. We report a case of GB in a 43-year-old patient with long follow up and no recurrence up to 100 months after surgery. So far, this is the second case of GB occurring in the adult age >40-year-old. Hence, GB should be considered in the differential diagnosis of microscopically comparable conditions in adults carrying a worse prognosis and different clinical approach. Gastroblastoma (GB) is a rare epithelial-mesenchymal gastric tumor featuring monotonous spindle and epithelial cells in relatively young patients . It was Here, we report the second case of a GB in a >40 years old patient with clinical and follow up information, along with a review of the relative literature.A 43-year-old woman with unremarkable history was referred to our Institution following a generic diagnosis of a gastric tumor in another hospital center. In Following an intestinal bleeding, in September 2010, an endoscopic examination revealed a 2.5 cm submucosal, ulcerated lesion of the stomach, yet a first biopsy was not diagnostic material. The endoscopic ultrasound and a computed tomography (CT) scan confirmed the presence of an antral mass of 5 cm, originating from the muscularis propria with an endoluminal growth and a dishomogeneous enhancement. After two months, distal gastrectomy with a complete tumor resection was performed by means of laparoscopy.Macroscopically, the resected antrum showed a transmural submucosal mass, mostly solid with a hemorrhagic cystic portion, measuring 5.3 cm in largest dimension with a grey cut surface. The overlying antral mucosa was normal and focally ulcerated. A microscopic evaluation revealed tumor involvement and was confined in the muscolaris propria of the gastric antrum.Histologically, the tumor showed a distinct biphasic pattern featuring epithelial areas haphazardly mixed with predominant spindle cell fascicles without any well-defined or abrupt transition . The epit translocation, chromosomal rearrangement specific for synovial sarcoma, was investigated with fluorescent in situ hybridization (FISH) utilizing a commercial SS18 (SYT) probe . FISH analysis did not reveal SYT rearrangement, excluding the diagnosis of synovial sarcoma.As far as immunohistochemistry, the epithelial component mainly expressed pan-cytokeratin , low-molThe patient was discharged after 11 days without any post-surgery complications and was included in an oncologic follow-up. Notably, at 100 months after surgery, the patient presents with no evidence of tumor recurrence or metastatic disease.GB is an extremely rare biphasic neoplasm firstly reported by Miettinen et al. in 2009 . Since tIn most reported cases, GB patients present non-specific symptoms or even no symptoms at all and it is often accidentally found. Histologically, GB tumors are characterized by two components, the epithelial and the mesenchymal one, represented in variable portion, both with low-grade features, large tumor size, relatively low-mitotic activity, low overall atypia, absence of conspicuous nuclear pleomorphism and low malignant potential. Normally, the disease is delimited to the stomach, without metastatic potential or disease recurrence after curative resection , 4–6, 8.The differential diagnosis for GB is challenging, including a number of biphasic malignant tumors. Particularly for adults, the combined morphologic, immunophenotypic and molecular features of our GB case allowed confident distinction from carcinosarcoma, inflammatory myofibroblastic tumor (IMT), teratoma, GIST, leiomyosarcoma, neuroendocrine tumors, mesothelial biphasic neoplasm and synovial sarcoma. Briefly, the most common biphasic tumor of the stomach that occurs in older patients is carcinosarcoma which shows, however, highly atypical squamous, adenocarcinomatous, or undifferentiated epithelial elements , resultiRecently, Graham et al. confirms the existence of GBs as a distinct entity, and demonstrate that they represent translocation-associated tumors, characterized by the presence of a somatic, recurrent, oncogenic MALAT1–GLI1 fusion gene . The preWe reported a new case of GB occurring in an adult patient with a long follow-up. For this particular case, a conservative surgery was the curative treatment. Also based on the relative literature, it seems that this peculiar neoplasm pursues a favorable clinical course despite the adopted suffix “-blastoma”. Overall, it is crucial to report, describe and discuss each GB case presented to have a broader vision of the tumor from a pathological and morphological point of view. Hence, we believe that a prompt identification of GBs is important in clinical practice because it has a favorable prognosis if correctly managed.


Adenolipoleiomyoma is a very rare lesion of the uterus. Only four cases were reported. We describe one case of adenolipoleiomyoma presenting as a polyp in a postmenopausal woman with menorrhagia. Adenolipoleiomyoma is a very rare lesion and the histogenesis remains unclear. We discuss the origin and the differential diagnosis of this lesion. An adenolipoleiomyoma is a very rare lesion of the uterus. This is a type of adenomyomatous polyp that contains müllerian-type glands, smooth muscle, and adipose tissue. Only four reports of adenolipoleiomyoma have been described –4. One oThis is a fifty-five-year-old woman with past appendectomy. She was perimenopausal and had no treatment. Her brother had a rectum neoplasia. She had four children. She suffered from anemia because she had menorrhagia since few months. Ultrasonography examination revealed a polymyomatous uterus and a vascularized polyp of 23x17 mm in the uterine cavity. Mammography and breast ultrasonography were normal. CA125 was high . Total hysterectomy with bilateral ovariectomy was performed because its symptoms lasted for too long. Histological examination showed a subatrophic endometrium with bands of irregular proliferation, slight-to-moderate adenomyosis, and benign subserosal leiomyoma of 34 mm in size. There was also a pedunculated polyp of 25 mm. Macroscopically, this polyp appeared white, fibrous, fasciculated, and focally yellow . MicroscAdenolipoleiomyoma is a rare polypoid uterine lesion composed of müllerian-type glands (glands of müllerian origin like endometrium), smooth muscle, and adipose tissue. The histogenesis of this lesion remains controversial.Mc Cluggage et al. and Payne et al. believe that uterine adenolipoleiomyoma is a benign hamartomatous lesion. They think that lesion represents a hamartomatous lesion with adipocytic metaplasia, a sort of direct metaplasia from a preexisting tissue present normally in the uterus , 3.Yavuz suggests that it is a variant of benign müllerian mixed tumour . Ridvan In the literature, the mean age is 45.8 years and the mean size of tumour is 5.2 cm. One case has been described in cervix [atypical polypoid adenomyoma that contains an architecturally complex and cytological atypical glandular component, whereas adenomyomatous polyp has simple glands and no significant atypia ;lipoleiomyoma involved by adenomyosis: in this type of lesion the structures are not clearly mixed;adenomyoma with adipocytic metaplasia that differs from adenolipoleiomyoma by the aspect of adipocytes (more irregular);benign variant of mixed müllerian tumour that contains very rarely three components;adenosarcoma that exhibits a more complex pattern of spindle cells with mitoses;common uterine leiomyoma that contains no glandular component , 7.Differential diagnoses areAdenolipoleiomyoma is very rare and the histogenesis of this lesion remains unclear. Although this tumour seems to be most frequently benign, prolonged follow-up will be necessary to confirm this benignity .


Giant cell tumor of bone is a benign, aggressive neoplasm commonly arising in the femur, tibia, and distal radius and less commonly in the hands and feet. We describe a 22-year-old woman who underwent wide resection of multiply recurrent first metatarsal giant cell tumor and reconstruction with iliac crest arthrodesis.  To our knowledge, there have been no previous reports of managing multiply recurrent giant cell tumor of the first metatarsal. The patient was without pain and exercising without difficulty 18 months following surgery. This method appears useful for reconstructing the foot following multiply recurrent giant cell tumor of the metatarsal. Giant cell tumor of bone (GCTB) is a benign, aggressive neoplasm with metastatic and high local recurrence potential. Histologically, these lesions consist of cytologically benign mononuclear round, ovoid, or spindle cells mixed with evenly distributed osteoclast-like multinucleated giant cells. GCTB makes up 20% of benign bone tumors and 5% of all primary bone tumors . This coGCTB most commonly occurs in the long bones, namely the distal femur, proximal tibia, and distal radius, altogether accounting for 50% of the cases . In the In terms of treatment, nonoperative methods are being used more frequently, including the use of denosumab, which is approved by the U.S. Food and Drug Administration for use in unresectable GCTB. However, operative treatment is most commonly pursued, and first-line treatment is intralesional curettage. Local adjuvants are often added to decrease the recurrence rate, and multiple studies suggest its increased efficacy compared to curettage alone –8. En blThere are no detailed reports in the literature regarding the management of multiply recurrent giant cell tumor of the first metatarsal. We report a case of a second recurrence of giant cell tumor of the first metatarsal in a female who was treated successfully with wide resection and iliac crest arthrodesis. The following technique shows promise for addressing this difficult clinical problem.A 22-year-old woman with a known history of giant cell tumor of the left first metatarsal was evaluated for worsening left medial midfoot pain. She had previously undergone curettage and polymethylmethacrylate (PMMA) cementation of a biopsy-proven giant cell tumor of the first metatarsal two and a half years prior at a different institution. Six months following the index surgery, she had a recurrence treated with repeat curettage, liquid nitrogen local adjuvant, and placement of bone substitute graft. After the second procedure, she was ambulatory, but occasionally used a boot for comfort and avoided high-impact activities. Physical examination demonstrated a prominent first metatarsal base and a well-healed dorsal incision. She exhibited tenderness to palpation throughout the area of the scar.Radiographs of the left foot showed an expansile, radiolucent lesion of the first metatarsal base surrounding the known cement implantation of the first metatarsal . MagnetiThe procedure began by harvesting iliac crest bone graft . The prior dorsal incision was extended along the entire first metatarsal and proximally across the tarsometatarsal (TMT) joint. A wide resection was performed by disarticulating the TMT joint, maintaining periosteal coverage surrounding the metatarsal, and osteotomizing the metatarsal about 4.5 cm from the TMT joint. The damaged cuneiform articular surface (from articulation with cement) was resected with a wafer osteotomy. The resection bed was treated with adjuvant thermal necrosis. Margins were extended further with 10% hydrogen peroxide. The first toe was held in appropriate length and rotation and pinned to the second metatarsal. The iliac crest graft was fashioned to fit appropriately, contouring the angles for an appropriate junction. The graft was secured with an anatomic plate and screw construct , hydrogen peroxide, ethanol, argon, high-speed burr, and polymethylmethacrylate. This patient was initially treated with curettage and PMMA cementation. Multiple studies suggest that this method is more effective in decreasing the chance of recurrence compared to curettage alone, with rates ranging from 14.3% to 22% , 8, 11. Bone grafting is often employed to fill the resultant bony defect because there is no risk of disease transmission, there is no donor-site morbidity, and it provides sufficient mechanical support for early mobilization and rehabilitation. However, this method does not appear to drastically decrease the rate of recurrence. One study exhibited 45% recurrence in 677 patients treated with this method . Since tMultiple studies have also investigated systemic medical therapy designed to stabilize local and metastatic disease. Bisphosphonates inhibit GCTB-associated osteoclast resorption and promote osteoclast apoptosis. Some studies have demonstrated stabilization of disease with bisphosphonate-aided treatments, although there is heterogeneity in the regimens and specific medications utilized , 18. DenTwo years after the first recurrence, the patient presented to our institution with a second recurrence. En bloc excision is often used for recurrent or recalcitrant cases, such as the one presented in this report. However, there are conflicting views, and many authors advocate utilizing curettage with adjuvants even for multiply recurrent tumors to preserve the native joint , 12, 21.In general, the chosen procedure should eradicate neoplastic tissue while preserving maximal function. Given that this patient had only a single cortex of her metatarsal remaining, the defect was uncontained and it was felt that the lesion had a very high risk of recurrence with repeat curettage, especially in the setting of a second recurrence with previous use of multiple local adjuvants. Greater morbidity was accepted in this case to prevent local recurrence and pulmonary metastasis, which has been shown to be increased in patients with recurrent disease . In addiExcision usually requires reconstruction; methods include arthrodesis, extensive bone grafting, and bulk or structural allografts. Multiple case reports of GCT of the first metatarsal treated with excision and reconstruction with either iliac crest or fibular graft have been reported with no signs of recurrence and resumption of normal activities at short to midterm follow-up , 30. PreIn summary, nonoperative methods are being used more frequently to treat GCTB, including the use of systemic therapy such as denosumab. Operative treatment is most commonly pursued, with intralesional curettage as the appropriate first step. Local adjuvants are often added to decrease the recurrence rate, and multiple studies suggest its increased efficacy compared to curettage alone. En bloc excision and even amputation can be used for recurrent or recalcitrant cases, such as in this case. The first recurrence in small bones typically occurs before two years, although it is possible for multiple recurrences to occur years after the initial presentation . This pa


Craniopharyngiomas and germinomas are both rare cranial tumors that most commonly present during childhood or adolescence. Although these tumors have different origins, their clinical and radiological features may be similar. In this article, we report the case of a 35-year female patient with clinical and radiological findings and increased human chorionic gonadotrophin (HCG) levels in the cerebrospinal fluid (CSF) that were consistent with a germinoma. However, pathological analysis revealed a craniopharyngioma. This case report indicates that HCG, which is regarded as a specific tumor marker for germinomas in the differential diagnosis of intracranial lesions, is also detectable in other kinds of suprasellar tumors, such as craniopharyngiomas. Craniopharyngiomas are rare benign tumors derived from the cellular remnants of Rathke's pouch, along a line from the nasopharynx to the diencephalon. Epidemiological studies have demonstrated that craniopharyngiomas account for ~3% of all intracranial tumors. Craniopharyngiomas are the most common form of non-neuroepithelial neoplasm in the pediatric population . Althoug*1 cm and could be markedly enhanced. The CT value of the solid part of the lesion on plain CT was 40 Hounsfield units (HU); in the enhancement, the value was 74 HU, and the cystic part showed no enhancement. The boundary of the lesion was less clear, the density was not uniform, and no obvious calcification was observed. The cavernous sinus was involved. There were no abnormalities in the ventricular system, sulcus, brain split and pool. Moreover, there was no shift in the midline structure, and no abnormalities were found in the skull structure. The sinuses exhibited no obvious abnormalities. Magnetic resonance imaging (MRI) of the brain and pituitary showed an irregular cystic solid mass in the suprasellar area, involving in the pituitary stalk, and the boundary between the lesion and pituitary was unclear. In addition, the mass pressed on the optic chiasm, and the solid part of the lesion was significantly enhanced, while the cystic part showed no enhancement. There was no abnormal signal in the brain or paranasal sinuses nor signs of calcification  showed an irregular cystic solid mass in the suprasellar area. The size of the mass was 1.4Under a microscope, the lateral fissure was separated at the saddle area, and CSF was released. The brain tissue collapsed, and a portion of the temporal lobe was removed. The tumor was located in the suprasellar area. The tumor was removed from the second gap along the longitudinal axis of the pituitary stalk and was frozen for analysis. The tumor and hypothalamus were closely related. Hemostasis was achieved, and the gauze inventory was correct. The surgery was complete following strict closure of the dura mater, bone flap reduction and fixation, suturing of the temporalis muscle and scalp, and placement of an external dura mater drain. The tumor specimens were sent for pathological analysis.After surgery, the patient did well and had no complaints of headache, vomiting, polyuria, polydipsia, sleepiness, or anorexia. She did not receive any hormone replacement. One year later, she was admitted to our endocrinology department for re-evaluation. Her urine volume and specific gravity were within the normal range . The urine osmotic pressure was 752 mOsm/L , the blood osmolality was 292 mOsm/L, and a pituitary stimulation test revealed normal frontal lobe function except for an impaired GH level Tables , 9. The Craniopharyngioma may occur at any age but most commonly presents during childhood or adolescence. Craniopharyngioma has two prevalence peaks, one at 5–14 years of age and another at 50–74 years of age. Compared with the general population, adult-onset craniopharyngioma patients have much higher mortality, specifically, up to 19-fold higher cerebrovascular mortality . Most crIntracranial germinomas account for 1–3% of all primary intracranial tumors in Western countries but 4–10% in East Asia . MoreoveThe combination of the clinical condition of this young woman, who complained of impaired vision and a mild anterior pituitary disturbance, with an intracranial tumor found at the midline, atypical radiological findings and an obviously increased CSF tumor marker (HCG) rendered the diagnosis of germinoma quite reasonable. A HCG level in CSF above 50 pg/ml and a CSF-to-serum HCG ratio of 2.0 or greater are strong indicators of germinoma . Since oIn conclusion, the clinical features and radiological findings of suprasellar tumors may be similar in both craniopharyngiomas and intracranial germinomas. Although tumor marker measurements in the serum or CSF are helpful for the diagnosis of germ cell tumors and have replaced the need for a biopsy in many cases, the absolute differentiation of atypical germinomas from rare craniopharyngiomas with an elevated HCG level in the CSF or serum is often not possible prior to invasive therapeutic or diagnostic procedures. This information is paramount in guiding the clinician to select the best procedure and avoid misdiagnosis.This patient provided written consent agreeing to undergo treatment and allow the publication of the information that was described in this case report.WJG treated this patient and collected the data and was a major contributor in writing the manuscript. WJG and WZG have contributed equally to this work. JL performed the histological examination. YG, GY, QG, LZ, JD, YP, JB, and ZL have done some assisted work. JTD and YM were the superior advisors. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Esophageal actinomycosis is a rare type of esophageal infection, with only approximately 24 cases previously reported in the United States. Most of these cases were described as erosions or ulcers when examined endoscopically. We present a 47-year-old woman who presented with dysphagia. Endoscopy showed a lower esophageal fungating mass, mimicking a malignant mass. Although there was a high suspicion of esophageal carcinoma, biopsy results showed esophageal actinomyces infection. Upper endoscopy is an effective and essential tool for the evaluation of dysphagia, especially in men older than 40 years and/or when there is weight loss. Abnormal findings can be recognized by upper endoscopy in 70% of the patients present with dysphagia.1Swallowing-associated problems affect 1 in 25 persons in the United States, and the prevalence increases with age. The estimated prevalence of dysphagia in patients older than 50 years is up to 22%.2 Candida and herpes simplex virus and less commonly cytomegalovirus and human immunodeficiency virus (HIV) are the most frequently reported organisms that can cause infectious esophagitis. The usual endoscopic findings include esophageal erosions and ulcers, but the definitive diagnosis is only made after obtaining biopsies of the suspected lesions.Infectious esophagitis is the second most common cause of esophagitis after gastroesophageal reflux disease.Esophageal actinomycosis (EA) is a rare esophageal infection that is generally found in immunocompromised patients only. EA is an extremely rare etiology of esophageal dysphagia. We present a case of EA mimicking esophageal malignancy in an immunocompromised host.A 47-year-old woman presented with progressive esophageal dysphagia. She has a past medical history significant for gastroesophageal reflux disease complicated by esophageal stricture status after dilation, type 2 diabetes mellitus, and chronic immunosuppressive therapy after a kidney-pancreas transplant about 7 years ago. Her dysphagia had been worsening lately and was associated with epigastric abdominal pain and weight loss. The patient denied heavy alcohol consumption or tobacco use. She had multiple esophageal dilations; the last was by balloon dilation about 3 months before her presentation. Physical examination was only significant for mild-epigastric tenderness.The patient was anemic, with initial hemoglobin of 6.8 mg/dL. Chest computed tomography scan showed a patulous esophagus in the proximal and mid portions. The esophagus was decompressed in the distal portion with some degree of soft tissue thickening with no evidence of paraoesophageal lymphadenopathy. Endoscopy showed a fungating, ulcerated mid-esophageal mass, causing partial esophageal obstruction, concerning for esophageal carcinoma Figure , arrow. The mass was biopsied during the procedure and the biopsy results showed fibrinopurulent exudate with bacterial overgrowth abundant with actinomyces, consistent with an esophageal actinomyces infection. There was no intact epithelium because of mucosal surface disruption. The sulfur granules and the fibrinopurulent exudate in the center of the sulfur granules is seen in the biopsy Figure . When thA following video capsule endoscopy and colonoscopy were unremarkable for similar lesions. The patient was started on intravenous penicillin for 8 weeks and was scheduled for a second-look endoscopy after this initial treatment course.Actinomyces are facultative anaerobic, Gram-positive bacilli. They commensally live within the oral cavity and gastrointestinal (GI) tract. They are slow-growing bacteria that can cause hard, pus-filled abscesses in the affected tissue.3 The mucosal breakdown can result from infections and surgery or can be traumatic during endoscopic procedures. The appendix, cecum, and colon are the most common GI tract sites of actinomycosis infection, which can occur weeks to years after a mucosal disruption. For unexplained reasons, actinomycosis occurs more frequently in men than in women.4EA is almost always preceded by mucosal disruption, which is necessary to facilitate the microorganism invasion, leading to various clinical senarios.5The number of the reported cases has increased recently, but the incidence is still extremely rare with only about 24 cases of EA reported in the literature.The diagnosis of actinomyces infections can be challenging because isolation and identification of the bacteria occurs in only a minority of cases and radiologic findings are often nonspecific. Actinomyces culture frequently fails due to either previous antibiotic therapy, cross contamination with other oral and GI flora, or inadequate sampling. Microscopic examination is essential for diagnosis, which typically shows necrosis, yellowish “sulfur granules”, and filamentous Gram-positive fungal-like pathogens. The sulfur granules are centers of the organism colonies, surrounded by a rosette of clubbed filaments. A course of 4–6 weeks of antibiotics, typically with intravenous penicillin V, followed by a prolonged oral maintenance regimen is necessary for successful treatment. In some cases, surgical drainage may be required.6 In that case, EGD showed an esophageal ulcerated lesion, which was found later to be EA. Arora et al and Chou et al reported cases of EA in association with esophageal candida infection.8 In both cases, the lesions were described as esophageal ulcerations. Nagaraju et al described a case of EA in a 28‐year‐old woman with end‐stage renal disease on regular hemodialysis.9 The endoscopic description of the EA lesion showed extensive esophageal necrotic areas.EA infection is an extremely rare cause of an esophageal mass lesion. Most previously described EA cases were noted to resemble esophagitis, esophageal ulcers, with the most commonly reported symptoms being odynophagia and dysphagia. Welling et al reported a case of a 27-year-old African-American man who presented with odynophagia.10 EGD demonstrated esophageal ulceration in 10 of these 15 patients. Other reported EGD findings included granulation tissue, a traction diverticulum, plaques, strictures, and fistulas. Of note, the authors reported good clinical outcomes in response to the intravenous penicillin.A review of 15 cases of EA diagnosed on the basis of biopsies between 1970 and 2004 by Abdalla et al showed that the majority of the EA cases were associated with either malignancy or HIV .Clinicians should be aware that EA is a cause of dysphagia and odynophagia, particularly in immunocompromised patients and patients with HIV or malignancy. EA diagnosis remains difficult and requires a high index of suspicion and clinical knowledge regarding its unusual presentations and ability to mimic malignancy.We present an extremely rare case of EA that likely resulted from the earlier traumatic esophageal dilation. This patient had no odynophagia due to the absence of the classic erosions or ulcers seen in other reported cases of EA. Her dysphagia resulting from the obstructive EA mass interestingly mimics esophageal malignancy, which makes it easy to misdiagnose.Author contributions: A. Alshati wrote the manuscript and is article guarantor. L. Appleton, JT Maddux, and B. Dangerfield revised the manuscript. M. Almohammedawi edited the manuscript.Financial disclosure: None.Informed consent was obtained for this case report.


T1 and T2 hypointense signal on MRI, presumably owing to abundant haemosiderin deposition. We also discuss the imaging findings of CT and 18F-fludeoxyglucose positron emission tomography scans, as well as the pathological correlation.Giant cell tumours (GCTs) are benign tumours commonly found in the long bones. Rarely, they may occur in the larynx, often resulting in hoarseness and anterior neck swelling. Since Wessely reported the first case of laryngeal GCT in 1940, 35 cases have been identified. Herein, we present a case of a 53-year-old male with GCT of the larynx that showed  Herein, we present a case of a 53-year-old male with GCT of the larynx that showed T1 and T2 hypointense signal on MRI, presumably owing to abundant haemosiderin deposition. We also discuss the imaging findings of CT scan and 18F-fludeoxyglucose positron emission tomography (FDG-PET) scans, as well as the pathological correlation.Giant cell tumours (GCTs) are benign tumours commonly found in the long bones. Rarely, they may occur in the larynx, often resulting in hoarseness and anterior neck swelling. Since WesselyA 53-year-old male complained of hoarseness and presented at the ENT clinic. Laryngoscopic examination revealed polypoid degeneration of the right true vocal cord. In the course of the clinical observation of the polypoid degeneration of the true vocal cord for 2 years, a submucosal swelling of the false vocal cord (FVC) was found on laryngoscopic examination. CT scan, MRI and FDG-PET scan were performed as imaging work-ups of the FVC submucosal lesion. The patient had normal renal function.Unenhanced CT scan revealed an expansile heterogeneously iso-low attenuated mass centred in the right thyroid cartilage, measuring 40 × 45 × 46 mm in size. The right thyroid cartilage was entirely replaced by the tumour, associated with erosion of the cortex . On enhaT1 and T2 weighted images  of 12.3] in the tumour . There wTotal laryngectomy was performed because a malignant tumour was suggested on open biopsy.On gross examination, the resected specimen had a well-defined lobulated shape with heterogeneous nature, including haemorrhage and necrotic degeneration . On micr3 The most common site is the distal femur (23–30% of cases), followed by the proximal tibia (20–25%), distal radius (10–12%) and sacrum (4–9%).2GCTs account for about 4–9.5% of all primary bone tumours and usually show a slight female predilection, with ratios ranging from 1.1 : 1 to 1.5 : 1, and often occur in the third decade of life.3 The majority of head and neck GCTs occur at the skull base and in the temporal bones.3 Primary giant cell tumours of the larynx (GCTL) are exceedingly rare, show male predilection and often occur in patients aged between 23 and 67 years .4 The most common site is the thyroid cartilage, followed in order by the cricoid and the epiglottic cartilage.7 Clinical symptoms of GCTL are hoarseness, dyspnoea, dysphagia, pain and palpable neck mass.7 The tumours are usually submucosal and protrude into the endolarynx. Endoscopic examination might show submucosal swelling of the vocal cord and/or the FVC, but the laryngeal mucosa is usually intact and does not show an ulcerative or haemorrhagic change unlike squamous cell carcinoma.5GCT of the head and neck region is rare, and accounts for approximately 2% of all GCTs.5 The mass might extend into the soft tissues of the larynx and into the paraglottic spaces.7 Small foci of calcifications and mild contrast enhancement within the tumour have been reported.7 In the present case, the tumour showed heterogeneous iso- to low density with heterogeneous contrast enhancement.On CT scan, GCTL shows a homogeneous soft tissue mass with cortical expansion and destruction of the thyroid cartilage.T1 weighted images and a heterogeneous hyperintensity or hypo- to intermediate intensity on T2 weighted images.5 Heterogeneous enhancement on gadolinium-enhanced T1 weighted images is attributable to the histopathological findings with rich stroma containing numerous, thin-walled capillaries and secondary degeneration resulting in cyst formation.7There are few reports of MRI findings for GCTL. The tumour showed hypointensity on 8 reported that GCTL showed high uptake on FDG-PET (maximum SUV of 11.1), which was similar to the present case (maximum SUV of 12.3). Avid uptake of FDG in GCT is caused by an enhanced vascular fraction with increased 18F-FDG transport and overexpression of hexokinase-2, a key enzyme in the glycolytic pathway in both giant and spindle cells in GCT.10Chang et alT1 and T2 weighted images, as well as diffusion-weighted images and apparent diffusion coefficient, which are common (63%) in GCTs, and support the diagnosis of GCTs.11 These hypointense signals were explained by the paramagnetic susceptibility effect of abundant haemosiderin deposition due to extravasated or phagocytized erythrocytes in the tumour.11In the present case, GCTL showed marked hypointensity on both T2 hypointense signal in the laryngeal skeleton, undifferentiated pleomorphic sarcoma, previously named malignant fibrous histiocytoma, should be considered. A certain histopathological subtype, formerly known as giant cell malignant fibrous histiocytoma, can contain abundant giant cells and haemosiderin deposition due to extravasated or phagocytized erythrocytes in the tumour.6Regarding the differential diagnosis of T2 weighted images owing to their histological similarity to GCT.7 However, both GCRG and brown tumour are extremely rare in the larynx. GCRGs most frequently affect the mandible, maxilla, hands or feet, and brown tumours usually occur in patients with primary or secondary hyperparathyroidism, which was not seen in the present case.4Giant cell reparative granuloma (GCRG) and brown tumour may also show hypointensity on T2 hypointense laryngeal lesions include amyloidosis and sarcoidosis, which may present as laryngeal submucosal mass but not arise from the laryngeal cartilage.Other potential 6 These tumours usually show internal chondroid calcification on CT scan, hyperintensity on T2 weighted images and marked enhancement after administration of contrast.12 The other rare differential diagnoses include osteosarcoma, osteoblastoma and metastasis to the laryngeal skeleton.Regarding the differential diagnosis of the tumour in the laryngeal skeleton, chondroma and chondrosarcoma should be included as frequent pathologies.13 Radiation therapy is currently not recommended because of the increased risk of sarcomatous change.13Complete surgical resection is required for the treatment of GCT, and adjuvant therapy is unnecessary.T2 hypointense submucosal laryngeal mass.Primary GCT of the larynx is rare and should be considered as a differential diagnosis for GCTL can demonstrate MRI hypointense signal owing to susceptibility effect by haemosiderin deposition.The differential diagnosis of GCTL should include GCRG and undifferentiated pleomorphic sarcoma, especially when susceptibility effect is seen in the lesion.18F-FDG transport.GCT of the larynx can present with high uptake on FDG-PET because of an enhanced vascular fraction with increased Written informed consent was obtained from the patient for publication of this case report and any accompanying images.


Strumal carcinoid tumor of the ovary (SCTO) is a very rare kind of ovarian tumor. The symptoms of SCTO are often nonspecific and misleading. Therefore, a full understanding of the characteristics, diagnosis, and treatment methods of SCTO is important.In this study, we report a 63-year-old woman with SCTO whose most obvious symptoms were abdominal distention and weight loss of 5 kg for about 1 month.Her carbohydrate antigen 125 (CA125) levels were higher than normal. Gynecologic sonography showed an 8.8 × 7.5 cm mass with mixed density and an irregular shape behind the uterus. Pathologic and immunohistologic examinations confirmed SCTO of the right ovary.The patient underwent complete surgical resection of the whole uterus, bilateral ovaries, and fallopian tubes.The patient recovered well with no obvious complications and was discharged on the 10th day postsurgery.Complete surgical resection is vital to treat SCTO. Postsurgical pathologic and immunohistologic examinations can confirm a diagnosis of SCTO. SCTO is derived from the endoderm and always comprises thyroid tissue intimately mixed with the carcinoid tumor.Carcinoids are a kind of neuroendocrine tumor that usually occurs in the gastrointestinal and respiratory systems. Primary ovarian carcinoid is a very rare ovarian tumor, accounting for 0.5% to 1.7% of all carcinoids and about 1% of ovarian cancer. Primary ovarian carcinoid is divided into 4 categories based on their histopathologic characteristics: insular, strumal, trabecular, and mucinous.In the present study, we report a rare case of SCTO and share our experience of the basic characteristics, diagnosis, and treatment methods of SCTO.2This study was approved by the Ethics Committee and institutional Review Board of our hospital. The patient provided informed consent for publication of the case.A 63-year-old woman attended the Department of Digestive Internal Medicine of our hospital with abdominal distention and weight loss of 5 kg for about 1 month. She denied any history of nausea, vomiting, cough and expectoration, or fecal abnormalities. In addition, the patient also denied a history of hypertension, coronary heart disease, diabetes, or acute and chronic infectious diseases. The physical examination showed that the patient's general condition was good and her vital life signs were stable; however, her abdomen was slightly distended with no tenderness, and no rebound tenderness or muscle tension. The shifting dullness of the patient was positive. Laboratory tests showed almost normal liver and thyroid function; however, the patient's level of carbohydrate antigen 125 (CA125) was 768.10 IU/mL, which was higher than the normal level (0–35 IU/mL). Abdominal computed tomography (CT) examination showed some liver calcification, multiple gallbladder stones, and a large amount of fluid accumulated in the abdominal and pelvic cavities. Furthermore, the CT scan also showed a 7.7 × 7.1 cm mass with a mixed density in the right side of the pelvis. Gynecologic sonography showed that the uterus was floating, was in the anterior place, and was about 3.9 cm × 3.1 cm in size with a normal shape. Gynecologic sonography also showed an 8.8 × 7.5 cm mass with a mixed density and irregular shape behind the uterus  and the left ovary and the bilateral fallopian tubes were normal. The whole uterus, bilateral ovaries, and fallopian tubes were then resected and rapid pathologic examination indicated SCTO of the right ovary. The postsurgical pathologic examination showed thyroid adenomatous changes and carcinoid tumor changes in the right ovary Fig. . Immunoh3 There is no consensus concerning the tissue origin of SCTO. Researchers agree that SCTO comprises carcinoid and thyroid follicles and is a type of single layer teratoma. Most cases of SCTO occur in one side of the ovary; however, Zahradka and Schulz reported 1 case in which SCTO was found in both sides of the ovaries.Primary SCTO is very rare and accounts for <0.1% of ovarian cancer cases.Patients with SCTO always present with no obvious symptoms, and most of them attend the hospital because of lower abdominal masses that are found incidentally. Some larger SCTOs can result in different levels of abdominal pain. In our study, the patient denied an obvious history of abdominal pain; however, she had abdominal distention caused by a large volume of paracentesis. Peptide YY can inhibit many intestinal functions, including the secretion of gastric acid, gastric emptying, the secretion of chloride from the small intestine and colon, and insulin secretion. Peptide YY also inhibits the movement of the jejunum and colon.,7 As a result, the release of peptide YY is considered a possible explanation for the constipation symptoms of patients with SCTO. For female patients with constipation for unexplained reasons, SCTO should be considered.Long-term constipation may be the main symptom in a small number of patients with SCTO. Motoyama et al identified large amounts of cells that could release peptide YY in SCTO tissues. Ashton reported a case of SCTO with hyperinsulinemia, hypoglycemia, and pigmentation. The patient in our study showed no signs of endocrine dysfunction.Some patients with SCTO present with endocrine dysfunction. Robboy and Scully summarized 50 cases of SCTO, and found that 8% of the patients showed increased levels of steroid hormones, and the thyroid follicles of the tumor tissues played a role in thyroid function in these patients with SCTO. Pathologic and immunohistologic examinations are the gold standard for the diagnosis of SCTO. The pathologic examination always shows the thyroid adenomatous changes and signs of carcinoid tumor. The immunohistologic examination shows features of carcinoids, such as positive staining for CgA, Galectin-3, NSE, and Syn.The SCTO has no typical clinical symptoms and no specific features in imageologic examinations. Therefore, a correct diagnosis of SCTO is difficult before surgery. High levels of CA125, which could lead to a large volume of paracentesis, are always found in patients with SCTO. However, higher CA125 levels are also a feature of malignant ovarian tumors.,13,14 SCTO is often associated with teratomas, which can be malignant, and the thyroid components of SCTO can also become thyroid papillary or follicular carcinomas. In such cases, surgical treatment plus additional chemotherapy or radiotherapy should be applied to treat SCTO.Surgical treatment is the main therapeutic option for SCTO. For young women with SCTO, the affected ovary and fallopian tube should be resected. However, for patients with SCTO beyond reproductive age, the whole uterus, bilateral ovaries, and fallopian tubes could be resected.In the reported case, SCTO occurred in an elderly woman whose most obvious symptom was abdominal distention. Complete surgical resection of the whole uterus, bilateral ovaries, and fallopian tubes was performed. Pathologic and immunohistologic examinations confirmed a diagnosis of SCTO. Our study also discussed the basic characteristics, diagnosis, and treatment methods of SCTO.Conceptualization: Wei Chai.Data curation: Wenlei Zhang.Formal analysis: Li Zhou.Investigation: Wenlei Zhang, Xiaoyan Sun.Project administration: Li Zhou.Resources: Wenlei Zhang, Guifeng Jia.Software: Wenlei Zhang, Guifeng Jia.Validation: Wei Chai, Guifeng Jia.Visualization: Wei Chai.Writing – original draft: Wei Chai.Writing – review & editing: Xiaoyan Sun, Guifeng Jia.