This article aims to give an overview of some of the common conditions seen in emergency general surgery and the recommended choice of imaging. For junior doctors, choosing the correct imaging modality can be difficult so we aim to provide a summary of the evidence behind radiology for emergency general surgery. Four of the most important acute surgical conditions were chosen, alongside abdominal aortic aneurysm. A literature search was carried out to review the most up-to-date evidence regarding imaging choices. Cases were chosen from everyday practice to put the imaging into context. This article gives an overview of the most common imaging modalities used in emergency general surgery. It can be used by medical students and junior doctors to help understand the reasoning behind imaging choices on the acute surgical take. Abdominal imaging is a critical step in the investigation and management of patients presenting with abdominal pain. Plain radiographs, ultrasound (USS), computed tomography (CT) and magnetic resonance imaging (MRI) are among the many imaging modalities used to investigate abdominal symptoms to allow swift and appropriate diagnosis and management. For junior doctors, there is often uncertainty when choosing the initial imaging modality and this can cause unnecessary delays while awaiting senior input. It is important for all grades of doctors to understand the basic imaging indications for common surgical presentations to ensure prompt treatment can commence. This article gives an overview of common conditions seen in emergency general surgery and provides recommendations for the most appropriate imaging pathways for patients presenting with abdominal pain. Four very common acute general surgical conditions were chosen, alongside abdominal aortic aneurysm, which although does not occur as regularly, but is extremely important to be aware of. A literature review was carried out to explore the most up-to-date evidence regarding imaging choices and cases were chosen from everyday practice to put the imaging into context.Case oneA 28-year-old female attends the emergency department with a two-day history of umbilical pain radiating to the right iliac fossa. The pain has a gradual onset and is constant. There is associated nausea, anorexia and low-grade fever. Although the sensitivity and specificity of diagnosing appendicitis on USS are lower than that of CT, the absence of ionising radiation lends USS to be the investigation of choice, especially in paediatrics and young adults, where there is diagnostic uncertainty . A systeThe differential diagnosis of right iliac fossa pain is wider in the population above the age of 40 so CT is often used first-line in these patients to rule out other causes including right-sided diverticulitis or malignancy . A typicCase twoA 68-year-old male attends the emergency department with severe left iliac fossa pain. He has known diverticulosis that was seen on colonoscopy two years ago. The pain is constant, gradually worsening and radiating across his lower abdomen. On examination, he has peritonism in his left iliac fossa. He has raised inflammatory markers.Diverticular disease is increasingly common across the Western world. Studies show a prevalence of colonic diverticula in up to 50% of people over 50 years of age with 10-25% developing complications such as inflammation or diverticular bleeding . The manCT is the imaging of choice for diverticulitis in the acute, symptomatic stage. It is used to establish the diagnosis, its severity and any associated complications. It classifies the severity of complicated diverticulitis radiologically using various methods. The most used method is the Hinchey Classification score, as seen in Table Common findings on CT include pericolic stranding, segmental thickening of the bowel wall, abscess formations or diverticular perforation which will show extravasation of gas and fluid into the peritoneal cavity. An example is shown in Figure Case threeA 48-year-old female presents with a three-day history of constant right upper quadrant (RUQ) pain radiating to her shoulder tip. She feels generally unwell and feverish. Her inflammatory markers are raised.The first-line imaging for RUQ pain is ultrasound imaging . It is tOnce cholecystitis is confirmed on USS and the patient is responding to initial management, no further imaging is required. However, USS has limited value in the evaluation of complications from acute cholecystitis so further imaging may be required and CT or MRI are the modalities of choice . FindingFurther imaging is usually required if USS shows a dilated CBD. Magnetic resonance cholangiopancreatography (MRCP) is an imaging technique used to visualise the intra- and extrahepatic biliary tree and pancreatic ductal system. It can be used to determine the cause of the duct dilatation, as it can visualise stones and strictures .If a stone is impacted in the CBD, progression to endoscopic retrograde cholangiopancreatography (ERCP) is required before cholecystectomy. This allows direct visualisation and definitive management of the stone. Any patient who has had complications from gallstones and is fit for surgery should be offered a cholecystectomy. The timeline varies depending on the condition. Laparoscopic cholecystectomy should be performed on the index admission for gallstone pancreatitis however for acute cholecystitis, it should be offered either within the first 72 hours of pain or after six weeks as an urgent outpatient.Case fourA 34-year-old female presents to the emergency department with epigastric pain radiating through to her back. She is vomiting and initial investigations show high inflammatory markers and raised amylase. She has a tender epigastrium on examination and prefers to be sat up to reduce the pain. She has recently been discharged from the hospital with an episode of acute cholecystitis. Her clinical condition continues to deteriorate despite normal supportive therapy over the following few days.Alcohol and gallstones are the two most common causes of pancreatitis in the adult population . Most paThe International Association of Pancreatology guidelines, set in 2013, advise monitoring the presence of systemic inflammatory response syndrome (SIRS) or organ failure on admission and for 48 hours to predict the development of a severe course of the disease ,12. TherIf typical clinical and laboratory findings are present, imaging is not required to confirm the diagnosis of acute pancreatitis . AbdominInitial CT assessment optimal timing is at least 72-96 hours after onset of symptoms. CT can comment on the presence of pancreatic necrosis as well as the site and presence of free fluid and peri-pancreatic fat stranding. Other local complications can be visualised by CT: fluid collections, pseudocyst formation, abscesses, haemorrhage, venous thrombosis and pseudoaneurysm. In the majority of patients with pancreatitis, routine CT imaging is not indicated as there is no evidence that early CT improves clinical outcomes . FiguresPatients with mild biliary pancreatitis should be offered a cholecystectomy on the index admission. However, in a case with severe biliary pancreatitis, patients with peri-pancreatic collections should have delayed cholecystectomy until the collections resolve or if they persist beyond six weeks.Case fiveA 62-year-old male presents with profuse vomiting, absolute constipation and abdominal pain. He has a grossly distended abdomen which is tender and tympanic on examination. His past medical history includes an open appendicectomy performed 40 years ago for perforated appendicitis. Initial investigations reveal a mild acute kidney injury.Bowel obstruction is a common presentation to the acute surgical unit, with the most common cause of small bowel obstruction being intraperitoneal adhesions (70% of cases) . This paAbdominal x-ray is commonly used as the initial radiological investigation for patients with acute abdominal pain, however, studies have shown that abdominal x-rays are diagnostic in only 50-60% of cases . There iContrast-enhanced CT imaging is the preferred higher imaging. Along with confirming dilation of the small bowel, a transition point can often be identified; along with other causes of small bowel obstruction and can often identify if there is associated strangulation. Contrast-enhanced CT sensitivity for the identification of intestinal ischaemia is as high as 90% . Causes Small bowel obstruction secondary to an incarcerated abdominal wall hernia warrants urgent reduction, usually in the form of surgical repair. Adhesional small bowel obstruction can usually be settled with non-operative management (90% of cases) but a small proportion of patients will need to undergo definitive surgical intervention, ranging from band adhesiolysis to a small bowel resection . TherefoCase sixA 73-year-old male presents to the emergency department feeling unwell and complaining of severe back pain. His initial observations include a blood pressure of 90/60 mmHg and HR 89. He has a past medical history of hypertension, peripheral vascular disease, atrial fibrillation and he smokes 40 cigarettes a day. He takes bisoprolol regularly. On examination, he has a slightly tender abdomen, and a central pulsatile mass is palpated.A ruptured abdominal aortic aneurysm has a mortality rate of over 90% . It is oEmergency contrast-enhanced triple-phase CT scanning is indicated for the investigation of a potentially ruptured abdominal aortic aneurysm (AAA) . CT is aThere is currently a screening program running in the UK for AAA. In England, men aged 65 are offered screening using an abdominal ultrasound scan. The diameter of the aorta determines the next steps in the patient pathway Table . This is This article provides an overview of common conditions that present on the acute surgical take. Understanding the indications for imaging and the rationale behind the choice of imaging is fundamental for junior doctors and medical students. This knowledge is vital for both day-to-day practice and examinations, and the evidence presented in this article can be utilised to further and improve your clinical practice.


Extramedullary plasmacytoma (EMP) can occur in various parts of the body. It is generally accepted that the highest site of occurrence is the head and neck region (80% to 90%), followed by the gastrointestinal tract and the skin. It is worth mentioning that the site of disease, in this case, was the urethral meatus, which is extremely rare in clinical practice.A 50-year-old female complained of an episode of painless gross hematuria without symptoms of frequent urination, urgency, abdominal pain, abdominal distension, fever, or oliguria. The patient has no history of smoking or drinking and denied any family history of solid malignancy or hematological disease.Urethrocystoscopy revealed urethral polypoid hyperplasia, which we initially thought could be a urethral caruncle. The patient was asked to undergo caruncle resection after 1 week of potassium permanganate sitz bath, and postoperative pathology revealed plasmacytoma. After that, a whole-body MRI showed no other lesions. She received postoperative radiotherapy.During radiotherapy, the patient’s condition and appetite were fair, and the skin mucositis was I°. Pelvic contrast-enhanced MRI and whole-body PET-CT 6 months after urethral meatus lumpectomy and radiotherapy showed changes without obvious abnormal signs. No recurrence or metastasis was detected after one year of follow-up.Urinary EMP is a rare disease. It is not easy to diagnose due to its rare site of occurrence and non-specific symptoms. The diagnosis of EMP requires a combination of imaging studies and pathological findings. Currently, surgery combined with radiotherapy or radiotherapy alone is the mainstay treatment and usually results in an acceptable local control rate. At the same time, chemotherapy cannot be ignored. Plasmacytomas include solitary plasmacytomas, extramedullary plasmacytomas (EMP), multiple myeloma (MM), and plasma cell leukemia. EMP is a rare malignant tumor arising in the extramedullary soft tissue. It accounts for approximately 4% of all plasmacytomas, including 80% in the upper respiratory and digestive tracts and a very rare occurrence in the urinary tract . We repoA 50-year-old female presented with a chief complaint of an episode of painless gross hematuria. On specialist physical examination, a bulge about 2 *2 cm in size was macroscopically observed in the external urethral meatus, without skin ulceration, tenderness, soft, and the rest were unremarkable. She had no specific past medical history. Thus, she underwent urethrocystoscopy in the outpatient clinic, which revealed a urethral meatus neoplasm Figure 1Postoperative pathological diagnosis Figure 2According to the above results, the patient was preliminarily diagnosed with a plasma cell neoplasm. So we continued to improve the relevant examinations such as blood and bone marrow except for the cumulative possibility of multiple myeloma. β-2 microglobulin decreased, and serum alkaline phosphatase, free monoclonal light chain assay, blood, urine protein electrophoresis, and bone marrow biopsy were negative, making the diagnosis a solitary EMP. At the same time, we also did a whole-body MRI, which showed no obvious lesions. We then contacted the oncologist to develop the next radiotherapy plan. At present, the patient is followed up for one year after radiotherapy, and there is no recurrent lesion in the whole body.EMP is an extraosseous or extramedullary tumor formed by monoclonal proliferation of B lymphocytes, generally without myeloma-related clinical manifestations and related laboratory positive indicators such as anemia, excessive monoclonal immunoglobulin in serum or urine, hypercalcemia, and renal failure. The clinical manifestations of EMP vary according to the site of tumor onset, lack of specificity, and most present with pain and discomfort at the lesion site due to local tumor compression. Some patients have palpable tumors during physical examination. The tumor in this patient was located in the urethral meatus, which is unprecedented in clinical practice. This tumor location increases the difficulty of diagnosis. The patient in this case had a preoperative diagnosis of female urethral caruncle without associated imaging studies. Postoperative pathological examination revealed plasmacytoma.It is generally believed that EMP may be occult MM. The diagnosis of EMPs is problematic because it requires confirmation by extensive radiology, hematology, and histopathology –8. At prPrimary urethral plasmacytoma is a rare tumor, and to our knowledge, this patient is the first case of plasmacytoma to occur in the external urethral meatus, and the patient had no abnormalities in the urethra. No definitive treatment strategy exists. There are currently three main treatment modalities for localized EMP, radiotherapy, surgical treatment, and postoperative radiotherapy. As for chemotherapy, it is generally used for patients with recurrence after treatment or systemic metastasis . The cheSome studies have found that lymph node metastasis and primary tumors larger than 5 cm are independent poor prognostic factors for EMP . The proIn conclusion, EMP in women is extremely rare, especially in the urethral meatus. EMP can either recur locally or progress to MM. Based on this case, it seems slightly inappropriate to operate without perfecting the imaging examination; therefore, we concluded that in the case of the first diagnosis of urethral lesions, the imaging examination of at least the pelvic part should be done as far as possible. Fortunately, thanks to timely postoperative diagnosis and treatment, the patient’s current disease control is fair. Also, we would like to emphasize the importance of multidisciplinary collaboration in the treatment process.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article.JT: Revising the manuscript critically for important intellectual content. WS: Drafting the manuscript. LZ and DZ: Data collection and sorting. YF: Provide valuable opinions in the interdisciplinary field. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Dysplasia epiphysealis hemimelica (DEH), also known as Trevor's disease, is a rare overgrowth of cartilage that commonly arises in the epiphyseal bone of children. We report a rare case of DEH originating from a talus accompanied by multiple intra-articular free bodies in a 7-year-old patient with ankle instability. After the primary surgery for free body removal and microfracture technique for the cartilage defects in the ankle joint, the free body recurred. Secondary surgery of arthroscopic free body removal with lateral ankle ligament repair succeeded in treating the patient, without further recurrence of the free body. Dysplasia epiphysealis hemimelica (DEH) is a rare asymmetrical epiphyseal cartilaginous overgrowth that is commonly seen in children or teenagers, mostly males . It was A 7-year-old Japanese boy presented to a nearby clinic owing to an increasing mass and pain in his left ankle for 6 months. He experienced a sprain of his left ankle several months before the onset of his symptoms. Gradually increasing pain hindered him from walking long distances and exercising. He was diagnosed as having synovial osteochondroma by a local physician and referred to our hospital. Physical examination revealed a palpable hard mass on the anterior and posteromedial sides of his left ankle. He had a full ankle range of motion of 15° in dorsiflexion and 40° in plantar flexion with his knee flexed. Instability and apprehension were evoked by an anterior drawer test on his left ankle. Left ankle plain radiography revealed multiple oval free bodies 10–15 mm in size at the anterior and posterior ankle joint spaces Figures . ComputeOn macroscopic examination, some mass lesions were colored brown, including the protuberance from the talus, while others were white . MicroscHowever, 3 months after the primary surgery, the patient experienced recurrent left ankle sprain, and 10 months postoperatively, he first experienced a temporary locking of his left ankle when he plantarflexed the ankle. He had a sharp pain at the posterior side of the ankle joint during the locking position. Lateral plain radiography revealed the growth of a new oval ossified free body in the posterior joint space of his left ankle during postoperative follow-up Figures . RadiogrPostoperatively, a below-the-knee splint was applied for 3 weeks with non-weight-bearing for 1 week. Full weight-bearing was initiated 1 week after the operation. Six months after the operation, the patient experienced neither ankle sprain nor severe ankle pain and could live a daily life without any inconvenience. A recurrence of free body or protuberance was not confirmed by the plain radiographs during the postoperative follow-up of 6 months . We compEXT gene mutation; however, no specific mutation has been reported on DEH [EXT gene mutations in the present case. However, considering the localization of the tumor, we deleted the possibility of osteochondroma for the confirmed diagnosis. Synovial osteochondroma presents as a large number of osteochondral lesions originating from the synovium inside and outside of the joint. The most common age of onset is 30–60 years, and the most common locations are the knee (70%), hip (20%), shoulder, elbow, ankle, and wrist [FN1-ACVR2A gene fusions in synovial osteochondromatosis is reported [DEH is a rare disease characterized by the overgrowth of cartilaginous tissue asymmetrically at the epiphysis of extremities. The incidence of DEH is reportedly 1 in 1,000,000 , 9 Tabl. Histolod on DEH . We coulnd wrist . Accordind wrist . Patholond wrist . The higreported , 18. As To the best of our knowledge, only a few cases of intra-articular multiple DEH have been reported , 9 Tabl. Only a The treatment should be individualized depending on the clinical findings. Asymptomatic lesions can be treated nonoperatively, as there are no known cases of malignant transformation . Surgica


Magnetic resonance imaging (MRI) is being increasingly used for imaging suspected recurrence in prostate cancer therapy. Functional MRI with diffusion and perfusion imaging has the potential to demonstrate local recurrence even at low PSA value. Detection of recurrence can modify the management of postprostatectomy biochemical recurrence. MRI scan acquired before salvage radiotherapy is useful for the localization of recurrent tumors and also in the delineation of the target volume. The objective of this review is to assess the role and potential impact of MRI in targeting local recurrence after surgery for prostate cancer in the setting of salvage radiation therapy. MRI can diagnose local prostate cancer recurrence after radical prostatectomy even at low PSA value.DWI-MR is almost comparable with DCE-MRI in detecting local recurrence.MRI enables a better delineation of identified recurrence and a precise anatomical analysis of the prostate bed than CT.Radical prostatectomy (RP) is a standard treatment for localized prostate cancer (PCa). Of 100 men treated with RP, approximatively 15–60 will develop biochemical recurrence (BCR) within 10 years . The meaSome clinico-pathological features and characteristics of PSA recurrence represent important variables when trying to distinguish between a local and distant recurrence. Indeed, Gleason score (GS) ≥8, seminal vesicle involvement, or pelvic lymph node (LN) invasion at the time of surgery seem to be correlated with distant recurrences. Similarly, a BCR occurring within 6 months of RP or a PSA doubling time of less than 12 months are strong indicators of metastases , 8. On tThe options for treatment of recurrence after RP are, according to the European Association of Urology (EAU), salvage radiotherapy (SRT) at least to the prostatic fossa, continuous or intermittent hormonal therapy (HT), or simple monitoring . Proper Positron emission tomography (PET) with choline or PSMA has become the reference in detecting metastases in the skeleton, in distant lymph nodes, and in the viscera .Prostate magnetic resonance imaging (MRI) with functional sequences allows early detection of local recurrence and may also be a valuable correlative imaging modality for equivocal PET findings . MRI proHowever, the role of MRI in this indication is still discussed and has not been validated . The aimp < 0.001), but relapse could be located in 13 (7%) patients with a PSA <0.5 ng/ml. When the PSA value was ≤0.3 ng/ml, Liauw et al. , and dynamic contrast-enhanced (DCE) imaging sequences . T2W imaRP includes total removal of the prostate and seminal vesicles, along with pelvic lymph node dissection. Postradical prostatectomy MRI findings include descent of the bladder which is anastomosed to extra prostatic distal urethra. The vesico-urethral-anastomosis (VUA) should be visualized as a ring of postoperative fibrosis with low signal intensity on all sequences  . In this specific indication, the values of b must be greater than 1,400 s/mm2 and up to 3,000 s/mm2 , in combination with SRT, particularly if the PSA is higher than 0.5 ng/ml , 34, 58.Multiparametric MRI could be a useful tool before SRT, showing local or regional relapse with sensitivity and specificity reaching 90%. Combined with PSMA PET-CT, ideally during the same session, it allows to spare some patients with distant relapse from a futile SRT. In the future, it could be proposed to patients with BCR, particularly when the PSA is higher than 0.3–0.5 ng/ml, to facilitate the delineation of target volume and allow dose escalation on a specific area.All authors have participated in the conception and drafting of the manuscript under the supervision of RP, IL, and CH. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Jejunal adenocarcinoma (JA) is both a rare type of gastrointestinal malignancy and an uncommon cause of small bowel obstruction (SBO). It typically presents with vague symptoms, such as abdominal pain, nausea, vomiting, and, in some cases, weight loss. Due to this vague presentation as well as lack of definitive imaging techniques, diagnosis tends to be delayed and patients typically present at later stages. We present a case of a patient who presented with acute onset abdominal pain. Imaging revealed the presence of an SBO with the presence of a suspicious small bowel stricture. He eventually underwent upper endoscopy to find the mass, with subsequent biopsy indicating JA. We hope to bring greater awareness to jejunal carcinoma as a potent cause of SBO in adults. Abdominal pain is a common symptom of patients presenting to the emergency room and encompasses a wide differential. Most commonly caused by adhesions (60%), small bowel obstruction (SBO) often presents with abdominal pain and frequently occurs in patients who have undergone prior abdominal surgical procedures. Other less frequent causes include hernias, Crohn’s disease, and volvulus . Bowel oJAs occur most commonly around the age of 60 and present with vague, non-specific symptoms such as abdominal pain, nausea, and vomiting. In some cases, they are often diagnosed emergently as bleeding or obstruction. The vague presentation, underappreciated prevalence, and poorly defined diagnostic modalities can lead to its delayed diagnosis, overall potentially leading to a poorer prognosis. Some reports indicate over 80% of JAs being diagnosed at stage III or stage IV disease . It is eOur patient is a 59-year-old African American male with only relevant past medical history of uncontrolled hypertension who presented to the emergency department endorsing severe abdominal pain associated with intractable nausea and vomiting. According to the patient, his symptoms started four days prior to presentation, and there were no similar episodes in the past. Despite attempts at diet modification, his symptoms persisted, prompting his visit.Initial workup and blood work showed hypertensive emergency with acute kidney injury. The patient was eventually started on nicardipine drip to manage his blood pressure. Computerized tomography (CT) scan of the abdomen/pelvis without contrast was performed, which demonstrated a soft tissue density at the duodenojejunal junction measuring 3.2 x 2.0cm Figure .The patient was decompressed with nasogastric suction and scheduled for upper endoscopy. Endoscopy showed an exophytic mass at the level of the jejunum causing partial SBO Figures , 3.The area was successfully injected with India ink for tattooing. Biopsy of the mass demonstrated the architectural and cellular features of jejunum adenocarcinoma, and a diagnosis was made Figures , 5.The patient was scheduled for surgical resection; however, the mass was deemed unresectable due to its proximity to the superior mesenteric artery. He finally underwent gastrojejunal bypass. The patient then followed up as an outpatient for cancer marker identification and targeted chemotherapy.Despite the small bowel encompassing around three-fourths the complete length of the GI tract, SBAs represent some of the rarest of GI malignancies, with rates as low as 1 case per 100,000 individuals, and reported to be less than 5% of all GI malignancies ,8. A varRisk factors for JA include alcohol use, smoking, preexisting adenoma, Crohn’s disease, Lynch syndrome, and Puetz-Jeghers syndrome among others, none of which our patient had . PresentCT scan remains the preliminary modality of choice for patients presenting with GI symptoms; however, studies depict only around a 50% accuracy in detecting lesions, lacking data regarding the intestinal mucosa and often missing smaller and flatter lesions . OverallThe treatment of choice remains complete resection, with complete tumor removal with clear margins proposing the best overall survival . AlthougOur case represents a small subset of patients with JA who may develop small bowel obstruction as a result of tumor invasion and growth. With the paucity of data on this subject in the medical literature, the mainstay of diagnosis involves biopsy and histopathological analysis. In our case, the patient was planned for surgical intervention; however, due to late presentation of the mass and spread to surrounding vasculature, it was deemed not resectable. This paper was written to shed light on the clinical diagnosis of small bowel malignancy and a unique presentation leading to diagnosis. At this point, little is known about the etiology of these small bowel malignancies. Future studies with larger sample populations and molecular diagnostic datasets could pave the way to establishing targetable tumor markers and sound treatment approaches. We feel that this process starts with a greater awareness of the pathology and its potentially unique presentations in an attempt to better aid patients affected with this GI malignancy.


Actinomycosis is a rare bacterial infection that can affect almost any site in the body. Its occurrence at the nasal septum is extremely rare. We present the case of an 84-year-old diabetic woman, with a past medical history of breast cancer that came to medical attention because of progressive nasal obstruction and severe sleep apnea. Nasal endoscopy revealed a submucosal mass at the anterior nasal septum obstructing both nasal cavities and extending to the anterior hard palate. With a cancer metastasis in mind, she was submitted to surgical resection of the lesion through a Rouge-Denker approach, with the final histologic diagnosis of actinomycosis. She was then treated with a three-month cycle of amoxicillin and remains without recurrence. This case describes a rare disease that should be considered in the differential diagnosis of sinonasal lesions, especially in diabetic patients and after dental procedures. Actinomyces are Gram-positive non-acid fast filamentous anerobic (or microaerophilic) bacteria that belong to the normal flora of the oral cavity, gastrointestinal (GI), and urogenital tracts [Actinomyces can become pathogenic after mucosal injury and cause a subacute or chronic granulomatous infection known as actinomycosis, which can mimic a large array of pathologies from malignancies to tuberculous infections [l tracts . In rarefections -2. The efections -4. This fections . Althougfections , the invfections , 5, 7-11We report the case of a nasal actinomycosis that caused the destruction of septal and hard palate cartilaginous-bony structures.An 84-year-old Caucasian woman was referred to the otorhinolaryngology clinic due to a three-month history of severe sleep apnea and bilateral permanent nasal obstruction. Additionally, she reported mucous rhinorrhea, without epistaxis. She denied smell disturbance, headache, nasal pain, pruritus, or sneezing. There were no systemic symptoms such as fever, weight loss, or night sweats. She denied any history of previous trauma, surgery, or dental procedures.Her past medical history included a breast carcinoma with bone dissemination, for which she received immunotherapy. There was also a history of controlled hypertension, type 2 diabetes, and dyslipidemia. She had no smoking history or alcohol consumption.Nasal endoscopy demonstrated a submucosal tender septal mass obstructing both nasal cavities. There were neither crusts nor purulent discharge and mucosa was intact. In the oral cavity, there was a tender absence of a portion of the bone in the hard palate. Teeth were fixed and free of caries. The CT scan showed a hypodense mass with an inside calcification destroying the anterior septum and hard palate Figure . Considering the clinical presentation and patient’s medical history, the first diagnostic hypothesis was a metastasis from previous breast cancer or another type of malignancy. However, the tender consistency and unremarkable mucosal appearance also raised the hypothesis of a malignant granuloma of midline or granulomatous systemic disease (granulomatosis with polyangiitis or sarcoidosis).An incisional biopsy and MRI were suggested to the patient, which she declined. With a malignancy in mind, however, she agreed with surgical excision of the lesion. A Rouge-Denker approach was performed, with submucosal dissection of the neoplasm, which had a soft consistency and granulomatous yellowish appearance. The anterior septal quadrangular cartilage was destroyed by the mass and was removed with part of the bony septum and nasal crest. The septal and hard palate mucosa were preserved. There were no surgical complications and the patient improved symptoms afterward.However, the histological result was unpredictable: there was no evidence of malignant transformation, but colonies of Actinomyces were detected instead Figure .Then, due to the multiple comorbidities, the patient was prescribed long-term amoxicillin 500 mg twice a day for three months. The postoperative CT scan, performed six months after surgery, was unremarkable Figure  and she Actinomyces is a commensal microorganism of the oral, GI, and genital mucosa. However, sometimes it can become pathogenic, usually following the destruction of normal mucosa in the presence of other bacteria that predispose to an anerobic environment, enabling the growth of these colonies. Therefore, actinomycosis most often occurs after surgical interventions such as dental extraction procedures, abdominal surgery, or intrauterine dispositive insertion. An immunocompromised state and systemic diseases like diabetes are also known risk factors for this disease, which is the case of the present patient [ patient -3.The infection usually courses with the development of granulation tissue, necrosis, abscesses, and sulfur granules capable of destroying surrounding structures . SymptomActinomyces [The diagnosis may be difficult through regular cultures considering Actinomyces are fastidious microorganisms and its isolation may take up to 14 days, with the risk of being considered negative in the normal laboratory setting. Newer laboratory techniques such as matrix-assisted laser desorption ionization-time of flight mass spectrometry can help identify this bacteria when cultures are negative [inomyces .Actinomyces inoculation in the submucosa is unknown. Probably the tissue structural changes promoted by hyperglycemia seen in diabetic patients increased the susceptibility to infection. As far as we know, there are only three reports in the literature of actinomycosis located in the nasal septum [In the present case, the submucosal invasion of septal and hard palate structures caused sleep apnea and nasal obstruction, and the past medical history of the patient induced the suspicion of neoplasia. Fortunately, the final diagnosis had a better prognosis. The cause of l septum , 8, 10.Owing to the rarity of this disease, there is no established treatment protocol. It usually consists of surgical debridement followed by long course antibiotics. Although penicillin G is usually the drug of choice, the antibiotics used have been multiple and can be tailored to disease extension, severity, and location -10, 12. Actinomycosis of nasal cavities is a rare presentation of the disease and mimics multiple pathologies such as neoplasms, mucoceles, and fungal infections. It should be considered in cases of nasosinusal lesions with bone destruction, especially in immunosuppressed patients and in those who have been subjected to any kind of surgical procedure.


Many causes of bowel obstruction arise from congenital anomalies and recognition of the underlying cause of obstruction can be challenging in these settings. These cases can be further complicated if two or more congenital anomalies are present. Malrotation of the gut is defined as a congenital developmental anomaly of the rotation of the intestine and encompasses a spectrum of abnormalities. Meckel’s diverticulum is another congenital anomaly which occurs secondary to the failure of the vitellointestinal duct to close and can present in 2% of the population. We describe an interesting case of a 19-month-old A 19-month-old boy presented to his local hospital with a 3-day history of non-bilious vomiting and generalised malaise. This was associated with a history of two days without opening bowels and worsening abdominal distension. His GP had started him on oral amoxicillin for a suspected tonsillitis 2 days prior to presentation whilst his mother did not report any fever or any indication that he had abdominal pain. He had been passing dark, strong-smelling urine with decreased frequency.He was previously fit and well and had been born at term in Brazil. He was followed up by a cardiologist for left-sided superior vena cava with monthly echocardiograms until 6 months of age with no significant family history of note. He lived with his parents and 4-year-old sister, none of whom had had any vomiting.Upon review after transfer to a specialist centre, he was clinically dehydrated with sunken eyes. His abdomen was markedly distended, but soft, non-tender and not peritonitic. He had active bowel sounds and passed a formed stool with no evidence of rectal bleeding shortly after transfer. A nasogastric tube was on free drainage with a small volume of light yellow aspirate in the bag.9/L (4–11 109 l−1), C-reactive protein (CRP) 129 mg l−1 (<5 mg l−1)], and suggested dehydration . On capillary blood gas, he had a slight respiratory alkalosis , with a normal lactate (1.1).Initial investigations showed raised inflammatory markers [white cell count (WBC) 16.5 10A plain abdominal radiograph performed at his local hospital showed multiple dilated central bowel loops with some peripheral faecal loading . There wUpon transfer, the main differentials were intussusception or partially treated appendicitis with septic ileus. An abdominal ultrasound was performed, which demonstrated multiple dilated bowel loops and large volume free fluid. The appendix was not visualised, and no intussusception was seen.Computed tomography (CT) abdomen and pelvis was performed for further assessment of the dilated bowel loops, and confirmed high-grade small bowel obstruction with a transition point in the left upper quadrant involving an anterolateral loop of small bowel, leading to a thin-walled, blind-ending tubular structure measuring up to 18 mm in diameter . The appThe CT demonstrated abnormal bowel orientation with a left-sided colon, but normal appearing position of the DJ flexure . The caeThe dilated tubular structure seen on CT was felt most likely to represent an inflamed appendix in the left upper quadrant with an associated bowel obstruction, on a background of a rotational bowel anomaly given the SMA/SMV orientation and left-sided large bowel loops . The posThe patient was subsequently taken to theatre for an exploratory laparotomy. The intraoperative findings were of a malrotation with the caecum and appendix positioned in the left upper quadrant and dense Ladd’s bands covering a right-sided DJ flexure. The terminal ileum was strangulated by a Meckel’s band  which enPost-operatively, the patient recovered well after a period of ileus. He had a repeat ultrasound scan after spiking a fever on the fifth post-operative day which did not show any collection, and his fevers resolved. He was discharged on the ninth post-operative day.1,2 There is a spectrum of appearances depending on the embryological stage of development at which the anomaly occurs, ranging from omphalocoele to non-rotation, incomplete or reversed rotation, internal hernia and mobile caecum/unattached duodenum.3 Malrotation can lead to the life-threatening complication of midgut volvulus, which can result in obstruction and necrosis of up to the entire midgut.2 The clinical incidence of malrotation is estimated to be 1 in 6000 live births and may occur as an isolated condition or in association with other anomalies. However, autopsy studies suggest the actual incidence may be as high as 1 in 100.4Malrotation is a congenital anatomical anomaly of fetal intestinal rotation. It is defined by abnormal position of the bowel within the peritoneal cavity and is usually accompanied by abnormal mesenteric bands or absence of fixation of portions of the bowel.5The classical clinical manifestation of malrotation in newborns is bilious vomiting with or without abdominal distention, associated with either duodenal obstructive bands or midgut volvulus. However, in an important minority (such as this case), presentation may be atypical.6 These diverticula are typically asymptomatic however can present with complications such as diverticulitis, haemorrhage, intussusception, obstruction or neoplasm. Ectopic mucosa  may be found on histological examination. On CT, Meckel’s diverticulum is typically seen as a blind-ending fluid filled structure in continuity with the antimesenteric border of the terminal ileum.6Meckel’s diverticulum is recognized as the most common congenital anomaly of the gastrointestinal tract occurring in 2% of the population. It represents a remnant of the omphalomesenteric duct which connects the yolk sac to the midgut through the umbilical cord. Failure of the duct to close results in a diverticulum in 90% of cases, which can be found on the antimesenteric border of the distal small bowel, typically 100 cm from the ileocecal valve.7 These prior reports have also attributed the delayed presentation of malrotation to the absence of fibrous bands between the caecum and peritoneum.7,8 However, in this case, Ladd’s bands were found overlying the DJ flexure at the time of surgery and therefore it is surprising that this did not present in the neonatal period.Concurrent intestinal malrotation with Meckel’s diverticulum has been reported in a very small number of cases to date; however, it is notable that this case is unique in that the patient remained asymptomatic until this acute presentation. Prior reports of concurrent malrotation and Meckel’s diverticulum describe a more acute on chronic picture with the chronic symptoms likely secondary to episodes of subacute volvulus.7,8 This case is unique in that the primary cause of the acute presentation was small bowel obstruction secondary to a Meckel’s band and necrotic Meckel’s diverticulum with incidental malrotation noted both on imaging and intraoperatively.Intraoperatively, this patient was also found to have a mesodiverticular band which strangulated the terminal ileum and resulted in small bowel obstruction. Previous case reports of concurrent Meckel’s diverticulum and malrotation have described acute presentations secondary to malrotation with incidental intraoperative findings of Meckel’s diverticulum.5Small bowel obstruction with a Meckel’s diverticulum accounts for 40% of symptomatic Meckel’s and can occur through a variety of mechanisms. These include trapping of a bowel loop by a mesodiverticular band (as was the case in this particular patient), volvulus of the diverticulum around a mesodiverticular band, intussusception as well as incarceration in an inguinal hernia (Littre’s hernia).9Intestinal obstruction due to the mesodiverticular band of Meckel’s diverticulum is seen rarely and becomes an even more unusual occurrence in the paediatric setting. A mesodiverticular band forms due to failure of involution of one of the two embryological vitelline arteries, resulting in a fibrous band that typically extends from the tip of the Meckel’s diverticulum. This can result in bowel obstruction by strangulating a loop of bowel.In this unique case, the presence of a rotational abnormality was successfully noted and was key to highlight the possibility of pathology (such as appendicitis or Meckel’s diverticulum) usually affecting a different region of the abdomen. The pathology was localised to the left upper quadrant, which was helpful for surgical planning.10When diagnosing malrotation (on upper GI contrast studies), the typical teaching is to evaluate whether the third part of the duodenum has a retroperitoneal course and to locate the position of the DJ flexure, which in normal anatomy should be lateral to the left lumbar pedicle at the level of the gastric pylorus. On cross-sectional imaging, the SMA/SMV relationship may be reversed or abnormal in malrotation, although this is not always reliable.In this case, the third part of the duodenum did appear to have a retroperitoneal course on the CT with the DJ flexure apparently appropriately sited in the left upper quadrant. However, the CT was re-reviewed following the operative findings and in retrospect the DJ flexure position was felt to be slightly lower than the pylorus, but not convincingly right-sided on imaging. An important radiological learning point from this case is that malrotation represents a spectrum of abnormalities and the imaging findings can be subtle or indeterminate.Another important learning point is the consideration of a Meckel’s diverticulum in addition to an inflamed appendix in the differential for a blind-ending dilated tubular structure, particularly if the structure is not definitively seen to arise from the caecal pole as in this case. Furthermore, identifying a possible malrotation was crucial to intraoperative decision-making.In conclusion, this case of concurrent malrotation with a rare cause of small bowel obstruction presented itself with a challenging clinical and radiological scenario. This unique case highlighted the importance of considering rare causes of small bowel obstruction as well as being aware of congenital anomalies that may complicate image interpretation.Malrotation is a spectrum of rotational abnormalities with a range of imaging appearances. Evaluate the SMA/SMV relationship and position of the DJ flexure to aid diagnosis.Blind-ending tubular structure with bowel obstruction in a paediatric patient should raise the possibility of both appendicitis and Meckel’s diverticulum. Often surgery may be the only way to differentiate between these two entities.Large bowel loops seen predominantly on the left and small bowel loops of the right should raise the suspicion of malrotation.CT imaging may not provide a conclusive diagnosis in complex case such as this but can be helpful for localising pathology and planning surgery.


Primary aortic intimal sarcoma is a very rare disease and most patients present with features similar to those of atherosclerotic plaque and thrombus; however, primary aortic intimal sarcoma presents with features similar to those of intramural hematoma (IMH) on CT imaging and clinical presentation had never been previously reported. Here we report a case involving a 49-year-old woman with primary aortic intimal sarcoma masquerading as IMH on radiological images and clinical presentation. We also discuss some of the diagnostic pitfalls and hope that these diagnostic pitfalls will be very useful for clinicians. The m2A 49-year-old woman visited the emergency room for acute chest pain radiating to the back. She had known hypertension: the blood pressure in the left upper limb, right upper limb, left lower limb, and right lower limb was 210/65, 218/60, 176/90, and 175/90 mm Hg, respectively. The D-dimer level was normal at initial admission. An electrocardiogram showed a normal sinus rhythm. Considering that the patient had typical clinical symptoms of acute chest pain radiating to the back, with asymmetry of limb blood pressures, and a normal D-dimer level and electrocardiogram, the diagnosis of IMH was suspected. Chest nonenhanced computed tomography (CT) was performed, which showed crescent-shaped thickening of the thoracic aorta wall with the same attenuation as that of the lumen and linear calcification ingression . ComputeThree months after endovascular stent graft implantation, follow-up CTA  showed eInformed consent: Informed consent was obtained from the patient’s family.3Primary aortic intimal sarcoma can be diagnosed only by postoperative histopathology and immunohistochemical markers, while its preoperative diagnosis is challenging because of various clinical manifestations and no specific imaging features. Based on previous case reports ,4,5,6,7,According to the previously reported cases, the diagnosis of IMH depends on the identification of the intimal tear, the false lumen, and the presence of most hyperdense intramural thrombus on unenhanced images ,9,10,11.According to previous studies, the prognosis of primary aortic intimal sarcoma is dismal ,16,17,18


Background: Angiosarcomas are a broad category of vascular origin neoplasms that are poorly characterized in veterinary species. Lymphangiosarcoma (LAS) is an uncommon type of angiosarcoma reported in humans and canines arising from lymphatic endothelium. LAS can be differentiated from other angiosarcomas in dogs based on expression of Prospero-related homeobox gene-1 (PROX-1) or lymphatic vessel endothelial receptor-1 (LYVE-1). Composite hemangioendothelioma (CHE) is a rare angiosarcoma subtype described in people and characterized by a variable biologic behavior and infrequent metastasis. This variant of angiosarcoma histologically combines features of retiform hemangioendothelioma and epithelioid hemangioendothelioma. Information regarding the cytologic and histopathologic appearance and clinical course of dogs with vascular tumors that exhibit features of CHE are unknown. Here, we report a case of pleomorphic LAS with features of CHE arising in a dog and treated with surgery and adjuvant chemotherapy.Case presentation: A 10-year-old intact male Labrador retriever presented with an approximately 6-cm-diameter cutaneous mass caudal to the left elbow that was progressively growing over 1.5 years. On physical examination, palpable extensions were identified coursing proximally over the triceps with concurrent loco-regional peripheral lymphadenopathy. Fine needle aspirates (FNA) and cytologic assessment of the cutaneous mass, left prescapular, and accessory axillary lymph nodes reported that this appeared to be a metastatic epithelial neoplasm, although a mixed carcinoma or collision tumor could not be excluded. An incisional biopsy of the mass was submitted for histopathology and was consistent with a well-differentiated angiosarcoma with features of CHE. The neoplasm expressed vimentin, CD31, von Willebrand factor (vWf), and PROX-1, supporting the diagnosis of LAS. Complete staging was performed, and no additional metastatic lesions were identified. Left forelimb amputation and lymph node removal were performed. Based on the diagnosis of metastatic LAS, doxorubicin chemotherapy was administered. 7 months post-amputation, the tumor recurred at the amputation site without evidence of metastatic disease.Conclusion: This report describes a malignant, locally aggressive lymphatic origin vascular tumor in a dog, with features consistent with descriptions of CHE in humans. Cytologic features in this case were discordant with its true mesenchymal etiology, obfuscating diagnosis. The morphologic features of the mesenchymal neoplastic population and immunohistochemistry (IHC) labeling ultimately supported a diagnosis of pleomorphic LAS with features of CHE. Angiosarcomas comprise a diverse group of tumors arising from either vascular or lymphatic endothelium. Lymphangiosarcoma (LAS) is a rare, locally aggressive tumor in the dog originating from the endothelium of lymphatic vessels . While LHemangioendothelioma (HE) is a well-described subset of vascular tumors in humans. These malignancies typically demonstrate a wide range of biologic behavior . HEs areWhile this spectrum of vascular neoplasms has been relatively well described in people, HE is rare in dogs. Hemangiosarcoma, however, is a very commonly diagnosed entity in the dog, primarily arising in the spleen, right atrium and auricle, skin and subcutaneous tissues . To dateA 10-year-old, 36.4-kg male intact Labrador retriever presented to The Ohio State University Veterinary Medical Center for evaluation of a slowly growing cutaneous mass. The owners reported a flat, cutaneous mass caudal to the left elbow that slowly increased in thickness and alopecia over a period of 1.5 years prior to evaluation. Prior to presentation, the mass was aspirated by another veterinarian and was diagnosed as a carcinoma based on cytology. Physical examination identified a semi-fixed, 6 cm, raised cutaneous mass . AdditioFNA samples from the elbow mass and left superficial cervical lymph node were collected and submitted for cytologic evaluation. Cytology from the primary elbow lesion was suggestive of a carcinoma with moderate, mixed inflammation, evidence of previous hemorrhage, and reactive fibroplasia, although initial report noted that carcinosarcoma or mixed-type carcinoma could not be excluded. Multiple clusters of epithelial cells frequently containing intracellular, eosinophilic secretory material were found in acinar formations, which was suggestive of a glandular neoplasm . A similOne week following initial presentation, the dog was presented to The Ohio State University Veterinary Medical Center for further staging. The owners reported that the dog did not exhibit any signs of discomfort, lameness, or signs of systemic disease. On physical examination, a firm, flat, mobile, subcutaneous, alopecic, 4.7 × 5.0 cm subcutaneous mass was palpable caudal to the left elbow, with firm subcutaneous extensions coursing proximally over the triceps. The left superficial cervical and axillary lymph nodes were also firm and enlarged on palpation. An abdominal ultrasound did not identify any clinically relevant abnormalities. An ultrasound guided FNA of the left accessory axillary lymph node was performed and submitted for cytologic evaluation. The sample was moderately cellular with moderate numbers of neoplastic cells found in clusters often associated with eosinophilic matrix material and occasionally found individually. Occasional spindle-shaped neoplastic cells were observed . Round tAn incisional wedge biopsy was then performed and submitted for histopathologic evaluation. The initial histologic diagnosis based on H&E staining was a well-differentiated angiosarcoma. Immunohistochemistry was subsequently performed, revealing strong labeling for vimentin  and CD31 . These findings in conjunction with absent labeling for cytokeratin  were supportive of the diagnosis of angiosarcoma. Epithelioid hemangiosarcoma was also discussed as a differential diagnosis based on cellular morphology in some regions of the neoplasm.Following microscopic diagnosis, a computed tomography (CT) scan with contrast  was performed. Other than the mass, its subcutaneous extensions, and the two previously noted metastatic regional lymph nodes, no pulmonary or other lesions concerning metastatic disease were identified. A left forequarter amputation was performed, and the left prescapular and left axillary lymph nodes were extirpated. The forelimb and both lymph nodes were submitted for histopathology. Histologic findings in the primary mass sampled following amputation were similar to that of the previous incisional biopsies of the tumor. Compared with the incisional biopsy, the limb amputation permitted more extensive sampling of the mass, revealing heterogeneity within the neoplasm in terms of both cell morphology and vascular channel formation. In the amputation specimen, the deep dermis contained an unencapsulated, locally invasive, malignant mesenchymal population forming expansile nodules with random intervening bands of collagen, multifocal central tumor necrosis, and reactive mixed inflammation . NeoplasAdditional IHC assessment was performed to further characterize the neoplasm, as well as discriminate between blood vessel and lymphatic endothelial origin . IHC wasIt should be noted that all tissue samples were evaluated by multiple veterinary anatomic pathologists from two separate institutions (OSU and CSU) as well as a human pathologist associated with OSU. A diagnostic consensus of pleomorphic LAS with features of CHE was made based on the histopathologic evaluation and the IHC staining profile.2 IV; doxorubicin hydrochloride, Novaplus) was administered every 3 weeks for a total of five doses. Approximately 2 months after amputation, repeat thoracic radiographs showed no significant abnormalities. Approximately 4.25 months after amputation, repeat staging with thoracic radiographs and an abdominal ultrasound were performed. At this time no recurrence of the initial sarcoma or overt metastatic disease was observed. Approximately 7 months after surgery, a 4 × 0.5 cm firm, tubular, subcutaneous mass was observed over the previous limb amputation site. Fine needle aspirate confirmed the mass was a reoccurrence of the previously diagnosed malignancy of the animal, though repeated thoracic radiographs and abdominal ultrasound did not detect overt metastatic disease.Based on the diagnosis of an angiosarcoma and the presence of loco-regional metastatic disease, adjuvant cytotoxic chemotherapy was recommended and pursued. Doxorubicin  were reported . While tIn conclusion, this report highlights the first reported case of canine LAS exhibiting CHE (features of EH and RH). In contrast to the previous two cases of RH in the dog, disease in the present case was more protracted. Angiosarcoma is a rare tumor type in domestic species; as a result, veterinary medicine currently lacks important understanding of the potential overlap in the clinical, histologic, and immunophenotypic features of the various vascular endothelial neoplasms falling under this categorical diagnosis. For this case, we use features of human vascular tumors to further characterize the neoplasm of interest; however, we are not suggesting that the human vascular neoplasm classification system would be an appropriate classification of dog vascular tumors. We merely are providing more information based on data that are available, which are predominantly human literature, in order to initiate more thorough evaluation and documentation of canine vascular tumors. Further reporting and characterization of veterinary vascular neoplasms is required to create an accurate classification system, which will eventually lead to appropriate implementation of treatment and improved understanding of typical biologic behavior.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.MC wrote the clinical report and drafted the manuscript. JL and RC provided the anatomic pathology case write up, provided photomicrographs of the histopathology and IHC, and edited the manuscript. MW provided the clinical pathology case write up, provided photomicrographs of cytology for the case, and edited the manuscript. GZ and VW performed the surgery for the dog, provided information about the surgery that was performed, and edited the manuscript. WK and LS provided clinical insight and edited the manuscript. 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Myolipoma is a rare benign lipomatous soft tissue neoplasm, occurring most frequently in adults in the abdomen, pelvis or retroperitoneum. We presented a case of a 39‐year‐old female with an epipleural lesion at the left paraspinal region identified using computed tomography. Magnetic resonance imaging revealed a fat‐containing lesion attached to the pleura over the left paraspinal region. Surgical resection was performed, and histopathological analysis revealed a tumour composed of interlacing bundles of neoplastic smooth muscle cells with low cellularity and rare mitotic figures intermixing with mature adipocytes. The presence of oestrogen and progesterone receptors in smooth muscle cells was noted. The mass was reported as myolipoma. To the best of our knowledge, this case is the first description of an intrathoracic myolipoma. Myolipoma should be considered as one of the differential diagnosis in intrathoracic tumour, with its benign clinical course with simple surgical excision. The presence of oestrogen and progesterone receptor in myolipoma was noted in our case, which was also noted in some of the reported myolipoma cases. Symptoms disclosed after pregnancy suggested the promotion of tumour growth by oestrogen and progesterone. Myolipoma is an extremely rare benign soft tissue tumour composed of a mixed proliferation of adipose and smooth muscle tissues. It presents as a large, painless and palpable mass in most patients. The tumour is benign with no reported cases of recurrence nor metastasis after surgical resection. Most cases of this tumour have been reported in the retroperitoneum, pelvis and abdomen. There are fewer reports of the tumour in the round ligament, spinal cord, eyelid, subcutaneous tissue and pericardium. We present the first case of an intrathoracic myolipoma described in literature.We present a case of a 39‐year‐old female who reported left upper back soreness over the past 6 years (since her first pregnancy). A chest x‐ray revealed a faint bulging mass over the posterior mediastinum, left paraspinal region, which was not found in an x‐ray taken 4 years previously. Computed tomography (CT) disclosed an epipleural, heterogeneous, contrast‐enhancing,, fat‐containing lesion at the left paraspinal region. Magnetic resonance imaging (MRI) showed an oval, fat‐containing, contrast‐enhancing mass in the left paraspinal region attached to the pleura Figure . ThoracoMyolipoma, a rare benign tumour that was first described by Meis and Enzinger in 1991, was mostly reported in the retroperitoneum, pelvis and abdomen.Myolipoma has been described as a completely or partially encapsulated mass. The presence of a stalk supporting the tumour was noted in the current case, but has been rarely mentioned in other published cases. Histologically, it consisted of mature adipocytes and well‐differentiated smooth muscle. Differential diagnosis includes lipoleiomyosarcoma, well‐differentiated liposarcoma, dedifferentiated liposarcoma, spindle cell lipoma, mammary‐type myofibroblastoma and fat‐forming solitary fibrous tumour. In the present case, the immunohistochemical stains were positive for SMA, HHF‐35, desmin and h‐caldesmon, and negative for melanoma markers (HMB45 and Melan‐A), MDM2, CDK4, CD34 and Sat6. Differential diagnosis of myolipoma using immunohistochemical staining to distinguish other neoplasms is summarized in Table Consistent with the current case, the presence of both oestrogen and progesterone receptors was reported in myolipomas of the broad ligament and pericardium. Symptoms were first disclosed following the patient's first pregnancy. Rapid tumour growth occurred in the past 4 years, in which a second pregnancy occurred. It has been suggested that the growth of the myolipoma could be affected by pregnancy‐related hormonesMyolipoma presents with a benign clinical course, with surgical excision as a curative treatment. To date, there have been no reports of recurrence, metastasis or malignancy. In summary, myolipoma should be considered as a differential diagnosis of fat‐containing intrathoracic masses in order to make an accurate diagnosis. Specific pathological and immunohistochemical characteristics of the tumour, including a positive stain for SMA, desmin and/or HMGA2, as well as a negative stain for HMB‐45 and MDM2, are helpful in the diagnosis of myolipoma.None declared.The authors declare that appropriate written informed consent was obtained for publication of this case report and accompanying images.


Anorectal malformations (ARMs) are one of the more common congenital anomalies encountered in pediatric surgery where the majority are diagnosed in the early neonatal period. The etiology of ARM remains uncertain and is likely to be multifactorial. A majority of ARMs result from abnormal development of the urorectal septum in early fetal life. There can be a broad range of presentation features varying from low anomalies with perineal fistula to high anomalies mandating intricate management. To develop a standardized system for comparison in follow-up studies, the Krickenbeck classification was introduced according to the type of fistula. According to the Krickenbeck classification of ARM, those with a rectoperineal fistula are classified as low-type ARM and are usually managed with a perineal anoplasty without colostomy. In this case series, we describe two rare cases of distinct high and intermediate ARM with rectoperineal fistulas, which were thought to be low-type ARM but were subsequently found to have urethral involvement. Our cases consisted of high and intermediate ARMs, which were successfully treated with posterior sagittal anorectoplasty as described. These cases exemplified rare variants of ARM where rectoperineal fistulas can be associated with high-type anomalies. Rare-variant ARM with rectopenile or rectoscrotal fistula can be associated with high-type anomalies in contrast to classical rectoperineal fistulas. A high index of suspicion should remain in cases with previous urinary tract infection despite normal imaging. Careful planning is also needed with consideration of possible need for urethral repair during anoplasty, which was needed in both our cases. Anorectal malformations (ARMs) are among the more commonly seen congenital defects seen in pediatric urological surgery having an incidence from 1 in 2,000–5,000 live births . There cWritten informed consent was obtained from minor's legal guardian for the publication of any potentially identifiable images or data included in this article.The first case is a 4-months-old male infant with known ARM  who undeThe second case is a full-term male infant who was antenatally well with no oligohydramnios or polyhydramnios. He was delivered via normal vaginal delivery. There was no passage of mucous or meconium per urethra at birth. At birth, he was diagnosed with an ARM with rectoperineal fistula opening at scrotal raphe with bifid scrotum appearance. Abdomen x-ray showed rectal gas below the pubococcygeal line consistent with a low imperforate anus. Ultrasound of the kidney, ureters, bladder, and perineum showed a dilated pelvicalyceal system . Distal ARMs have been reported from 1 in 2,000 to 5,000 live births, with an inclination toward males . In maleThe type of ARM is essential for classification and guides the recommended treatment plan. The initial classification of ARM was based on the position of the rectum in comparison to the levator ani or pelvic floor. Wingspread classification was established according to the level of the arrest of rectal descent and patient's gender . HoweverThere are only a few case reports of ARM with perineal fistula of the rare high-type variant –10. For The management of ARM has evolved from classical procedures to PSARP and even minimal invasive approaches with laparoscopic abdominoperineal rectoplasty techniques . TogetheARMs are uncommon but complex congenital anomalies that require an individualized treatment strategy. These treatment strategies are unique to each patient and essential to improve functional outcomes. Rare-variant ARM with rectopenile or rectoscrotal fistula can be associated with high-type anomalies in contrary to classical rectoperineal fistula. These rare anomalies should be highlighted when a fistula is seen in the perineum, and a diverting colostomy is recommended as the initial surgical procedure prior to definitive operation. Atypical presentations may not necessarily follow conventional treatment approaches, and a high index of suspicion should remain in cases with previous urinary tract infection despite normal imaging. Careful planning is also needed with consideration of a possible need for urethral repair during anoplasty, which was needed in both our cases.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from minor's legal guardian for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Angiofibromas represent <1% of all head and neck tumors and occur primarily in the nasopharynx. Extra-nasopharyngeal angiofibromas are rarer. Remarkably, only a case of external auditory canal location has been reported. We present a case of an angiofibroma in this unique location in a female who presented with fullness of right ear and hypoacusis for 6 months. The clinical examination found a mass in the right external auditory canal attached to the posterosuperior wall. Preoperative audiometry revealed average right conductive hearing loss of 37.5 dB. A computed tomography scan revealed a mass on the right external auditory canal. Surgical resection of the mass was performed and the histopathological assessment confirmed the diagnosis. Post-operative audiometry showed an improvement in hearing function. There was no recurrence after 5 years. The prognosis of these tumors is good after total bloc resection. Angiofibromas account for <1% of all head and neck tumors and occur primarily in the nasopharynx (PNA) and mainly affect adolescent males . Extra-nOur patient was a 40-year-old female, with unremarkable disease history, who presented with a fullness of the right ear for 6 months which was associated with progressive hypoacusis and intermittent ipsilateral tinnitus. The clinical examination showed a mass in the right external auditory canal, attached to the posterosuperior wall, which was smooth, pink, firm, mobile, well limited and hemorrhagic on contact . Weber aA surgical resection of the mass was performed via a retro-auricular incision. The mass was resected with the eardrum being intact . HistoloAngiofibromas are benign fibrovascular tumors with thin-walled and irregularly shaped vessels embedded in a fibrous or cartilaginous stroma containing many spindle-shaped or stellate cells . There aet al. [Despite being histologically similar, there are remarkable differences between PNA and ENPA, which support their classification as clinically distinct entities . For PNAet al. . Howeveret al. , 11. Conet al. , 13. Otaet al. . ClinicaAngiofibromas are very rare in the head and neck regions. Their location in the external auditory canal remains even rarer. The definitive diagnosis requires a histological assessment of the surgical specimen after total excision. Being benign, these tumors are of good prognosis. Biopsy without a prior imaging is strongly contra-indicated due to the risk of bleeding.


Endometriosis of the small bowel is a rare clinical event. The clinical condition presents with vague abdominal symptoms and is usually not diagnosed acutely, unless clinicians have a high index of suspicion. Most patients are diagnosed after multiple clinical encounters. We present a case of endometriosis causing small bowel obstruction diagnosed postsurgically. Endometriosis is defined as the presence of normal endometrial tissue located outside of the endometrial cavity and myometrium , 2. It iA 41-year-old female presented to the emergency department (ED) with a chief complaint of abdominal pain. The patient reported having chronic abdominal pain for more than two months with worsening pain in her right lower abdomen. On physical examination, pertinent laboratory studies, and radiological studies, a clinical diagnosis of small bowel obstruction was determined by the ED physician. The salient radiological studies, abdominal X-ray and Computed Tomography (CT) scan of her abdomen and pelvis, showed short segments of small bowel wall thickening and dilated loops of bowel, which were consistent with a clinical diagnosis of small bowel obstruction Figures . A surgiThe patient's chart was reviewed postsurgically, and it was revealed that she first presented to the ED with left lower abdominal pain six years prior to admission. During that visit, the patient reported dysuria and menorrhagia. At that same visit, an ultrasound study revealed a small mildly complex right ovarian cyst measuring 3.6 × 2.2 centimeters. The patient was treated conservatively and discharged home. Subsequent to this first ED visit, the patient presented multiple times to the ED with similar complaints of abdominal pain and continued to be treated conservatively with pain medications.The specimen consisted of a 23-centimeter length of small bowel varying in external diameter from 4 to 6 centimeters. The bowel mucosa was erythematous with focal areas showing edema. The bowel wall showed multiple loops of adherent serosa and multifocal areas of thickened muscularis externa, with a maximal thickness of 2.2 centimeters. The appendix was also submitted to our laboratory as a separate specimen. The appendix was grossly unremarkable.Histologic Hematoxylin and Eosin (H&E) sections of the small intestine demonstrated multiple areas of endometrial tissue within the muscularis externa Figures  and 4. TMultiple authors have proposed multiple theories on the etiology and pathogenesis of endometriosis. These theories comprise the following: (1) the regurgitation theory of retrograde menstrual blood flow; 2) the metastatic theory in which endometrial tissues spread via blood or lymphatic channels; (3) the metaplastic development theory in which coelomic epithelium transforms into endometrial tissue; and 4) the most recent stem cell theory in which bone marrow stem cells differentiate into endometrial tissue at ectopic anatomical sites [ the meta the mostFrom infertility issues to unmanageable pain, endo.metriosis causes untold morbidity, including economic and social distress, for women and their families –9. That


Metastatic lesions to the appendix are rare. They usually present with acute appendicitis or remain asymptomatic and are diagnosed incidentally. Metastases to the appendix have been reported from a number of primary tumor sites including ovary, colon, gastric and lung. We report a laparoscopic appendectomy for a metachronous metastatic lesion to the appendix from the uterine cervix.A 68-year-old woman, who underwent radical hysterectomy for cervical cancer 16 years previously, presented with nausea and gradually worsening right lower quadrant abdominal pain. Abdominal computed tomography scan showed an enlarged appendix and periappendiceal fat stranding. She was diagnosed with appendicitis and underwent laparoscopic appendectomy. Pathological findings showed adenocarcinoma in the submucosa and muscularis propria. Gastrointestinal endoscopy and positron emission tomography with computed tomography (PET–CT) did not show other lesions. Immunohistochemical analysis showed cytokeratin 7 (CK7) positive, cytokeratin 20 (CK20) negative, estrogen receptor (ER) 70–80% and progesterone receptor (PgR) 40–50%. The ER and PgR expression was similar to the cervical lesion 16 years previously, and the diagnosis was a metastatic lesion to the appendix from the uterine cervix.Metastasis to the appendix from cancer of the uterine cervix is a rare lesion. Metastatic lesions to the appendix are extremely rare, and usually present with symptoms of acute appendicitis or remain asymptomatic and are diagnosed incidentally . PreviouA 68-year-old woman who underwent radical hysterectomy and adjuvant radiation therapy total 50 Gy) for adenocarcinoma of the uterine cervix ) 16 years previously, presented with nausea and gradually worsening right lower quadrant abdominal pain. Physical examination showed a blood pressure of 174/112 mmHg, heart rate of 76 beats/min, respiratory rate of 20 breaths/min, and normal temperature. Abdominal examination showed rebound tenderness in the right lower quadrant, consistent with localized peritonitis. Laboratory tests showed an elevated white blood cell count was 8600/μl. Abdominal computed tomography scan showed an enlarged appendix and periappendiceal fat stranding Fig. . Gastroi0 Gy for Appendiceal tumors are very rare and metastatic lesions to the appendix are extremely uncommon. Metastases or direct invasion by a separate primary malignancy account for 77.2% of all pathologically confirmed appendiceal malignancies . A metasTumors of the appendix that are not obviously of appendiceal origin should prompt a search for other primary tumors. It is important to review the complete history, gastrointestinal endoscopy, gynecologic examination and PET–CT, because the most commonly reported lesions are from ovary, colon stomach and lung , 3. In tThe majority of cervical cancer recurrences are found within 2 years of the original diagnosis . The mosMost patients with metastases from cervical cancer are not curable by resection, but some have disease that is isolated to the lymph nodes or a limited area and are candidates for surgical resection. Complete resection of a metastatic appendiceal tumor without other metastases has no influence on the prognosis .


The stump appendicitis is a rare complication with incidence of 1 in 50,000 appendectomy cases.Patient with a history of emergency open appendectomy one year back presented with symptoms as that of acute appendicitis like pain abdomen localized in right iliac fossa, nausea, vomiting and anorexia. Complete blood count showed leukocytosis.Aside from classical clinical symptoms similar to acute appendicitis other causes of acute abdominal pain were ruled out with clinical laboratory and radiological investigations. This creates a dilemma and delay in diagnosis if investigations are not done promptly.Due to prior surgical history of appendectomy and low index of suspicion, the diagnosis of stump appendicitis is often delayed which may result in serious complications like stump gangrene, perforation and peritonitis. •Stump appendicitis is one of the rare complications of appendectomy.•Stump appendicitis can occur mainly in patients who have undergone either laparoscopic or open appendectomy and may pose a serious diagnostic dilemma.•Surgical resection (appendectomy) either open or laparoscopic is the most appropriate treatment in these cases.•The interval between the initial appendectomy and the new presentation can range from 4 days to 50 years. The stu2We reported this case following the updated consensus-based Surgical Case Report (SCARE) guidelines .3A 28-year-old male presented to the Emergency Room with complaints of right lower abdominal pain for 12 hours, which was insidious in onset, continuous, non-radiating, dull aching type with no exacerbating and relieving factors. It was associated with nausea and anorexia as well. His past surgical history included open appendectomy for acute appendicitis one year back with an uneventful postoperative period. No current medication use, family history was insignificant and the patient is a non-smoker. The patient was afebrile and the vitals were within normal limits. Abdominal examination showed scar of previous gridiron incision. There was tenderness and rebound tenderness in the right iliac fossa. Mild guarding was present with no other peritoneal signs.The routine laboratory tests were unremarkable except for leukocytosis of 14,500 cells per cubic mm with neutrophilic predominance (90%). Transabdominal ultrasonography showed evidence of fluid collection in the right paracolic gutter with no other abnormalities. However, Contrast Enhanced Computerized Tomography (CECT) of abdomen and pelvis revealed a small structure at the base of caecum with enhancing walls along with stranded surrounding fat, suggestive of inflamed appendiceal stump. This confirmed the diagnosis of stump appendicitis The patient was immediately shifted to the operation room. A consultant general surgeon with prior experience performed the surgery. Abdomen was opened via gridiron incision. The paracolic gutter was packed with purulent fluid. The caecum and ascending colon were mobilized, and taenia coli were traced up to the base of the appendiceal stump. There was evidence of perforated abscess at the site of the stump. The purulent fluid . was draThe peritoneal cavity was thoroughly washed with normal saline. The tissue sample was sent for histopathological examination Following surgery, the patient was transferred to post-operative room. He was put on parenteral antibiotics and analgesics. He did well during the postoperative period, and was discharged on day five. On follow up after two weeks, the patient was stable and healthy.4Stump appendicitis is a well-recognized entity  though iThe age of patients presenting with stump appendicitis ranges from 8 to 80 years and male to female ratio is 1.1:1 . It may A review of 61 cases by A. Subramanian and M.K. Lang showed mean stump length of 3.3 cm and appendiceal stumps of less than 0.5 cm are unlikely to result in future stump appendicitis . Mangi a10.13039/100004811CT scan aid in the diagnosis of Stump Appendix [High index of clinical suspicion supported by investigations such as abdominal ultrasound scan or Appendix . CT scanAppendix . DiagnosAppendix .The completion appendectomy is the treatment of choice for stump appendicitis, most commonly done as an open operation (72%)  but a su5Stump appendicitis can represent a diagnostic dilemma if the treating physician is unfamiliar with this uncommon clinical entity. The timely use of CT scan allows the prompt diagnosis in cases with perforated sump appendicitis. Completion appendectomy either open or laparoscopic method is the definitive modality of treatment.The primary takeaway lesson from this case report is that the treating physician/surgeon should have a high index of suspicion for this rare entity while dealing with a patient having abdominal pain and a past surgical history of appendectomy, in order to establish a timely diagnosis and avoid potential complications that might follow.The case report is exempt from ethical approval in our institution.This research did not receive any specific grant or funding from funding agencies in the public, commercial, or not-for-profit sectors.Sunil Basukala (SB) = Conceptualization, Supervision.Sunil Basukala (SB), Bishnu deep Pathak (BDP), Soumya Pahari (SP) = Writing - original draft.Sunil Basukala (SB), Bikash Bahadur Rayamajhi (BBR), Bikram Basukala (BB), Suman Gurung (SG) = Writing - review & editing.All the authors read and approved the final manuscript.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.Not applicable.Sunil Basukala (SB).Not commissioned, externally peer-reviewed.All authors declare that they have no conflict of interest.


Adrenal incidentalomas are often found during investigation for another tumor or unrelated problems. Except for adrenal myelolipoma , adrenal lipomatous tumors are uncommon generally and are often described as case reports in the literature. Since the amount of fat is variable, without the help of advanced imaging techniques, some adrenal lipomatous tumors may be misdiagnosed before pathologic examination. Herein, we report a case of adrenal adenoma with myelolipomatous metaplasia that was excised as a periceliac mass in the setting of recurrent pancreatic cyst.A 45-year-old Iranian woman with hypertension and end-stage renal disease presented with recurrence of a pancreatic cyst (previous pathologic report was mucinous cyst adenoma). During exploratory laparotomy, the mentioned pancreatic cyst was tightly attached to the stomach and jejunum. There was also a periceliac round rubbery lesion (firstly diagnosed by endoscopic ultrasound) that was excised for ruling out malignancy. Histologic examination of the periceliac mass was found to be adrenocortical adenoma with foci of myelolipomatous metaplasia. The pancreatic cyst histology was just a pseudocyst.Our case highlights the significance of complete evaluation of incidental findings before surgical intervention, even in the setting of another primary tumor. Myelolipoma and myelolipomatous change (metaplasia) are two different entities. Although very similar as to pathogenesis, there are still some differences. Adrenal incidentalomas are often found during investigation for another tumor or unrelated problems. In general, most adrenal incidentalomas (70–80%) are benign adenomas that cause no symptoms. Differential diagnosis consists of pheochromocytoma, adrenocortical carcinoma, lymphoma, and metastases from various malignancies. Adrenal lipomatous tumors  should also be included –5. SinceA 45-year-old Iranian woman was transferred to our center to be evaluated for abdominal pain and recurrence of a pancreatic cyst. One year ago, she underwent central pancreatectomy and cholecystectomy at another center because of incidental finding of a large pancreatic cyst, and the pathologic report was benign mucinous cyst adenoma. Then, she presented with upper abdominal pain, mildly elevated carcinoembryonic antigen (CEA) level, and recurrence of pancreatic cyst, which were found on follow-up. She was a case of hypertension (HTN) and end-stage renal disease (ESRD) for 5 years due to idiopathic nephrotic syndrome, and she was taking prednisolone, metoral, and amlodipine. She was dialyzed twice a week. She was a married housekeeper lady, G2P2A0L2, without any history of smoking or alcohol consumption. She had normal menstruation, and there was not any history of abdominal cramp, polyuria, polydipsia, polyphagia, and recent weight gain. The patient’s psychologic and family history was not significant. On physical examination, blood pressure was 130/80 mmHg with normal pulse rate and temperature, 76 beats per minute and 37.1 °C, respectively. Her body mass index (BMI) was 24.5. Chest examination was unremarkable, and the abdomen was soft with no organomegaly. She had normal face and body fat distribution without any hirsutism or pink stretch mark on the abdomen and trunk. There was no significant problem on neurologic examination.3/µl, hemoglobin: 13.2 g/dl, and platelet count: 224 × 103/µl] were within normal ranges. Liver enzymes including aspartate aminotransferase (AST), aspartate aminotransferase (ALT), and alkaline phosphatase (ALP) were 23(3–40), 21(3–40), and 146(80–306) IU/L respectively. Abdominal sonography showed a large cystic lesion in the body and tail of the pancreas. In addition to pancreatic cyst (measuring 10 × 8 × 4 cm), endoscopic ultrasound discovered a 2 × 2 × 2 cm solid mass at the left periceliac area. Exploratory laparotomy revealed the mentioned pancreatic cyst with tight attachment to the posterior wall of the stomach and jejunum and the periceliac lesion with suspicious attachment to the left kidney. For ruling out malignancy, the specimens of distal pancreatectomy, splenectomy, and periceliac lesion excision were sent for pathologic evaluation. Gross sectioning of the pancreas showed a hemorrhagic cyst with 1 cm maximum wall thickness. The periceliac lesion was a round creamy yellow solid firm mass with heterogeneous cut surface.The patient had high blood urea nitrogen (BUN) and creatinine, 27 (6–20) mg/dl and 4.2 (0.6–1.3) mg/dl , respectively. Serum fasting blood sugar (96 mg/dl) and complete blood count (CBC) [white blood cell (WBC): 10.8 × 10On microscopy, sections of the periceliac mass showed an adrenocortical adenoma (ACA) with multifocal areas of adipose tissue admixed with bone marrow elements (including megakaryocytes), features in keeping with ACA (approved by immunohistochemistry) with myelolipomatous change, instead of malignancy Figures , 2. The Our patient was a middle-age woman with multiple chronic diseases (ESRD and HTN), recurrent cyst of the pancreas, and a new periceliac mass, which was incidentally found by endoscopic ultrasound during post-partial pancreatectomy follow-up. Since the previous pathology report of the pancreas was consistent with mucinous neoplasm and regarding the malignant potential of mucinous cystic lesions, it was considered as a suspicious malignant lesion. Fortunately, on pathologic examination, the periceliac mass was an adrenal gland showing ACA associated with myelolipomatous metaplasia. During the 10-month follow-up visits, no related symptom or abnormal radiologic findings were noted.Adrenal incidentalomas are clinically silent adrenal masses that are found during the investigation of unrelated problems. Myelolipoma is a lipomatous tumor, which is the second most common primary adrenal incidentaloma following ACAs, accounting for about 3% of the incidentalomas , 7. GeneAdrenal myelolipoma was first described by Arnold as “adrenal lipoma” in 1866, but it was Gierke in 1905 who described the myeloid component. The term “myelolipoma” was coined by Oberling in 1929. Most of the early studies described it as an incidental autopsy finding or as occasional case reports. Despite its benign behavior, adrenal myelolipoma is clinically relevant as it might cause significant difficulties in differential diagnosis of other adrenal tumors . MyeloliIn terms of pathogenesis, it seems that chronic adrenal stimulation, such as necrosis or inflammation due to cancer, Cushing’s disease, HTN, diabetes, obesity, and stressful lifestyle could lead to metaplasia of the reticuloendothelial cells, which could lead to the development of adrenal myelolipomas. This hypothesis is supported by the increased incidence of the lesion in the advanced years of life. Another hypothesis claims that adipocytes develop from the mesenchymal stem cells in the endothelium; this results in inflammation causing the adrenal cortex to secrete mediators responsible for the recruitment of hematopoietic progenitors. The myelolipomatous metaplasia also occurs in response to stress related to stimuli such as necrosis, infection, stress, or trauma , 12–15. Generally, there are no specific laboratory tests that would be diagnostic of adrenal myelolipoma, and in contrast to ACA, which could be functional or nonfunctional, most myelolipomas are silent. The National Institute of Health Consensus Panel on adrenal incidentaloma (2002) concluded that adrenal myelolipoma could be regarded as an exception to the mandatory metabolic work-up of a newly discovered adrenal mass –10. It aUltrasound is usually inadequate for the diagnosis of myelolipoma. On CT and MRI, the diagnosis of myelolipoma can be confidently made when an adrenal mass is composed of at least 50% fat. In larger masses with lesser amounts of fat, lipomatous or myelolipomatous degeneration of other adrenal tumors should be considered. On the other hand, the typical imaging features of adenoma in CT and MRI include small size, homogeneous and well-circumscribed, presence of intracellular lipid, and low-to-intermediate signal intensity on T2-weighted images. When ACAs show atypical features , the possibility of an adrenal collision tumor or secondary degenerative changes should be considered , 18.On pathologic examination, it is easier to distinguish myelolipoma from an adrenocortical tumor with myelolipomatous metaplasia. In fact, myelolipoma is a well-demarcated combination of fat and myeloid tissue, while myelolipomatous metaplasia is usually present as scattered ill-defined foci of fat and myeloid tissue within another tumor.In management of adrenal incidentalomas, European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors recommend determining if an adrenal mass is benign or malignant at the time of initial detection, which is just possible through CT scan and MRI study. Patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies do not need surgical intervention, whereas adrenalectomy has been suggested in patients with unilateral adrenal masses with radiological findings suspicious of malignancy (heterogeneous features and size > 4 cm) .Until now, a few adrenocortical tumors showing myelolipomatous metaplasia with full separated demographic and pathologic data have been reported Table .Table 1DAlthough myelolipoma and myelolipomatous metaplastic change are very similar in pathogenesis, there are still some fine differences that help us make a more accurate diagnosis. Table Among 20 cases of myelolipomatous metaplasia that we reviewed, the primary adrenal pathology in 13 cases (65%) was ACA . Sixteen cases (80%) were female, and just four cases (20%) were male. This sex pattern could be justified by female predominance of ACA. The mean age was a little lower in myelolipomatous metaplasia, and the dominant side was left in contrast to myelolipoma (most cases are right sided). Common chronic diseases were HTN and DM in both groups. Myelolipoma is usually a well-defined mass with fat component that is easily seen grossly, while myelolipomatous metaplasia is an ill-defined microscopic finding. In addition to adrenocortical hyperplasia, adrenocortical carcinoma, adrenocortical neoplasm of uncertain malignant potential, and oncocytoma, some metaplastic changes were accompanied with vascular lesions such as endothelial cyst (two cases), cavernous hemangioma, and epithelioid angiosarcoma.Adrenal tumors with myelolipomatous change may show heterogeneous appearance and could mimic malignancy even using advanced radiologic studies. Although in our case no further radiologic evaluation was done, regarding the recurrence of pancreatic cyst, the histology of the primary cyst, and also surgery protocols in approach to suspicious adrenal incidentalomas, finally there was no change in the patient treatment, but it is very important to consider incidentalomas before operation to reduce surgical complications and it should be in the differential diagnosis when we deal with multiple tumors.In a patient with a primary tumor, considering any new mass as malignancy should be avoided. Our case highlights the significance of complete evaluation of incidental findings by laboratory tests and radiologic studies before surgical intervention, even in the setting of another primary tumor. Based on observations in this case report and to the best of our knowledge, myelolipoma and myelolipomatous change (metaplasia) are two different entities. Although very similar considering pathogenesis, there are still some differences. In terms of epidemiologic and pathologic features, it appears that myelolipomatous metaplasia follows the primary adrenal tumor more than myelolipoma.