Background: Medulloblastoma of the posterior fossa is commonly encountered in pediatric populations but rarely reported in adults. Adult cases of medulloblastoma typically occur in younger patients, tend to arise intra-axially within the cerebellar hemisphere, and usually exhibit classic histopathologic features.Case Report: A 54-year-old male presented with headaches, dizziness, gait instability, and frequent falls that had worsened during the prior 3 months. Imaging and histopathologic analysis revealed extra-axial, dural-based posterior fossa medulloblastoma with desmoplastic/nodular histopathology, mimicking a petrous meningioma. The mass occupied the left cerebellopontine angle. The patient underwent microsurgical gross total resection of the tumor followed by proton beam radiation therapy and was disease-free at 1-year follow-up.Conclusion: Few dural-based posterior fossa medulloblastomas resembling petrous meningiomas have been reported, and to our knowledge, this is the first description of a case to be treated successfully with proton beam therapy in an older adult. Although rare, medulloblastoma can occur extra-axially in the cerebellopontine angle of older adults, potentially mimicking a petrous meningioma. This rare possibility should always be kept in mind, especially if expectant, nonsurgical management is being considered. To optimize outcome, posterior fossa medulloblastoma should be treated with aggressive microsurgical resection followed by radiation therapy. When available, proton beam therapy should be considered. The patient had baseline left hemiparesis secondary to an ischemic stroke 4 years prior. Physical examination revealed new left-sided horizontal nystagmus, bilateral dysmetria, and unsteady gait. Head computed tomography and brain magnetic resonance imaging (MRI) revealed a large, extra-axial, dural-based, heterogenous mass with intrinsic cystic foci, occupying the left cerebellopontine angle with surrounding perilesional vasogenic edema and mass effect on the adjacent fourth ventricle . The imaOther differential diagnoses included vestibular schwannomas and the less commonly encountered epidermoid cysts. Given the posterior location of the lesion relative to the vestibulocochlear nerve, the diagnosis of vestibular schwannoma was less likely. In this setting, the diagnosis of petrous meningioma was considered more likely, especially given the appearance of dural attachment to the lesion.The patient underwent a left lateral suboccipital crani-otomy and microsurgical gross total resection of the lesion via a retrosigmoid approach. The tumor had a well-defined capsule with a broad base of insertion on the petrous dura, including a multitude of dural arterial feeders that were consecutively bipolar coagulated and divided. A few smaller pial arterial feeders, arising from the adjacent cerebellar hemisphere, were also identified and were disconnected in similar fashion. Overall, the tumor appeared to be predominantly extra-axial, with a clear dissection plane separating it from the pial surface of the cerebellum. However, in its most inferomedial portion, the dissection plane was less distinct, as the lesion appeared to infiltrate the adjacent cerebellar parenchyma.Pathologic examination revealed an infiltrating, high-grade neoplasm with sheets of primitive, small, round, and blue tumor cells; prominent nuclear molding; scant cytoplasm; high mitotic activity; and focal nodule formation . ImmunohThe patient had a favorable, uneventful postoperative course. His neurologic symptoms resolved, and his gait notably improved. He was discharged to a rehabilitation facility on postoperative day 9.Given the pathologic findings, a postoperative MRI of the entire craniospinal axis was performed and was negative for metastases. Nonetheless, prophylactic craniospinal radiation therapy was indicated and administered using proton beam therapy for a 3-month treatment course. Treatment consisted of 36 Gy in 18 fractions to the entire brain and spinal canal, followed by additional radiation to the surgical bed in the posterior fossa, totaling 20 Gy in 10 fractions. The total dose to the surgical bed was 56 Gy in 28 fractions.At 1-year follow-up, the patient was completely asymptomatic and, aside from his known baseline left hemiparesis, his neurologic examination was unremarkable. Repeat MRI showed no evidence of tumor regrowth or recurrence . To our 5 The summary of reported cases in older adults presented in the 13 Generally, these tumors exhibit classic histopathology and do not involve the dura but rather arise intra-axially within the cerebellar hemisphere.12 In contrast, our patient had an extra-axial, dural-based lesion with desmoplastic/nodular histopathologic features. In the setting of malignancy, desmoplastic reaction is thought to represent a local response to tumor cells, resulting in increased collagen deposition and fibrosis. However, dural-based medulloblastomas tend to differ in that respect. In these tumors, desmoplastic reaction has been shown to involve dense reticulin deposition among tumor cells within the tumor rather than an external response to surrounding cells.14 Unlike metastases, melanocytic tumors, or glioblastomas, medulloblastomas are not classic meningioma mimickers.15 Favorable features of medulloblastoma  include residual tumor <1.5 cm2, negative spine MRI and cerebrospinal fluid cytology, classic or desmoplastic histology, and location within the brain that allows for uncomplicated gross total resection.16 High-risk features include bulky residual disease, evidence of leptomeningeal dissemination or distant metastasis, and large cell/anaplastic histology.13While generally rare in adults, posterior fossa medulloblastomas have been reported primarily in patients in their 20s or 30s rather than those in their sixth decade of life, as in the present case.Given the location of our patient's tumor in the CPA and its involvement of the lateral hemisphere, gross total resection was likely achieved more readily than if the medulloblastoma had been in the cerebellar vermis. The tumor location within the lateral hemisphere was also less likely to have an attachment to the floor of the fourth ventricle, which would complicate resection given the proximity to the brainstem. Thus, the lateral location of the medulloblastoma may have allowed for a more radical gross total resection and contributed to a more favorable prognosis in this patient. The absence of dissemination to the spine was another favorable factor.12 The patients were treated with gross total resection followed by conventional radiotherapy. Compared to conventional radiation, which utilizes megavoltage x-rays, proton therapy delivers less radiation to surrounding normal tissues.17 This precision allows for curative doses of radiation therapy to the target volumes, while reducing the risk of radiation-related toxicity to normal tissues and radiation-induced malignancy resulting from whole-body radiation exposure.18 A 2020 study showed that use of proton beam therapy in adults with brain tumors spanning a variety of histopathologies and locations markedly increased between 2004 and 2015.19 However, few studies have compared conventional radiation therapy to proton beam therapy in the treatment of medulloblastoma. One study of medulloblastoma treatment using proton beam therapy in young adults specifically demonstrated a lower incidence of radiation-induced toxicity compared with conventional radiation, including weight loss, esophagitis, and low white blood cell count.20 However, differences in survival outcomes between patients with medulloblastoma treated with proton therapy and photon therapy have not been comprehensively studied.Our review of the literature revealed few adult patients with medulloblastomas mimicking petrous meningiomas.21 Nonetheless, studies have demonstrated longer survival times for adult patients who were treated with adjuvant chemotherapy for medulloblastoma. However, these studies generally reported outcomes of younger adults with medulloblastoma  compared with our patient who was 54 years.23 Given the rarity of medulloblastoma in older adulthood, the efficacy of adjuvant chemotherapy for this patient group is not well-defined. Treatment of similar tumors with and without adjuvant chemotherapy has been reported with favorable outcomes (13 For our patient, the pros and cons of adjuvant chemotherapy were discussed with a neuro-oncologist, and the decision was made not to proceed with this treatment.In contrast to childhood medulloblastoma for which adjuvant chemotherapy is standard treatment, the role of chemotherapy in the management of medulloblastoma in adults remains controversial. While some studies suggest a survival benefit with postoperative chemotherapy, serious concerns exist regarding the potential toxicity of chemotherapy in adult patients, especially given the lack of randomized controlled trials.outcomes .13 For oAlthough rare, medulloblastoma can occur extra-axially in the CPA of older adults, potentially mimicking a petrous meningioma. This possibility should be kept in mind, especially if expectant, nonsurgical management is being considered. To optimize outcome, posterior fossa medulloblastoma should be treated with aggressive microsurgical resection followed by radiation therapy. When available, proton beam therapy should be considered. The role of chemotherapy in adult posterior fossa medulloblastoma is not well-defined.


Giant intracranial aneurysms (GIA) are rare and manifest primarily through subarachnoid hemorrhage (SAH), cerebral ischemia, or progressive symptoms of mass effect. Transcranial Doppler (TCD) can be used to monitor cerebral vasospasm after treatment of intracranial aneurysm allowing the adjustment of therapeutics and avoiding complications. The authors present a clinical case of a patient with a ruptured intracranial giant aneurysm in which TCD was essential to monitor vasospasm and intracranial hypertension (IH). A 53-year-old male was admitted due to a sudden headache and impaired consciousness, left hemiparesis, and dysarthria. Cerebral CT scan and CT angiography at admission showed a giant aneurysm of the right middle cerebral artery (MCA) with extensive and diffuse intraventricular SAH of Fisher grade IV and Hunt and Hess grade 4. Clipping, placement of an intracranial pressure sensor, and external ventricular drain (EVD) were performed on the same day, with difficulty in preserving the M2 branch and complicated by postoperative extensive right MCA ischemia. On day three of hospitalization, TCD revealed an increased pulsatility index (>1.5) with clinical deterioration leading to re-intervention for a decompressive craniectomy. On day six, a TCD follow-up was performed to monitor blood flow complications, and particularly vasospasm, showing a severe increase in middle blood flow velocity (MBFV) in the right MCA of 205 cm/s and Lindegaard Index > 6. Daily surveillance by TCD was maintained to guide clinical management since the attempt to withdraw the EVD led to clinical deterioration with subsequent worsening of vasospasm. Improvement occurred after surgery as ventriculoperitoneal shunt insertion was performed. TCD had a major role in the clinical orientation of SAH as well as in intracranial pressure management and was decisive to establish long-term treatment. With a poorly defined natural history, giant intracranial aneurysms  comprise a minority of all aneurysms (5% incidence) and approximately 5-10% are present in the pediatric population [Expected history is unfavorable, as depending on its size (diameter ≥ 30 mm), the rupture risk of intracranial aneurysm commonly intensifies. They carry high mortality (80%) and manifest primarily through subarachnoid hemorrhage (SAH). Symptoms range from gradual neurological deficits to catastrophic SAH and certain patients may suffer multifocal cerebral infarcts or transient ischemic attacks caused by dislodged intra-luminal thrombus . In SAH,Transcranial Doppler (TCD) has a major role in the identification and monitoring of vasospasm and intracranial hypertension (IH), therefore, helping in the clinical and therapeutic orientation of SAH. It stands out as the only non-invasive, real-time diagnostic technique that adds hemodynamic information to structural images ,7.A 53-year-old male was admitted to the emergency department due to a sudden headache and impaired consciousness. Neurological examination disclosed meningeal signs, left hemiparesis, and dysarthria. Cerebral CT scan and CT angiography displayed an extensive and diffuse intraventricular SAH of Fisher grade IV and Hunt and Hess grade 4 and a giant right middle cerebral artery (MCA) aneurysm measuring 33 millimeters Figures , 2.Aneurysm clipping and placement of an intracranial pressure sensor and external ventricular drainage (EVD) were performed on the same day. It was impossible to preserve the M2 branch and the procedure was complicated by an extensive right MCA infarct. After the procedure, the patient was admitted to the neurocritical care unit, under invasive mechanical ventilation, and deeply sedated. Vasopressor support with noradrenaline to maintain cerebral perfusion pressure and oral nimodipine were started.On day three of hospitalization, after suspension of sedation, the patient presented clinical deterioration with an altered state of consciousness and hemiplegia. TCD showed an increased pulsatility index (PI) > 1.5 on TCD evaluation  of 205 cm/s and Lindegaard Index > 6 in the right MCA. Daily surveillance was maintained for clinical management since the attempt to withdraw the EVD led to clinical deterioration with subsequent worsening of vasospasm Figure . ImproveIn patients with ruptured intracranial aneurysms associated with subarachnoid hemorrhage, timely diagnosis and treatment of cerebral vasospasm (CVS) could be particularly beneficial in reducing morbidity and mortality ,9. Also,Days after SAH, delayed cerebral ischemia occurs and is part of a post-SAH syndrome. It denotes a treatable cause of morbidity and comprises inflammatory reactions and microthrombosis with arteriolar vasospasm culminating in cortical infarction .For a long time, the most relied exam for the diagnosis of CVS was digital subtraction angiography; however, it is an invasive, relatively expensive, and time-consuming exam and unfeasible to be performed daily .There has been substantial interest in developing noninvasive imaging methods that could detect intracranial aneurysm complications, both in asymptomatic and symptomatic patients. TCD has the advantage compared to digital subtraction angiography of not using ionizing radiation, greater mobility, and lower capital cost; additionally, there are no contraindications and it can be used to monitor cerebral hemodynamics in real time ,14. By uKlimo et al.  suggesteCerebral ultrasound is an emerging point of care instrument for intensivists, with a significant role in the diagnosis of acute intracranial pathology, such as noninvasive intracranial pressure measurement and of cerebrovascular diseases in the acute clinical setting in the neurocritical unit. Managing TCD, traditionally achieved in the neurosonology laboratory setting, has extended over the last years, opening a new window to the evaluation of cerebral anatomy not only in neurocritical patients but also in general intensive care unit patients ,19.PI provides information regarding quantitative alterations in the morphology of the TCD waveform. It is inversely proportional to the mean cerebral perfusion pressure, so, it increases with IH. In our particular case, the patient suffered clinical deterioration and presented an increased PI > 1.5 in TCD, suggesting IH. This information corroborated the need for surgical re-intervention .The spectral waveform derived from TCD is characterized by three components: cerebral flow peak systolic velocity, end-diastolic velocity, and mean flow velocity. However, an increase in velocity alone is not sufficient to reach a vasospasm diagnosis, given that several situations may cause velocities to increase, for example, in cases of stenosis, anemia, hypervolemia, or hyperthermia. Subsequently, the Lindegaard Index was introduced to increase the sensitivity of vasospasm diagnosis . Our casIn this case, daily surveillance with TCD was maintained to guide the clinical and therapeutic management of the patient, since the attempts to withdraw the EVD led to clinical deterioration with subsequent worsening of vasospasm, without compromising PI. This case culminated with ventriculoperitoneal shunt insertion due to chronic hydrocephalus after 18 days. Professional healthcare workers should be aware of the role that TCD may have in the surveillance of vasospasm and therefore prevention of delayed ischemia. The severity of vasospasm may correlate with CSF drainage.TCD was vital for therapeutic decisions. Permitting real-time information and early diagnosis of the patient’s clinical oscillations related to variations in EVD played a key role in the anticipation of complications derived from prolonged vasospasm. These conclusions support recent studies where CSF drainage may relate to the duration and severity of vasospasm.


This case describes the treatment and follow-up of a mandibular molar in an18-year-old female with a periapical cyst. Thus, it becomes important to knowwhich options should we take when faced with a clinical situation that we cannotresolve through conventional methods, and which techniques and approaches wehave to achieve treatment success. This case showed the treatment plan andfollow-up, by the use of CBCT images, from a previously treated mandibular molarwith a large periapical abscess and cystic lesion, in which, the first treatmentplan approach was to make the endodontic retreatment. During thechemo-mechanical preparation the presence of permanent intracanal purulentexudate made it impossible to dry the canals, impeding obturation of the rootcanal system. Due to this clinical situation, a surgical approach was performedwith the intention of reduce this permanent exudate and to execute adecompression technique. Clinical findings, periapical radiographs and cone beamcomputed tomographic, indicated almost complete resolution of the radiolucency,after a one-year follow-up. As these cells grow, thecentral cells become too far from the blood vessels to receive nutrients, becomingnecrotic According to Nair et al. ,,,The diagnosis of cysts is a challenge for the dentist and gathering all the necessaryinformation is essential to make a correct evaluation as well as to achievetreatment success The size of the lesion is one of the aspects that generates more doubts among theclinicians regarding what is the better treatment approach, whether surgical,non-surgical retreatment or even extraction. According to Tian et al. Nevertheless, Strindber et al. ,,The surgical decompression technique implies the creation of a small window in thecystic wall and subsequent placement of a drainage tube. Thus, the epithelial liningof the cystic lumen is confluent with the oral cavity without coalescing, causingdrainage of the cystic content and equivalence between intra and extra cysticpressures The aim of this case report was to describe the management of a mandibular largelesion using a decompression technique.An 18-year-old Caucasian female presented with discomfort on the right posteriorregion of the mandible. After informed consent was obtained, radiographic andtomographic exams were performed and a large periapical radiolucency-surroundingtooth 46 was identified. Nonsurgical root canal treatment had been performed ontooth 46, one year before. Oral examination also revealed a composite restaurationon tooth 46, and a facial edema on its region. Percussion and palpation were withinnormal limits, and no sinus tract or mobility was detected. Periodontal probingdepth was 7 mm in the mesial buccal area of tooth 46, and within normal limits onthe remaining areas.The preoperative periapical radiograph showed periapical radiolucency associated withtooth 46 A. Cone-bDuring the subsequent visit, inferior alveolar nerve block local and buccalinfiltration anesthesia was performed, using 5.4 mL of 4% articaine with 1: 100.000epinephrine . An envelope incision wasperformed to fully visualize the area between tooth 47 and 45, thus avoidingreleasing incisions close to the mental nerve emergence. A small vertical releasingincision was made distally to tooth 47 to allow flap mobility and avoid dehiscenceof the flap elsewhere. Bone perforation was achieved with a small spherical burmounted on a surgical handpiece A.CopiouThe patient returned one week later for post-operatory follow-up without significantcomplaint. The decompression tube remained unobstructed and with soft tissue marginshealing adequately.In the next appointment after surgery, the patient returned for endodonticretreatment of tooth 46. Inferior alveolar nerve block anesthesia was performed with1.8 mL of 4% articaine with 1: 100.000 epinephrine  and single tooth rubber dam isolation was achieved. The rootperforation near the mesiolingual canal was repaired with MTA  A, 3B, 3CIn a subsequent appointment, one week after, negotiation of the canals was performedwith 10K and 15K files, and working length determined and confirmed with anelectronic apex locator , with anirrigation regimen of 5.25% of sodium hypochlorite between each instrument. Duringthe endodontic retreatment, to remove the filling material, the canals were shapedwith ProTaper Next rotary system, until X2, with copious irrigation with 5.25% ofsodium hypochlorite between files, without the use of solvent. Followingpreparation, each root canal was flushed using passive ultrasonic irrigation.Initially, the canals were flooded with 5 mL of 5.25% NaOCl and a 20/.01 ultrasonicinsert  was coupled to an ultrasoundunit  and inserted 2 mm shortfrom the working length and activated for 30 seconds at 30% power. Subsequently, thecanals were flushed with 5 mL of 17% EDTA and activated for 30 seconds, followed bya new activation of 5.25% NaOCl solution for 30 seconds. A final irrigation wasperformed with 5 mL of distilled water Six weeks after the surgery, the tube was naturally expelled. The patient wasrecalled after 12 months A, 4B, 4C,The management of large cystic lesions has been a subject of a continuous prolongeddebate ,,,,,,Since the protocols of decompression are not consensual in the literature, theauthors underline that the comfort for the patient is questionable under the use ofthis technique and needs to be clarified with the patient before starting thetreatment. Tian et al. ,,,,A cyst is a pathological cavity lined with epithelium that contains liquid, gas orother aqueous material in its content ,,,,,,Sometimes a large periradicular lesion may have a direct communication with the rootcanal system  and respond favorably to nonsurgical treatment.Clinical studies have confirmed that simple nonsurgical treatment with properinfection control can promote healing of large lesions. When this treatment is notsuccessful in resolving the periradicular pathosis, additional treatment optionsshould be considered, such as marsupialization or tube decompression ,For Neaverth et al. Tian et al. The potential drawbacks of decompression include the need for long-term follow-up andpatient compliance, regular cavity irrigation, unavailability of biopsies forhistopathological examination, and possible infection of the exposed cavity ,The end of decompression depends on radiographic image and clinical visits. Gunraj,,The main advantages of CBCT imaging are its accessibility, easy handling and that itsoffers a real-size dataset with multiplanar cross-sectional and 3D reconstructionsbased on a single scan with a low radiation dose This case report showed that decompression technique for treatment of periapicalcysts allows a more conservative and easy approach for the clinician, and even ifdecompression fails, the procedure facilitates subsequent micro-apical surgery byreducing lesion size and minimizing potential damage to adjacent anatomicstructures.


The risk of complications associated with SEMS is low in well-selected patients. Stent erosion is a rare but serious adverse event that is associated with high morbidity and mortality. Here, we report the case of a 74-year-old patient with a colonic obstruction secondary to a pelvic mass that was treated with SEMS and radiotherapy, who developed a partial thickness stent erosion and recurrent hematochezia 6 years after placement. Endoscopic retrieval was not technically feasible. During attempted surgical resection, massive hemorrhage occurred from a colonic-arterial fistula to the left external iliac artery resulting in death. While SEMS remain an effective, minimally invasive approach for the management of bowel obstructions, prolonged  Self-expanding metal stents (SEMS) are increasingly utilized for palliative treatment of malignant colonic obstructions and may be used as a bridge to surgery in patients undergoing medical and nutritional optimization . SEMS arormation , 7.in-situ stent lifetime. Whether the risk of stent-related complications is increased by the receipt of abdominopelvic radiation is unknown. Here, we report the case of a 74-year-old patient with a malignant colonic obstruction secondary to a pelvic mass that was treated with SEMS and radiotherapy with a stent in-situ time of 78 months, who developed a colonic-arterial fistula to the left external iliac artery. To our knowledge, this is the first reported case of colonic stent erosion and fistulization leading to hemorrhage and death.Long-term complication rates associated with SEMS are not well-defined. For patients with metastatic colorectal cancer, improved systemic therapy may extend treatment duration and in situ within long a Hartmann’s stump.A 74-year-old woman presented to the emergency department with multiple self-limited episodes of hematochezia. Six years prior to presentation, she had undergone placement of a left colonic WallFlex stent for a large bowel obstruction. Her surgical history included a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. She experienced a recurrence 2 years later involving the bladder, vagina and sigmoid colon for which she had undergone debulking, segmental colectomy with primary anastomosis, chemotherapy and external beam pelvic radiation. Two years later, she developed a high-grade large bowel obstruction secondary to a benign stricture at the colorectal anastomosis. A 12 cm × 25 mm uncovered WallFlex colonic stent provided temporary relief of her obstructive symptoms. One year later she experienced recurrent pain, obstipation and intermittent, self-limited episodes of hematochezia. Colonoscopy revealed ulcerated mucosa within and just proximal to the stent with luminal narrowing; pathology showed mildly active, nonspecific colitis. The patient elected to undergo surgical intervention to treat her obstruction. Because of extensive adhesions precluding safe dissection, an end colostomy was matured, and the stent was left Five years later, she continued to experience intermittent lower GI bleeding requiring transfusions, leading to her current presentation. Flexible sigmoidoscopy demonstrated partial stent erosion into the mucosa with tissue ingrowth and severe friability within the Hartmann’s stump . The steSEMs are increasingly used to treat malignant bowel obstructions and benign strictures in select patients. Potential complications include migration, erosion, perforation, bleeding, need for additional procedures if decompression is inadequate, and rarely mortality. The risk of stent erosion causing intestinal perforation is reported at 4.8–6.4% , 8, withPrevious case reports have described entero-enteric fistula formation due to stent erosion . ExampleColonic stents remain an excellent option to palliate malignant obstructions. In this setting, patients frequently experience symptomatic relief, have shorter hospital stays, lower risk of adverse events and lower hospital mortality compared with those undergoing palliative surgery , 13, 14.in situ > 12 months.Overall survival among patients with advanced colorectal and gynecologic malignancies is improving with advancements in systemic therapy. In patients with unresectable disease, palliative stents may improve quality of life and reduce surgical risks. Patients should be counseled on the rare but serious risks including death. Close follow-up is warranted, particularly if the stent remains All authors contributed to the writing, editing and approval of the final manuscript.None declaredNone.Not applicable.


Fibroids are benign tumors of the female reproductive tract originating from the myometrial smooth muscle cells. They are a frequent occurrence in women of childbearing age but their incidence is rare after menopause. In addition, there is a remote possibility of malignant transformation to leiomyosarcoma in less than 1% of cases.We hereby report a case of large fibroid in a postmenopausal Indian female with rapid growth, raising the suspicion of malignant transformation into leiomyosarcoma. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathology report confirmed it to be benign leiomyoma without any evidence of neoplasia.Sudden enlargement of leiomyoma in postmenopausal women should not be ignored due to possible malignant transformation and is to be dealt immediately with hysterectomy followed by histopathology. Leiomyoma is one of the most frequent benign tumors in the reproductive age group, with an estimated prevalence of 40–50% in women older than 35 years , 2. HoweWe present the case of a 74-year-old postmenopausal Indian woman, with four previous normal vaginal deliveries who presented to us with complaints of progressive abdominal lump and feeling of heaviness in the abdomen for the last 7 years. However, the patient continued to ignore these symptoms and did not seek any treatment. Initially, the increase in tumor size was gradual until the last year, when the growth increased rapidly. She also had a complaint of generalized pain in the abdomen for 20 days. There were no associated symptoms of weight loss, gastrointestinal disturbance, breathing difficulties, or abnormal vaginal bleeding. She was postmenopausal for 25 years without any history of postmenopausal bleeding. There was no history of hormone therapy, nor breast, ovarian, or endometrial cancer in the family.2. Patient vital signs were stable. Abdomen examination confirmed large distended abdomen due to an abdomino-pelvic mass corresponding to 36 weeks of uterus reaching up to xiphisternum and arising from the pelvis, but its lower border could not be palpated. It was dull on percussion, had a smooth surface, was firm in consistency, non-tender, and slightly mobile in the transverse plane. There was no shifting dullness that negated the presence of ascites. Gynecological examination revealed an abdomino-pelvic mass corresponding to 36 weeks of pregnant uterus in size with normal external vulva and cervix. The uterus could not be appreciated separately. Clinical examination was followed by imaging investigations. Ultrasound depicted a well-defined cystic, solid multi-septated mass in the lower abdomen measuring 20.2 × 19.2 cm. It was septated with solid mural modules. Bilateral ovaries and uterus could not be visualized separately. The mass had good vascularity, raising the possibility of ovarian origin and neoplasia. On further evaluation, magnetic resonance imaging (MRI) revealed a large well-defined globular mass measuring 24 × 23.9 × 18 cm originating from the right lateral wall of the uterus, and was suggestive of a sizeable degenerating leiomyoma of the uterus. A provisional diagnosis of uterine leiomyosarcoma was made.On general physical examination, she was overweight with a body mass index (BMI) of 27 kg/mPre-operatively, the hematological and biochemical investigations were within normal range, including serum CA 125 (25.1 U/ml). After obtaining informed written consent and arranging adequate blood products, patient was undertaken for exploratory laparotomy. The abdomen was opened by a vertical midline incision. Peroperatively, a large intramural fibroid originating from the uterus filling whole of the abdomen was seen. Peritoneal washings were collected and a total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) was performed Fig. . No maliUterine leiomyomas, commonly called fibroids, are benign smooth muscle tumors of monoclonal origin containing varying amounts of connective tissue , 5. Theyet al. reported a case of 58-year-old menopausal female with huge fibroid measuring 22 × 16 × 25 cm deriving its blood supply from the omental vessels. They performed total abdominal hysterectomy with bilateral salpingo-oophorectomy and partial omentectomy. Histopathology revealed it to be benign leiomyoma with cystic changes [et al. also reported a 55-year-old menopausal woman with a large degenerating fibroid [et al. published a case of a menopausal woman who presented with acute abdomen due to fibroid degeneration [The patient may be asymptomatic or present with varied symptomatology, such as pelvic pain, irregular vaginal bleeding, acute abdomen, lump in the abdomen, pressure-related symptoms, or rapid increase in size, which was seen in our case. Ghaffar reported a case of a 56-year-old postmenopausal woman who presented with polycythaemia associated with rapid enlargement of the uterus due to a huge fibroid weighing 5.05 kg . Osegi e changes . Seet etneration . AnotherUterine leiomyomas are a rare entity in the postmenopausal group. The possibility of leiomyosarcoma, although rare, should be borne in mind when such patients present with sudden enlargement of fibroid. The initial clinical presentation is usually misleading, and correct diagnosis can only be made by histopathology. Definitive management in the form of hysterectomy should be offered to such patients to prevent further morbidity and mortality.


Sacrococcygeal yolk sac tumor (YST) is an infrequent extra-gonadal malignant germ cell tumor (GCT) that occurs exclusively within the first two years of life. A two-year-old girl came with a massive mass on her left buttock, which continued to grow, and within three months had become extremely large and hindered her from walking. Physical examination revealed a sacrococcygeal mass of 15 cm in diameter. Multislice CT showed an intraluminal inferior cava vein mass extending into the pelvic cavity with coccygeal osseous destruction, pulmonary metastasis, and multiple hepatic metastases. Laboratory data revealed elevated tumor marker values for alpha-feto-protein (AFP), lactate dehydrogenase (LDH), and Ca-125. Cytopathology following fine needle aspiration biopsy evaluation of the smear sample revealed a cellular tumor with pseudo glandular, microcystic, and solid patterns. The cytopathology did not show pathognomic findings. An immunocytochemistry (IHC) examination of the cell block showed a positive result for anti-AFP antibody. The patient was diagnosed and treated with chemotherapy for a sacrococcygeal YST. Clinical follow-up on the fourth month showed that the tumor had shrunk to 4 cm in size. Laboratory follow-up data after four months showed significant improvement. Unfortunately, the patient passed away on the seventh cycle of chemotherapy due to lung and hepatic metastases. Malignant germ cell tumors (GCTs) account for 3%-4% of all pediatric neoplasms. This malignancy primarily affects young individuals' testes and ovaries. Less than one case per million people per year are malignant GCTs. Malignant GCTs may develop in gonadal and extra-gonadal sites. Malignant ovarian GCT affect women and accounts for 3%-5% of all ovarian cancers. Only 2%-5% of malignant GCTs can originate from extra-gonadal sites and spread axially. Outside of the ovaries, the sacrococcygeal area is one of the most common places for tumors to form .In children, sacrococcygeal teratoma (SCT) accounts for 40% of all GCT cases and 78% of all extragonadal and extracranial GCTs -3. SCT iA two-year-old girl came with a massive mass on her left buttock. The patient had a history of falling at home, resulting in injury. The family brought her to an alternative medicine practitioner for treatment with no significant improvement. The family noticed a small lump on her left buttock, which continued to grow, and within three months had become extremely large and hindered her from walking. Due to the growing mass, her family took her to the hospital. The patient had no family history of malignancy. The doctor suspected malignancy and decided to refer the patient to a national referral hospital to get comprehensive management.A physical examination revealed a sacrococcygeal mass of 15 cm in diameter, which is still growing. Multislice CT (MSCT) showed an intraluminal inferior cava vein mass expanding into the pelvic cavity and gluteal region with coccygeal osseous destruction and suspicion of leiomyosarcoma Figure  and hepaAn ultrasound-guided fine needle aspiration biopsy (FNAB) was conducted, followed by a microscopic examination. Cytopathology evaluation of the smear sample revealed a cellular tumor with pseudo glandular, microcystic, and solid patterns. The background of the smear sample revealed diffusely scattered erythrocytes with myxoid areas. Polymorphic cells with vacuolated cytoplasm, large nuclei, and some bizarre, irregular membranes with prominent nucleoli were also found Figure . A microThe patient was diagnosed and treated for a sacrococcygeal YST. The oncology consultant selected a chemotherapy regimen consisting of cisplatin, etoposide, and bleomycin. The patient came in four months later after going through four cycles of chemotherapy. The tumor had shrunk to 4 cm in size, with a remnant of distant metastases in both the lung and the liver. Laboratory follow-up data on the fourth cycle (fourth month) revealed: elevated AFP level at 21.6 UI/mL ; normal LDH level at 257 U/L, and normal beta-HCG level at 0.2 mIU/mL  respectively. The laboratory data showed improvement due to the chemotherapy. Unfortunately, the patient passed away on the seventh cycle (seventh month) of chemotherapy. The patient most likely passed away due to lung and hepatic metastases.In children, a sacrococcygeal mass can lead to multiple diagnoses. It can be a congenital lesion such as meningomyelocele or other neural tube defects, an inflammatory lesion such as seen in rectal abscess, a benign or malignant GCT, or even rhabdomyosarcoma . MalignaAny mass in the sacrococcygeal region could cause a massive mass on the left buttock as clinical presentation. Constipation or swelling of the buttocks are the most common YST complaints, according to the literature. It is also always malignant, which means that the time between the onset of symptoms and hospital admission is often short, and the lesion has most likely spread .Merchant and Stewart published a case report in 2010 about a sacrococcygeal YST in an infant who presented with fluid collection that was initially treated as an abscess. Sacrococcygeal YST appeared as a protruding, growing sacral mass in the body's midline. It is important to note that YST may have different clinical manifestations during the initial assessment and a clinician should not rule out YST as an initial diagnosis [The MSCT showed that the mass is expanding into the pelvic cavity and is destructive to the bone. We can infer that the mass is malignant, suggesting a malignant GCT or rhabdomyosarcoma or leiomyosarcoma. It also showed nodular-type pulmonary and multiple hepatic metastases, supporting the tumor's malignancy. Imaging as a diagnostic tool for YST is surprisingly difficult. In this particular case, it was initially suspected as leiomyosarcoma. SCTs can be diagnosed by solid and cystic tumors with necrotic and hemorrhagic areas. Lung metastasis is common. It is unique that the patient has multiple hepatic metastases. Hepatic metastasis has only been reported in a case report of an abdominal YST by Chen et al. in 2019. It spreads hematogenously in over half of pediatric patients .Laboratory data revealed very high levels of alpha-feto-protein (AFP); a very high level of LDH and high level of Ca125; while beta-human chorionic gonadotropin (β-HCG) levels were within normal limits. High serum AFP may indicate hepatic disorders and malignancies in children, including hepatocellular carcinomas, GCTs, liver metastases, and pancreatoblastoma . Ca125 iThe diagnosis should be confirmed by FNAB to assess the cytopathology, followed by a microscopic exam of the cell block. The findings in this case support the diagnosis of YST. YST has multiple morphological patterns, according to the literature. Patterns include microcystic, endodermal sinus, solid, myxomatous, papillary, hepatoid, macrocytic, poly-vesicular vitelline, glandular , and alveolar-glandular. The most common pattern is the reticular microcystic pattern, which is formed by the vacuolated cytoplasm of tumor cells and looks like a honeycomb under a microscope . SchilleApproximately 80% of YST patients respond well to chemotherapy. In advanced cases, cisplatin-based chemotherapy follows surgical resection. In case of the tumors that had spread, the oncologist recommended chemotherapy. Unresectable cases with metastasis have varying prognoses. Higher AFP levels above 1000 ng/mL are also associated with a worse prognosis . AlthougIn conclusion, we report an infrequent case of sacrococcygeal YST in a two-year-old girl with multiple metastases. When dealing with a sacrococcygeal tumor, YST should always be considered in the differential diagnosis. In pediatric patients with pulmonary metastasis, a GCT should always be suspected. The levels of AFP should be monitored for a period of time. YST can manifest in a variety of clinical scenarios in young patients and should never be overlooked. Our case represents a very rare malignant YST with pulmonary and hepatic metastasis, all within a short period of onset to hospital admission. Laboratory and pathology examinations are especially important to confirm the diagnosis, determine the prognosis, and help to adjust the therapy for YST in children.


An 83-year-old postmenopausal female P5L5  presented with complaints of foul-smelling purulent discharge per vagina for 15 days associated with pain in abdomen. A midline mass was palpable per abdomen in the suprapubic region corresponding to 16 weeks size gravid uterus, which was soft to firm in consistency. On examination per vaginum, the atrophied cervix was found flush with the vagina and purulent discharge was seen draining through the cervix. Blood reports showed raised total leucocyte count with granulocyte predominance. Abdominal ultrasonography revealed a uterine cavity filled with echogenic contents, with no abdominal cavity collection. The patient was started on IV antibiotics and planned for dilatation and curettage. On histopathology acute on chronic senile endometritis was found with no evidence of malignant cells. Tuberculosis gene testing was found to be negative. We conclude that the senile endometritis leading to cervical stenosis as seen during dilatation and curettage had led to the pyometra and no evidence of malignancy was found. According to a study by Lee DH et al., pyometra, which is a deposit of pus in the uterine cavity, has an incidence of 0.01-0.5% in gynecologic patients . Some otAn 83-year-old female was admitted to our hospital with the chief complaints of purulent discharge per vaginum for 15 days, which was associated with lower abdominal pain. The discharge was foul smelling, yellow in color, mucopurulent, and copious in amount. It was not associated with itching and the pain was insidious in onset and dull aching and localized to the lower abdomen and aggravated on work while relieved on medications. There was no history of similar complaints in the past. There was no history of vaginal bleeding.The patient was a known case of hypertension for the past 10 years and was on regular medication. There was no history of diabetes, tuberculosis, or other major medical or surgical illness in past. She had undergone tubal ligation 40 years back. She was menopausal for 33 years and had five full-term normal deliveries. Bowel and bladder habits were normal and normal sleep and appetite. On examination she was afebrile, her pulse was 82 beats per minute, regular in rate and rhythm, respiratory rate was 18 breaths per minute, and blood pressure was 122/80 mm of Hg. The central nervous system, cardiovascular system, and respiratory system examination findings were found to be normal. A midline mass was palpable per abdomen in the suprapubic region corresponding to 16 weeks size gravid uterus The mass was tender soft to firm in consistency having restricted mobility. On per speculum examination, both labia were fused partially in the posterior end , which could be easily separated with blunt finger dissection done gently. Per speculum examination revealed the vagina full of foul-smelling purulent discharge, which was copious in amount  came out negative.Pus culture was suggestive of Pyometra is a condition in which the uterine cavity is filled with purulent content. Most of the time it is because of cervical stenosis due to cervical malignancy, but in this case, the senile endometritis associated with cervical stenosis led to pyometra. The common causes of pyometra in postmenopausal age include malignancy of the genital system including post-radiotherapy complications, benign conditions such as an endometrial polyp, senile endometritis, idiopathic conditions leading to cervical stenosis, or postoperative infection. Out of these, 22.2% of cases are associated with malignancies, 3.7% with genital tract abnormalities, and 74.1% are due to idiopathic causes ,6. PropeFurthermore, the endometrial samples should undergo a histopathological examination to rule out malignancy in the form of cervical cancer ,9. The pPyometra is a serious medical condition, which should be diagnosed and treated as early as possible. Usually in a massive pyometra at this age, one may consider malignancy as the only cause, but benign conditions such as senile endometritis should be kept in mind while working towards a diagnosis. Malignancy should be ruled out in every case and care must be taken to prevent and manage uterine perforation. USG is the first and most important investigation to quantify and tell the type of fluid collected in the uterus and rule out uterine perforation. CT scan and MRI should also be considered for quantification of collection and to rule out pyoperitoneum.


The differentiating feature is ophthalmic lesions and blindness by 20 years.•Usual diagnosis is made in a postnatal examination with gross abdominal mass, polydactyly, and genital malformation. Hydrome2This female neonate was born at 39 week's gestation to a 35-year-old mother, gravida five and parity five with no previous history of medical interruption of pregnancy. Her prenatal history and laboratory parameters were normal. At 36th week of gestation, and ultrasonography revealed a large abdominal mass as well as dilated lateral ventricles of the brain. She was born through spontaneous vaginal delivery without requiring neonatal resuscitation and an APGAR score of nine at one and 5 min.Postnatal examination revealed a birth weight of 2.9 kg, a head circumference of 36 cm, and a length of 43 cm. Facial features were suggestive of trisomy 21. She was in respiratory distress that needed nasal oxygen at 2 L/min. On abdominal examination, there was a large cystic mass with no displacement. Upper and lower extremities had postaxial polydactyly with bilateral pes cavus . ComputeShe was treated with ultrasound-guided aspiration of HMC and approximately 1 L of fluid was drained. Respiratory effort improved after fluid aspiration and a temporary drain was left inside for decompression and she has normal genitalia . The ped3The first case of MKKS in Pakistan was reported by Malik et al., in 2012 . MKS is MKS is a rare, autosomal recessive disorder that occurs due to a mutation in the MKKS gene at 20p12 locus. HMC is the hallmark of MKKS that presents as a midline large abdominopelvic cystic mass with vaginal atresia or imperforate hymen. Polydactyly or brachydactyly is present in 90% of the cases ,8. This Our patient had no bowel or urinary obstruction and genitalia were normal. However, there was dilation of lateral ventricles of the brain and patent foramen ovale. Some case reports show hydrops fetalis, hydronephrosis, and respiratory failure . Once th4In conclusion, these rare syndromes require comprehensive evaluation in the prenatal period by a multidisciplinary team of obstetricians, geneticists, pediatricians, and ophthalmologists. To date, MKKS management involves neonatal assessments only. Its prenatal ultrasonic diagnosis has never been reported. Our case presents prenatal suspicion and postnatal evaluation, management, and treatment of MKKS. We believe our case report of MKKS may contribute to the diagnosis and management in the prenatal period.Externally peer reviewed not commissioned.None.Written informed consent was obtained from the parents 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.S.R, I.U, and K.S.K conceived the idea; T.Z, J.M, R.U.A, and M.S.A collected the data; K.S.K, R.U.A, T.Z, I.U, and I.N did write up of the manuscript; and finally, I.U, M.S.A and S.R reviewed and revised the manuscript for intellectual content critically. All authors approved the final version of the manuscript.All ethical requirements were fulfilled before commencement of study.Not required.Name of the registry: Not required.Unique Identifying number or registration ID: N/A.Hyperlink to your specific registration (must be publicly accessible and will be checked):Muhammad Sohaib Asghar.The authors declare that there is no conflict of Interest.


Laparoscopic cholecystectomy is a routine, gold standard treatment for acute cholecystitis and symptomatic cholecystolithiasis. Gallbladder perforation and bile leakage, as well as gallstone spillage, are frequently observed during surgery, with a rate of up to 40%. In case of intraoperative gallbladder perforation, gallstones can get lost, leading to intra-abdominal, abdominal wall or surgical site abscess formation. Such complications can result in diffuse abdominal pain, which are challenging to diagnose.A fit 63-year old man in presented to our institution with a painful swelling in his right flank after a long hike. His past medical history was unremarkable apart from a laparoscopic cholecystectomy after recurrent episodes of cholecystitis. Our working diagnosis was a lumbar abscess beneath a skin callus secondary to friction from the backpack he was wearing. We intended to drain the abscess but were not able to localize a pus collection. We therefore proceeded to an ultrasound-guided fine needle aspiration for further diagnosis of the suspected fluid collection. We were able to aspirate the entire perifascial fluid collection and the patient reported symptom relief shortly thereafter. Microbiological investigations were positive for Hafnia alvei, part of the normal gastrointestinal flora. We extended our search for a focus of infection, such as diverticulitis with retroperitoneal fistula for example, however, the colonoscopy was normal. An outpatient MRI scan of the abdomen and lumbar spine was reported to show a Petit’s hernia or a sequestered hematoma extending from the paracolic gutter through the retroperitoneum into the lumbar fatty tissue. More than a month later, the patient was re-admitted with the same symptoms of swelling and pain in the right lumbar region. On examination, a seven centimeter fluctuant swelling was palpable.With a clinically confirmed lumbar abscess, we again prepped the patient for surgical debridement. This time, we found a foreign body, in the subcutaneous tissue, resembling a gallstone. In addition, a course of antibiotic therapy with cefuroxime was administered. Further evaluation of the MRI and additional CT scans led to the suspicion of a retroperitoneal abscess secondary to missed abdominal gallstones . This hyThis case represents the difficulty in connecting a patient’s past history of gallbladder removal to a current retroperitoneal, subcutaneous lumbar abscess. Previously reported subcutaneous swellings or abscess formation caused by ectopic gallstones in the abdominal wall have mostly been connected to laparoscopic port or percutaneous port sites,  whereas et al. It is estimated that 2.4% of these stones are not retrieved [In addition, the microbiological results showing Hafnia alvei in the drained abscess misled us when searching for an infectious origin of the retroperitoneal abscess. Usually intra-abdominal abscesses caused by iatrogenic gallbladder perforation or retained gallbladder stones, most often contain the same flora as an infected gallbladder, such as Escherichia coli . Therefoetrieved .As only 0.08% to 0.3% of cholecystectomy-related complications are due to retained gallstones , the levIn case of gallstone spillage, we advise a systematic intraoperative exploration and adequate irrigation starting in the perihepatic region and Morrison’s Pouch following down the right paracolic gutter to the Pouch of Douglas. With respect to the positioning of the patient during the procedure, it also might be worthwhile to do a final overview in the Trendelenburg position to account for any backflow of sealed fluid or gallstone collections between intestinal or mesenteric folds.We believe that a thorough, systematic intra-operative exploration and removal of spilled gallstones during cholecystectomy could reduce this particular long-term postoperative complication and suggest the exploration protocol described above should be mandatory in case of lost gallstones.


Enterolith formation is a rare condition precipitated by decreased bowel motility. It may cause obstruction or other complications and the diagnosis usually is confirmed after surgery and analysis of the stones or fragments. It is often seen in association with intestinal abnormalities such as diverticula and inflammation or in biliary tract fistulas where stones migrate to the duodenum and small bowel. We report an unusual case of a primary true enterolith formation in a patient without any underlying bowel condition or any previous surgery. Primary enterolith formation in the duodenum and small bowel is rare and is usually associated with conditions such as diverticular disease, strictures, previous surgery, and chronic inflammation, that cause decreased motility and accumulation of certain matters leading eventually to stone or fragments formation ,2. In adThe reported prevalence varies from 0.3% to 10% and is related to etiology, and underlying risk factors . We repo9/L and C-reactive protein 211 mg/L). Imaging revealed a small bowel obstruction with evidence of a 3x4 cm foreign body in the distal jejunum causing upstream dilatation  small bowel resection with side-to-side jejunojejunostomy was performed. There was no associated small bowel pathology on gross examination and the gallbladder was normal on visualization and palpation. The resected bowel was opened and a cluster of fragmented stones was extracted. They appeared hard in consistency with tendency to crumble into smaller pieces after manual handling Figure .Given the fact that there was no evidence of biliary pathology nor any findings of indigestible or insoluble material, there was very strong suspicion for those stones to be an enterolith. Histology did not reveal any pathological intestinal tissue but stone analysis was not possible. The patient had an uneventful recovery and was discharged five days later. There was no evidence of underlying abdominal pathology that could potentially explain the mechanism of enterolith formation on this patient.Intestinal hypo motility or prolonged stasis is the most common predisposing factor for primary enterolith formation. Causes include diverticular disease (e.g. Meckel’s diverticulum), areas of anastomoses, blind pouches, afferent loops, adhesions, and inflammatory strictures  . IntraluEnteroliths may vary in size, number, and configuration ranging from a few millimeters to 10 cm, as a single stone or cluster of fragments . SymptomTreatment is usually surgical and is indicated in patients presenting with obstruction, perforation, or other complications. The type of surgery is directed by the associated pathology. Surgical options include digital fragmentation of the stones and manual propelling into the large bowel, enterotomy, and stone extraction or small bowel resection. Resection is commonly performed in the presence of diverticula, severe inflammation or strictures, necrosis, and perforation ,9. The uSimilar to our case, the formation of primary enterolith or stone material inside the small bowel without any precipitating factor has been reported in the past, however, the mechanism remains unclear ,6,7. In In conclusion, enterolithiasis is a rare cause of intestinal obstruction and sometimes can present without any predisposing factor. Surgery can provide definitive diagnosis and treatment. Surgeons should be careful, while dealing with cases of acute intestinal obstruction and consider less common causes in their differential diagnosis including enteroliths and dysfunctional bowel motility. Obtaining detailed history is very important to identify potential causes of enterolith formation and should always include the possibility of foreign body ingestion. Analysis of the enterolith and associated bowel pathology may be useful to identify the potential mechanism of formation.


A choristoma is defined as a growth of histologically normal tissue in an abnormal location. Epibulbar osseous choristoma is the rarest type among all ocular choristoma with less than 100 cases reported. Here, we report a case of epibulbar osseous choristoma combined with dermolipoma and a literature reviewA 15-year-old female patient presented with an accidentally found subconjunctival mass in her left eye. Slit lamp examination revealed a 10 × 10 mm elevated, sigmoid-shaped mass in the supratemporal quadrant of the bulbar conjunctiva. We performed a debulking excisional biopsy of the mass.The pathology confirmed osseous tissue surrounded by mature adipose tissue. At 1 week after the operation, the wound was clear and the patient was satisfied with the treatment. A systematic literature review of 14 previously published cases taken from PubMed dating back to 1987 along with ours was undertaken. The average age at presentation was 11.6 years and there was a female preponderance with 10 cases being female and the other 5 cases being male. Supratemporal conjunctiva was the most common site of presentation. There was no systemic disease associated with any of the cases. Since it is a benign tumor, it can be managed by observation, but if necessary, it can be treated by surgical removal.In pediatric subconjunctival mass, particularly located in supratemporal quadrant of bulbar conjunctiva, osseous choristoma should be considered in the differential diagnosis. Pre-operative CT scans will helpful to not also reduce complication with surgical excision but also helpful in prediction of diagnosis and prognosis. Epibulbar osseous choristoma is the rarest type of all ocular choristoma with less than 100 cases reported since its first report in 1863.–4 It is most commonly found in the supratemporal quadrant of the bulbar conjunctiva. While it is believed to be congenital, it is often found in childhood because of its asymptomatic nature and its location underneath the eyelid. It can present as a single-tissue of mesodermal or ectodermal origin or comprise 2 or more different tissues of mesenchymal and ectodermal origin. Here, we present a case of an epibulbar osseous choristoma surrounded by ectopic adipose tissue and briefly review published literature on similar cases.A choristoma is defined as a benign mass of normal tissue in an abnormal location. Predominant locations of ocular choristoma include epibulbar region, ocular adnexae, and choroid.A 15-year-old female patient was referred to our hospital with an accidentally noticed conjunctival mass at the supratemporal side of her left eye. The patient denied of any underlying medical condition or ocular history. Her visual acuity was 20/20 in both eyes and intraocular pressure was normal. Slit-lamp examination revealed a 10 × 10 mm sized, elevated, yellowish fat-colored, rich in blood vessels, and sigmoid-shaped mass at supratemporal side of bulbar conjunctivae in the left eye  were females, and 5 cases (33.3%) were males. This female preponderance of epibulbar choristomas has been reported in previous literature review by Gayre et al  and Vachette et al . Eight lesions (53.3%) were found in right eye, and 7 lesions (46.7%) were found in left eye. None of the cases had associated systemic diseases. The lesions were found in the supratemporal , lateral canthal , and inferotemporal  areas. One case which appeared in inferotemporal area extended to limbus. While 10 of the 14 previously reported cases and our case revealed just bone and dermolipoma on histopathology, the other 4 cases included tissues other than fatty tissue and bone indicative of complex choristoma.We conducted a systematic literature review on previously reported cases via PubMed using the keywords “congenital subconjunctival mass,” “epibulbar osseous choristoma” and “epibulbar dermolipoma.” Full-text, free-access, English-printed articles with pathologically confirmed epibulbar osseous choristoma and dermolipoma identified 14 cases  can be helpful in determining whether the mass involves nearby structures such as sclera or extraocular muscles. Futhermore pre-operative CT will not only reduce unexpected complication with surgical excision but also helpful in prediction of diagnosis and prognosis. In review of literature, CT images of epibulbar osseous choristoma revealed a cystic mass with fat-like low-density and a high-density radio-opaque mass which is indicative of a calcium component.,17–24,26 This differentiates epibulbar osseous choristoma from low-density lesions like fat, dermolipoma, or epibulbar dermoid and helps predict the diagnosis.In general, epibulbar osseous choristoma can be managed by observation since it is mostly asymptomatic and malignant transformation has never been reported in the literature.In conclusion, epibulbar osseous choristoma combined with dermolipoma are rare conditions. However, 1 should consider its diagnosis when the mass is located in supratemporal subconjunctival space. Since it is a benign tumor, epibulbar osseous choristoma can be managed by observation, but if necessary, it can be treated by surgical removal, and pre-operative CT will helpful.Conceptualization: Ju Mi Kim, Won-Kyung Cho.Data curation: Woo Young Son, Hae Joung Sul, Won-Kyung Cho.Formal analysis: Jeongah Shin, Won-Kyung Cho.Methodology: Ju Mi Kim, Won-Kyung Cho.Project administration: Won-Kyung Cho.Supervision: Jeongah Shin, Won-Kyung Cho.Validation: Won-Kyung Cho.Visualization: Won-Kyung Cho.Writing – original draft: Ju Mi Kim, Won-Kyung Cho.Writing – review & editing: Woo Young Son, Jeongah Shin, Won-Kyung Cho.


Extralobar pulmonary sequestration is an uncommon congenital pulmonary malformation. Clinically, pedicle torsion of extralobar pulmonary sequestration is extremely rare. Due to inadequate awareness of its atypical presentation and imaging characteristics, clinical diagnosis is very difficult, and it is extremely easy to misdiagnose.There were 6 children , aged 3–12 years old. The main clinical symptoms of the children were abdominal and chest pain (3 cases), abdominal pain (1 case), chest pain (1 case), and vomiting and abdominal distension (1 case). Two cases were accompanied by fever. Preoperative ultrasound revealed a well-bordered mass with soft-tissue density, accompanied by pleural effusion. On contrast-enhanced computed tomography scans, the mass showed no obvious enhancement. A blood supply was only present in 1 case, and there was no feeding artery shown in the other 5 cases. Extralobar pulmonary sequestration with haemorrhagic infarction was pathologically confirmed. On postoperative days 2–6, the children were discharged uneventfully. There were no complications during the median follow-up of 4 months.Torsed extralobar pulmonary sequestration usually occurs in childhood or adolescence, with abdominal and/or chest pain as the primary symptoms. Imaging examination shows a well-defined soft-tissue mass without enhancement. The feeding vessel is not clearly displayed in the mass, and extralobar pulmonary sequestration is accompanied by varying amounts of pleural effusion. Video-assisted thoracoscopic surgical resection is associated with excellent prognosis. Pulmonary sequestration (PS) is an uncommon congenital pulmonary malformation, accounting for 1.5% of all congenital pulmonary malformations . PS is aSix cases comprising 3 males and 3 females were studied, with an age range of 3–12 years and a weight range of 15.4–38.4 kg. The ELS was located on the left side in 2 cases and on the right side in 4 cases. All children were free of comorbidities. The general information of these 6 children is summarized in Table The initial symptoms of the 6 children on admission included abdominal pain and chest pain in three cases, abdominal pain in one case, chest pain in one case, and abdominal distension and vomiting in one case, and two of them had fever. The course of illness ranged from 1 to 10 days .Preoperative colour Doppler ultrasound and chest computed tomography (CT) examination revealed a well-bordered mass with soft-tissue density between the diaphragm and the lower lobe of the lung accompanied by a small amount of pleural effusion in 2 cases, medium pleural effusion in 3 cases and large pleural effusion in 1 case. On contrast-enhanced CT scans, the mass showed no obvious enhancement, the blood supply was only presented in 1 case, and no feeding artery was shown in the other 5 cases. On serial imaging, the pleural effusion and the mass diameter increased progressively in one child , and intraoperative haemorrhage ranged from 1 to 10 ml . The children did not have any intraoperative or postoperative complications, and their symptoms were relieved immediately after surgery. On postoperative days 2–6, they were discharged home uneventfully. There were no complications during a median follow-up of 4 months .Symptomatic ELS caused by pedicle torsion is extremely uncommon in clinical practice, and early diagnosis is challenging.It has been reported that only 1 case of vascular pedicle torsion occurred in 13 cases of ELS treated in a single centre from 2000 to 2009 . In the Clinically, ELS with torsion shows no specific manifestations or symptoms, and it is difficult to diagnose. The literature showed that chest pain or discomfort was recorded as the main symptom among adult patients , 19, wheAbdominal pain seems to be the primary symptom of ELS with torsion in children. 80% of ELS in children is located between the lower lobe of the lung and the diaphragm, typically in the left hemithorax . The typImaging examinations, such as Doppler ultrasound, CT and magnetic resonance imaging (MRI), can play an important role in confirming the diagnosis. The discovery that the blood supply artery originates from the branch of a systemic artery rather than a pulmonary artery is strong evidence for the diagnosis of ELS , 14. UnfThe exact reason for torsion of ELS remains unclear. The literature suggests that activity or respiratory exertion may be the predisposing factor for vascular pedicle torsion; for example, some patients had performed vigorous activity  prior to the onset of illness . Unlike The ELS with torsion usually occurs in children or adolescents and has abdominal and/or chest pain as the primary symptom. Imaging examination shows a well-defined mass comprised of soft tissue between the lower lobe of the lung and the diaphragm. Contrast-enhanced CT shows that each mass had no enhancement or only marginal enhancement. The feeding vessel was not clearly displayed, and it was accompanied by varying amounts of pleural effusion. Video-assisted thoracoscopic surgical resection for ELS is associated with excellent prognosis.


Gliomas are the most common primary tumors of the central nervous system and are categorized by the World Health Organization into either low-grade (grades 1 and 2) or high-grade (grades 3 and 4) gliomas. A subset of patients with glioma may experience no tumor-related symptoms and be incidentally diagnosed. These incidental low-grade gliomas (iLGG) maintain controversial treatment course despite scientific advancements. Here we highlight the recent advancements in classification, neuroimaging, and surgical management of these tumors.A review of the literature was performed. The authors created five subtopics of focus: histological criteria, diagnostic imaging, surgical advancements, correlation of surgical resection and survival outcomes, and clinical implications.Alternating studies suggest that these tumors may experience higher mutational rates than their counterparts. Significant progress in management of gliomas, regardless of the grade, has been made through modern neurosurgical treatment modalities, diagnostic neuroimaging, and a better understanding of the genetic composition of these tumors. An optimal treatment approach for patients with newly diagnosed iLGG remains ill-defined despite multiple studies arguing in favor of safe maximal resection. Our review emphasizes the not so benign nature of incidental low grade glioma and further supports the need for future studies to evaluate survival outcomes following surgical resection. Gliomas are the most prevalent primary central nervous system (CNS) tumors with an age-adjusted incidence of 6/100,000 , 3. As hLGGs account for nearly 17–22% of all primary brain tumors . The natiLGGs may undergo malignant transformation, a process in which the tumor converts to a biologically aggressive HGG . The incWhile there has been significant improvement in understanding the pathogenesis of iLGG prognosis due to scientific advancements, the surgical management of these tumors remains a controversial topic. Recent literature highlights a shift in neurosurgeons’ opinions surrounding treatment for iLGGs from a conservative “wait and see” approach to implicating early preventative resection . Early gA review of the literature was performed using Boolean operators and a combination of search terms including "surgical management” AND “incidental gliomas", "surgical management of incidental gliomas", "incidental” AND “low grade gliomas", and "incidental glioma management". Independent reviewers screened titles, abstracts, and full-text manuscripts for pertinent studies. Abstract-only texts, book chapters, animal studies, articles in languages other than English, and studies without any primary focus on incidental gliomas were excluded from this review. The authors created five subtopics of focus: histological criteria, diagnostic imaging, surgical advancements, correlation of surgical resection and survival outcomes, and clinical implications.IDH-mutant gliomas and 1p/19q co-deletion being predominantly associated with iLGGs [The natural history of glioma depicted in Fig. th iLGGs , 18, 28.A comprehensive understanding of the molecular and genetic features of gliomas is fundamental to guide clinical management. Several genetic markers of gliomas have been identified including: (1) mutations of isocitrate dehydrogenase 1 (IDH1) and isocitrate dehydrogenase 2 (IDH2), (2) codeletion of chromosome arms 1p and 19q, 3) alpha thalassemia retardation syndrome X-linked (ATRX) gene loss, 4) tumor suppressor protein p53 mutation, (5) promoter methylation of O6-methylguanine-DNA methyltransferase (MGMT), and (6) telomerase reverse transcriptase gene (TERT) promoter mutations . IDH mut alpha th tumor suNot only do iLGGs share a similar genetic composition to LGGs, but it is also approximated that iLGGs have a radiological tumor growth rate of 4 mm/year . In a sel-tyrosine (18F-FET), and 6-fluoro-l-DOPA(FDOPA) to guide glioma detection during biopsy or resection [Neuroimaging plays an important role in the diagnosis of iLGGs and may provide insight to their molecular profiles . In receesection , 42. LGGesection . The metesection .Recent imaging advancements not only serve in diagnosis of gliomas, but also can be employed during neurosurgical procedures to increase maximal extent of resection (EOR) and improve survival outcomes. Diffusion tensor imaging (DTI) uses similar principles to DWI except it is more sensitive to the diffusion of protons along white matter tracts . DTI canSurgical resection remains the primary first-line treatment for LGGs and HGGs; however, the decision to resect iLGGs is a well-disputed debate entwined in ethical and medical concerns . iLGGs a3 volume increase over an average of 28 months which supports early resection when iLGG tumor volumes tend to be lower and accordingly allow for greater rates of EOR [Although optimal management of iLGGs is still a dilemma, there has been a growing consensus amongst neurosurgeons that these tumors are not as indolent as originally characterized to be, which has sparked new evaluation of survival outcomes in iLGG patients who undergo early surgical resection . Even sms of EOR . Zeng ets of EOR . This sts of EOR . Howevers of EOR . Additios of EOR , 26. Thes of EOR , 36, 48.s of EOR , 26.Although some groups have shared concern about sacrificing cognitive function in young patients with iLGGs for early resection, recent data shows neuropsychological results were not impacted by awake surgery . A novelRegarding individualizing treatment options for patients diagnosed with iLGG, there is a lack of consensus. Some studies oppose early resection and favor surveillance with serial clinical examination and MR imaging because iLGGs harbor IDH1 mutation leading to a delayed disease progression and malignant transformation , 18, 50.An optimal treatment approach for patients with newly diagnosed iLGG remains ill-defined. In iLGG patients, the decision to resect early is a medical, ethical, and socioeconomic challenge which must be carefully weighed to assess the immediate and delayed consequences of choosing a conservative versus surgical approach . UnnecesTreatment of iLGG is controversial due to their asymptomatic nature and lack of associated histologic confirmation leaving the physician to counsel a patient based solely on MRI . Shah etSignificant progress in management of gliomas, regardless of the grade, has been made through modern neurosurgical treatment modalities, diagnostic neuroimaging, and a better understanding of the genetic composition of these tumors. However, the clinical protocol for surgical management of iLGGs remains controversial. Although more is known about the natural history of iLGGs, additional information is necessary to thoroughly assess the impact of early surgical resection on prognosis. Our review emphasizes the not benign nature of iLGGs and further supports the need for future studies to evaluate survival outcomes following surgical resection.


Pleomorphic adenomas account for only about 6.5% of tumors in minor salivary glands, despite being the most common (70%) of all salivary gland neoplasms.The uvula per se is a rare location for occurrence of such lesions, with only a few cases having been reported so far. The differential diagnosis includes squamous papilloma, other minor salivary gland tumors and epidermoid cyst, which commonly occurs in the pediatric age group.A 43 year old male presented with a short duration history of sudden choking sensation while eating, followed by a foreign body sensation in the throat for 2 weeks. He saw a swelling at the back of his throat, which prompted him to come to the hospital. He did not have any difficulty in breathing, although there was a slight discomfort while swallowing as well as snoring at night.On examination, he was comfortable at rest, with no signs of respiratory distress. There was a roughly 2 cm globular smooth pedunculated mucosa-covered mass from the posterior aspect of the tip of uvula, with overlying prominent vessels . The remA magnetic resonance imaging (MRI) scan showed an ovoid enhancing mass lesion with well-defined margins hanging from tip of the uvula, measuring 2.3 × 2.1 × 2 cm (LS × TS × AP), without any invasion of surrounding tissues .Figure 2Excision was performed under general anesthesia. In head extension with a mouth gag, using bipolar diathermy, the pedunculated mass was identified attached to posterior aspect of entire length of uvula and adjoining soft palate on the right side. Incision was created along the attachment and the mass excised in toto along with a part of uvula and soft palate; a palatoplasty was done to create a neo-uvula.On gross examination the tissue appeared to be a firm cream-colored intact rounded tissue fragment measuring 20 × 20 × 20 mm with attached light brown mucosa measuring 15 × 10 mm. Slicing revealed a firm, mucoid, cream colored cut surface .Figure 3Microscopic examination of the lesion showed normal squamous mucosal lining epithelium containing minor salivary gland tissue which covered the entire surface of the lesion. A clear resection margin was present. The lesion was comprised of a well circumscribed benign mixed tumor composed of epithelial cells in sheets and cords embedded within a variably fibromyxoid stroma containing occasional myoepithelial cells. The epithelial cells were essentially monomorphic with plasmacytoid appearance. There was no evidence of nuclear atypia, mitoses, perineural or vascular invasion. These morphological features were those of a benign pleomorphic adenoma (benign mixed tumor). There was normal salivary gland tissue noted at the resection margin of the pedunculated lesion and therefore the lesion was considered completely excised .Figure 4The patient was followed up and after one month, the palatal scar had healed well on examination. At three months and six months after the procedure, the patient was doing well, without any changes in speech, velo-pharyngeal insufficiency or tumor recurrence.The most common benign tumor of the oral cavity is pleomorphic adenoma (50%), with the palate as the most common site. These tumors are seen between the fourth to sixth decade with a slightly female preponderance.Pleomorphic adenomas are slow growing tumors, with patients presenting with long-standing symptoms over several months: dysphagia, sleep disturbances and snoring. There was one case reported by Fidan et al.Pleomorphic adenomas arising in the uvula are quite rare, with few cases reported to date.MRI scan is the investigation of choice in evaluating such soft tissue lesions as they provide good demarcation. Pleomorphic adenomas have low T1 – weighted signal and high T2 – weighted signal on MRI.Surgical excision is the preferred method of treatment. Pleomorphic adenomas, if incompletely excised, can result in recurrence.Uvular lesions by themselves are quite uncommon. A possibility of minor salivary gland tumor should be kept in mind while encountering firm lesions of this area. Left untreated, these lesions can not only enlarge to cause significant morbidity in terms of airway and swallowing, but also carry a risk of malignant transformation.Consent taken from the Institute and patient for publishing clinical photographs and writing the case report.The authors declare no conflicts of interest.


Neurocysticercosis is primarily managed with anthelminthic, antiepileptic, and corticosteroid therapies. Surgical removal of the larval cyst is indicated when associated mass effect causes neurological symptoms, as demonstrated in two cases. Cyst resection was achieved via the far lateral approach for a cervicomedullary cyst in one patient and via the subtemporal approach for a mesencephalic cyst in another. The cyst wall should be kept intact, when possible, to avoid dissemination of the inflammation-evoking contents. As the contents are usually semisolid and can be removed via suction, it is not necessary to remove the gliotic capsule or adherent portions of the cyst wall in highly eloquent locations.https://youtu.be/GqbaJu5sy1o.The video can be found here:  MRI scan of the brain disclosed an enhancing mass presenting towards the right side of the brainstem, which is seen here at the cervicomedullary junction. At this point, it was not clear what the diagnosis was, but the patient was progressing rapidly, and surgery was felt to be indicated.0:57 The patient was placed into the park-bench position with the left side down, and a right-side reverse hockey-stick incision was planned for a far lateral approach. This approach will allow us to approach the brainstem from underneath, anterior and below the lower cranial nerves. The surgical strategy here is to make as direct an approach as possible to the brainstem without retracting on the brainstem or on the cranial nerves. For this, because the lesion presents laterally and anteriorly, we need a very extensive far lateral craniotomy including upper condylectomy. We are looking down upon the surgical site.1:40 We are drilling now the upper part of the right condyle. The upper part of the head is to the left and the lower part to the right. The upper portion of the condyle, above its junction with C1, is drilled away until is relatively flat so the dura can be reflected over this area. We see the lower brainstem and the cerebellum, as well as the eleventh nerve. The arachnoid is open sharply, which reveals the dentate ligament. The dentate ligament is sectioned. Opening a corridor towards the anterior brainstem, we can quickly come down on to the brainstem where a bulge is noted anterior to the twelfth cranial nerve.2:33 A very small opening is made when it becomes apparent what this is. The characteristic appearance of neurocysticercosis is immediately clear to the surgeon, and therefore, a very conservative process of gradually bringing the slippery cyst contents out without disturbing the wall is carried out. This has a very favorable prognosis, and so it is even more essential to remove it without disturbing the delicate neurovascular structures in the area or the brainstem any more than necessary.3:08 In this case, the patient made an excellent recovery, there was no residual on MRI, and the symptoms disappeared over a period of weeks. Here we can see the extent of the condylectomy, which does include the medial and superior portion of the condyle without disturbing the articular surfaces between the occiput and C1. The patient did not develop any instability over the ensuing years. Pathology confirmed neurocysticercosis. The patient went on to further treatment with albendazole. A more comprehensive review of systems did not reveal a reason for her to have contracted this condition.3:46 Case 2 is a 39-year-old male who presented with left-sided weakness and clumsiness. Imaging shows a hypodense lesion on CT scan in the right midbrain which comes into the ambient cistern. The same lesion is seen on MRI scan, and it is notable that this lesion is cystic with a great deal of mass effect but does not enhance.4:10 We see a small nodule located laterally on the surface which did appear to enhance while the center appeared to be clear. At this point, the patient was observed, but over a period of time, the lesion actually expanded and caused progressive symptoms and mass effect on the brain. We did suspect neurocysticercosis at this time, but because of the patient’s progressive left hemiparesis, loss of pain and temperature sensation, and right-sided clumsiness, felt that he was a candidate for surgical treatment.4:39 The patient was treated with a subtemporal approach, positioned with the head turned over to the left side to reveal the right subtemporal area, which was then tipped down to allow the temporal lobe to fall away from the middle fossa floor. A straight or curvilinear incision can be used in order to fashion a rectangular craniotomy whose floor is completely flat to the middle fossa. The anatomy of the subtemporal approach is depicted here. In this case, the top of the petrous bone has been drilled away and the tentorium cut, which reveals the access to the midbrain, pons, and upper cerebellum.5:23 The surgical strategy here includes making an approach underneath the temporal lobe and sliding up over the surface of the tentorium until we come to the lateral midbrain. At this point, the tentorium can be opened, taking great care to preserve the fourth cranial nerve, or if the lesion presents to the subarachnoid space, the lesion can simply be opened. The strategy for neurocysticercosis is somewhat different than for other lesions because a great deal of exposure is not required. Dissection of the cyst contents is usually quite simple.5:53 Here we see the dural opening with the middle fossa floor uppermost in the field and the superior part inferiormost. A simple subtemporal dissection directly down takes us almost immediately onto the surface of the midbrain laterally, where the lesion is identified. Even the process of respiration causes it to begin to herniate out once this capsule has been opened. The materials are usually quite slick and mobile and are easily delivered from within the center part of the lesion. It is not necessary to remove the wall beyond this. At this point, the worm is usually not alive any longer. It is actually the process of degeneration that sometimes causes them to swell and cause symptoms. Gradual traction allows it to be delivered from the midbrain. Great care should be taken not to provide traction, and if any resistance is felt, further dissection should be carried out. Other cyst debris are delivered out through the same opening, taking care not to disturb the wall of the brainstem any more than necessary. Here we see into the interior of the cavity.7:10 Pathology revealed this again to be neurocysticercosis with the characteristic pathologic finding of the scolex. The gross cyst seen in the picture on the lower right. Postoperative imaging revealed the empty cavity and relative relaxation of the brainstem. The patient’s symptoms improved, and gradually the anatomy returned to normal.7:34 Pearls and pitfalls. In these cases, it is advantageous to try to preserve the cyst wall as long as possible and to evacuate the contents with suction rather than allowing them to spill. It is important not to pull on the surrounding structures, which are usually not attached tightly to the cyst and are usually quite eloquent in this location. Patients should be treated with antiparasitic therapy if feasible but, if not, microsurgical removal offers an excellent way to reduce mass effect and provides prompt resolution of the patient’s symptoms.


Background: Complications of fibroids in pregnancy are well known, including postpartum hemorrhage, labor dystocia, and cesarean delivery. Outside of pregnancy and labor, the rare occurrence of spontaneous fibroid rupture has been documented. Case: The current case report involves a woman who presented with acute abdominal pain in the third trimester of pregnancy and was found to have spontaneous rupture of a fibroid before the onset of labor. Her initial presentation, diagnosis through use of point-of-care ultrasound, acute surgical management, and postoperative course are described. Conclusion: When assessing acute abdominal pain in a pregnant patient, fibroid rupture should be considered despite the absence of prior uterine surgery. Bedside point-of-care ultrasonography is a useful tool for assessment of abdominal pain in the third trimester of pregnancy.  Uterine fibroids are smooth muscle, benign tumors found in 12-25% of reproductive-age women Outside of pregnancy, spontaneous rupture of fibroid and subsequent hypovolemic shock necessitating emergency laparotomy for control of hemorrhage has been reported in young, nulliparous women as well as in post-menopausal women In both pregnant and non-pregnant patients presenting with abdominal pain and concern for active hemorrhage, point-of-care ultrasound (POCUS) has been utilized for triage and management decision making A 28-year-old, gravida 3 para 0, at 35 and 6/7 weeks of gestation presented to a triage unit with worsening abdominal pain. Her subjective history was notable for abdominal cramping the previous evening that progressively worsened through the morning of presentation. She described her pain as constant and sharp with radiation towards her back. She reported regular fetal movement and did not report any leakage of fluid or vaginal bleeding. Her review of symptoms was otherwise negative. Prior to pregnancy, her medical history was notable for a left-sided subserosal fibroid measuring 6.7 x 5.0 x 8.2 cm by transabdominal ultrasound that was identified in a workup for abnormal uterine bleeding. This fibroid then measured 8.4 x 10.2 x 6.1 cm at 20 weeks of gestation and 9.5 x 9.3 x 8.4 cm at 32 weeks of gestation . Her prenatal course was otherwise uncomplicated. Her medical history was unremarkable and prior to pregnancy she took no regular medications. Her surgical history was notable for one prior surgical abortion via dilation and evacuation.3/µL, serum creatinine of 0.7 mg/dL, AST/ALT 22/20 units/L, total bilirubin of 0.5 mg/dL, and LDH 195 U/L. Coagulation studies showed an INR of 0.9, PTT of 26 seconds, and fibrinogen of 700 mg/dL. On initial presentation, her vital signs were as follows: pulse of 122 beats per minute, blood pressure of 146/67 mm Hg, respiratory rate of 22/min, and oxygen saturation of 96% on room air. On physical exam, the patient was alert and oriented and in mild distress. Cardiac exam was notable for regular rhythm tachycardia by manual pulse palpation and pulmonary exam was unremarkable. Abdominal exam demonstrated a firm and severely tender abdomen in all four quadrants with rebound tenderness. Cervical exam was 1cm dilation, 50% effacement, and -3 station. On electronic fetal heart monitoring, the fetus had a baseline heart rate of 140 beats per minute, moderate variability, and no accelerations or decelerations over a 20-minute period. On external tocometry, there were regular contractions every 2 minutes. Transabdominal POCUS demonstrated a cephalic fetus and large, bilateral collections of free fluid in the maternal abdomen. Figure 2  and Figure 3  show representative findings in the right upper quadrant and pelvis, respectively. Laboratory evaluation showed a hematocrit of 37%, platelets of 415 x10In the setting of worsening abdominal pain with positive rebound tenderness and significant free fluid concerning for hemoperitoneum, possible uterine rupture was suspected. The patient underwent an emergency cesarean delivery under general anesthesia. Upon entry into the peritoneum, light brown serosanguinous fluid and dark blood was visualized without evidence of an active hemorrhage. Inspection of the uterus and adnexal structures revealed an 8 to 10 cm uterine fibroid on the left side that distorted the lower uterine segment . No uterine dehiscence or rupture was identified. To avoid a low transverse hysterotomy extending into the fibroid, a midline vertical hysterotomy in a classical fashion was performed. A viable, male infant was then delivered through the hysterotomy. The placenta was removed intact. The uterus was exteriorized and the hysterotomy was then closed in three layers. The fibroid was again inspected and a rupture in the fibroid capsule was appreciated . The serosal capsule was entered and the contents within the fibroid were hemorrhagic, liquefied, and nearly entirely degenerated with minimal fibroid tissue remaining (Supplementary Image 1). Given these findings, the decision was made to proceed with a myomectomy. The fibroid was grasped with a tenaculum and the capsule was dissected from the underlying myometrium using a combination of blunt and electrosurgical dissection to shell out the remaining contents of the fibroid. The defect was then repaired in three layers. The uterus was returned to the abdomen and the remainder of the surgery was completed without complications. The infant had APGAR scores of 3 and 8 at 1 and 5 minutes, respectively. Total estimated blood loss from the procedure was 1800 mL. Intraoperatively, the patient did not require any blood products or vasopressor therapy. Postoperatively, the patient was transferred to the postpartum floor in stable condition. Her postoperative course was notable for acute blood loss anemia with a Hgb nadir of 7.0 g/dL; the patient declined blood transfusion. Otherwise, her postoperative course was uncomplicated and she was discharged home on postoperative day #4 in stable condition. Final pathology resulted as benign leiomyoma.While it has been established that prior myomectomy is a risk factor for uterine rupture in pregnancy, there have been only a few reports of a ruptured fibroid complicating pregnancy. Spontaneous fibroid rupture postpartum at two days and nine weeks has been reported In women with prior myomectomy and entry into the endometrial cavity, cesarean delivery at 37 weeks of gestation is recommended for the prevention of uterine rupture in labor  While the rates of hemorrhage, fetal malpresentation, cesarean delivery, and other adverse obstetrical outcomes associated with fibroids are beginning to be understood, it is not definitively known to what effect myomectomy in pregnancy or planned cesarean delivery decreases the incidence of these outcomes. As this and other case reports suggest, the spontaneous rupture of fibroid in pregnancy is a very rare event. Thus, in a pregnant woman with fibroids, the risks associated with myomectomy in pregnancy or planned cesarean delivery likely outweigh the benefits of preventing spontaneous rupture of fibroid and other adverse obstetric outcomes associated with fibroids in labor.Importantly, this case demonstrates the usefulness of point-of-care transabdominal ultrasonography (POCUS) in the evaluation and management of acute abdominal pain in pregnancy. Ultrasonography is a useful diagnostic tool for the detection of hemoperitoneum, visualized as free fluid in the abdomen or pelvis, especially in the setting of blunt and penetrating abdominal trauma Among pregnant patients presenting with acute blunt or penetrating abdominal trauma, FAST exams have a sensitivity of 61-85% and specificity of up to 99% for the detection of intraperitoneal free fluid; this is similar to the non-pregnant population In the present case, POCUS showed significant free fluid in the pelvis in the bilateral lower quadrants concerning for hemoperitoneum. The differential diagnosis included uterine rupture, placental abruption, fibroid rupture, fibroid necrosis, rupture of adnexal mass, as well as vascular and gastrointestinal etiologies. Although uterine rupture and placental abruption are not usually diagnosed with ultrasound, POCUS in the present case allowed for the rapid identification of intra-abdominal hemorrhage with reasonable certainty. Whereas POCUS did not rule in or out specific etiologies in this case, it appropriately identified a concerning intra-abdominal process necessitating urgent intervention. While the patient did not have a history of blunt or penetrating abdominal trauma, her overall clinical presentation was concerning for acute hemorrhage. In the context of tachycardia, rebound tenderness, and ultrasonographic signs of intra-abdominal bleeding, the decision was made to proceed with emergency exploratory laparotomy and delivery. With the use of FAST exam, intraabdominal bleeding was identified without requiring transport to CT scanning or serial lab monitoring, and she was transported to the operating room for stabilization, likely preventing further clinical deterioration. Ultrasound was therefore a useful tool in the present case for the urgent triage of a pregnant patient presenting with signs and symptoms of an acute abdomen potentially requiring surgical intervention.Outside of obstetrics, the use of POCUS for the evaluation of unstable patients has been utilized in the fields of emergency medicine, anesthesia, and critical care. For example, the use and interpretation of bedside ultrasound are training requirements in these fields As the present case highlights, POCUS was vitally important for the evaluation and management of an obstetrical patient with an urgent clinical condition. Given that POCUS is a readily accessible and inexpensive imaging modality, formal training in these techniques like FAST exams should be included in obstetrics and gynecology residencies. Evaluation of obstetrical parameters like fetal growth and cervical length as well as gynecological assessment of the adnexa and endometrium are ultrasonographic skillsets taught during training. Combining basic familiarity in gynecological evaluation of fibroids, for example, along with emergency POCUS skills would allow for further ability to develop a differential and management plan for patients presenting with acute abdominal pain. With this basic familiarity in use of ultrasound, training in POCUS would not require significant burden regarding use of equipment or availability of machines. Obstetrics and gynecology residents will encounter patients with urgent clinical conditions in which POCUS may be helpful, such as in patients with ruptured ectopic pregnancy, postpartum hemorrhage, and abdominal trauma in pregnancy. Beyond the abdominal cavity, POCUS may be useful for the cardiothoracic systems as well for the evaluation of peripartum shortness of breath, post-operative hypoxia/fever, and other clinical presentations in which evaluation of the lung, pleura, and pericardial spaces may be beneficial for the triage of critically ill patients In review, this case highlights the importance of considering spontaneously ruptured fibroid when triaging a pregnant woman with acute onset of severe abdominal pain, even without a history of prior myomectomy. The present case also highlights the usefulness of POCUS to aid in the medical decision making when evaluating a pregnant patient with severe abdominal pain. When an acute surgical abdomen is suspected in pregnancy the FAST exam is a quick and useful tool during triage. Obstetrics and gynecology residency programs should consider implementation of formal training in POCUS.The patient consented to the use of de-identified information as well as the operative images. She provided full verbal consent for the publication with the understanding that while all information will be de-identified, absolute anonymity cannot be guaranteed.The authors have no conflicts of interest to declare. Video S1Video S2