Roux-en-Y gastric bypass, a procedure proven effective for treating morbid obesity and metabolic disorders, carries the risk of complications such as the formation of internal hernias. These hernias are often difficult to diagnose and can be potentially fatal because they can cause structural obstruction. Most internal hernias occur in the jejunojejunostomy mesentery space, followed by Petersen's space hernias, although herniation at other locations can also occur. Our case report presents an example of a rare internal hernia after laparoscopic Roux-en-Y gastric bypass. A 36-year-old woman presented with an uncommon internal hernia located between the liver and alimentary loop, resulting in the formation of a new space and consequently incarcerating the entire biliopancreatic loop. This type of internal hernia is rare and has not been reported in the literature, indicating that this is the first report of such a case. In this case, we realized that the diagnosis was challenging and imaging examinations could not help determine the etiology of the pain and obstruction. Therefore, videolaparoscopy revealed an uncommon hernia formed by firm adhesion between the hepatic segment III and the alimentary loop mesentery. Our case is an example of an internal hernia that was not detected with a normal computed tomography scan of the abdomen and pelvis. Only diagnostic laparoscopy revealed herniation, effectively preventing further complications for the patient. Early complications associated with this surgery include anastomotic leak, pulmonary embolism, wound infection, gastrointestinal hemorrhage, and mortality due to respiratory insufficiency. Late complications may include incisional hernia, bowel obstruction, internal hernia, stomal stenosis, and marginal ulcers.,4Roux-en-Y gastric bypass, which typically involves a small gastric pouch, a 50cm biliary limb, and a 150cm alimentary limb, has emerged as one of the most effective solutions for morbid obesity and metabolic disorders. Internal herniation occurs in approximately 6% of patients and can be attributed to significant weight loss or the inability to close internal spaces, with major symptoms including abdominal pain, nausea, and vomiting. Computed tomography (CT) is the optimal method for investigating hernias, and the primary risk factors are small bowel ischemia and necrosis; therefore, surgical investigation should be considered in these cases.,5 In this case report, we present an uncommon internal hernia that formed between the liver and the alimentary loop, creating a new space and subsequently resulting in the incarceration of the biliopancreatic loop.A study by Chang et al. revealed that hernias develop in 31% of all cases of postoperative intestinal obstructions following Roux-en-Y gastric bypass.Two years ago, a 36-year-old woman with morbid obesity and metabolic syndrome underwent vertical sleeve gastrectomy at our center, located in Santo André, Brazil. Following this procedure, the patient underwent revision laparoscopic Roux-en-Y gastric bypass for reflux disease. Four months after the second surgery, she presented to the emergency department with acute mesogastric abdominal postprandial pain, which had persisted for three consecutive days, accompanied by nausea and emesis. Physical examination revealed a soft abdomen without sudden decompression but with diffuse tenderness in the mesogastric region. Laboratory results were normal. Both CT and upper digestive endoscopy were performed but showed normal results. Consequently, videolaparoscopy was employed as a diagnostic method. Imaging revealed an uncommon internal hernia formed by a new space resulting from firm adhesion between hepatic segment III and the alimentary loop mesentery. The biliopancreatic loop was almost completely incarcerated, constituting an internal hernia and significant distension upstream of the alimentary loop without intestinal distress . LaparosCentro Universitário FMABC .This case study was approved by the Ethics Committee of ,7 Possible complications include the formation of an internal hernia, which can be challenging to diagnose and potentially fatal because it can cause obstruction. More than half of the internal hernias occur in the jejunojejunostomy mesentery, followed by Petersen's space hernia. When it presents with herniated limb, it can be twisted accompanied by the rotation of the mesenteric, resulting in venous and lymphatic engorgement and sometimes causing bowel obstruction.,9Sleeve gastrectomy and gastric bypass are currently among the most commonly performed gastrointestinal operations, with a very low 90-day mortality rate of less than 0.5%.In this case report, the patient presented with an uncommon internal hernia located between the liver and alimentary loop, forming a new space and consequently incarcerating the whole biliopancreatic loop. This type of internal hernia is rare and has not been reported in the literature, indicating that this is the first reported case of its kind. In this case, we realized that the diagnosis was challenging and imaging examinations could not help determine the etiology of the pain and obstruction. Videolaparoscopy was indicated, which helped diagnose and treat the patient. We introduced a 10-12mm optical trocar in the standard manner via an umbilical incision, and two 5mm laparoscopic ports were positioned in the right flank  and one 5mm laparoscopic port on the left flank . It revealed the presence of an internal post-bariatric hernia caused by firm hepatic adhesion to the alimentary limb that was not evident on the CT scan performed before surgery. An unusual internal hernia was formed by the firm adhesion between hepatic segment III and the alimentary loop mesentery, creating a new space in which the entire bilar limb was incarcerated but with no signs of intestinal ischemia. Lysis of the adhesion was performed, and the bilateral limb returned to its normal position and normal peristalsis to resolve the obstruction. The patient tolerated the procedure well and remained stable upon discharge on the first postoperative day.Our case is an example of the diagnosis of an internal hernia that involved abdominal pain after laparoscopic Roux-en-Y gastric bypass surgery. Despite normal abdominal and pelvic computed tomography scans, only diagnostic laparoscopy revealed herniation. Therefore, it is necessary to consider the diagnosis and persistence of clinical symptoms, even in the presence of normal examination results, warranting the consideration of diagnostic videolaparoscopy due to the risk of this pathology. Although this type of internal hernia is rare and has not been previously reported, it should be included in our diagnostic hypotheses due to the possibility of adhesion formation related to the proximity of the left hepatic lobe to the gastroenteroanastomosis and alimentary loop.Our case is an example of the diagnosis of an internal hernia that involved abdominal pain after laparoscopic Roux-en-Y gastric bypass surgery. Despite normal abdominal and pelvic computed tomography scans, only diagnostic laparoscopy revealed herniation. Due to the non-specific symptoms and potentially late presentation, diagnosing internal hernias can be challenging and pose risks to the patient, including potential ischemia and necrosis of the structures. Lytic surgery can serve as the primary treatment for these patients.


One of the most common surgical emergencies, intestinal obstruction is rarely the result of an inadvertently retained foreign object , which may not present symptoms for a lifetime. It also carries additional legal burdens, which may account for the rarity of its reports.We report a 24-year-old Sudanese female with a history of emergency Caesarean section two years before the admission presented with abdominal distension and absolute constipation, which was diagnosed as intestinal obstruction with a retained gauzed found within the small intestine. Moreover, a review of recent African-reported cases was done to find relatively similar cases.Adhering to the standard of care in surgical theaters and integrating new methods of prevention like tagged gauze could help to decrease the rate of such cases in the future. Forgetting a foreign body such as a mass of cotton material, sponges’ gauze, towels, or even instruments is one of the worst misadventures that a surgeon could ever have, which comes with several legal and social consequences  2]. For. For2]. The most common causes are emergency surgery, unplanned changes in operation, high body mass index, hurried sponge counts, long operations, unstable patient conditions, and inexperienced staff numbers . Even thWhile this condition typically presents with nonspecific clinical features, the patient may experience symptoms for the rest of his life. Moreover, it has the potential to cause serious clinical consequences like ileus, abscess, fistula, and bowel necrosis . Rarely,Here we present a Sudanese female with a history of emergency Caesarean section presented with intestinal obstruction features, which was found to be due to a gossypiboma formation.A 24-year-old female, gravida 2, para 2, who had previously undergone a Caesarean section at a rural hospital two years ago, arrived at the emergency room with a gradual onset of abdominal distension, abdominal pain, and absolute constipation for two days. She also experienced nausea and frequent vomiting of greenish material however, there is no fever, burning urination, or chest pain. There was no history of renal colic or intestinal obstruction.The patient was vitally stable upon examination. The abdomen was distended with mildly generalized tenderness, but there was no guarding or rigidity. Superficial palpation revealed no abnormalities, but deep palpation revealed a globular mass on the left iliac fossa (pedunculated) with clearly defined edges. On auscultation bowel sounds were present.TWBCs were 8.1, hemoglobin was 9.8, random blood glucose was 99 mg/dl, platelets were 329, blood urea was 27, serum creatinine 0.7, the c-reactive protein was 27, serum potassium was 3.3 mmol/l, abdominal ultrasound was normal, erect abdominal x-ray revealed multiple air-fluid levels  of the cases. It was commonly detected using computed tomography (61%) and radiography (35%). Furthermore, the median discovery time was of 2.2 years, all of which go in line with the characteristic of our case  13]..13].Another review was done in Sudan by Suliman et al. and published in 2013, which reviewed several local cases of Gossypiboma in Sudanese females after cesarean section. Which presented with signs of infection and bowel obstruction and required surgical intervention to remove the retained surgical gauze. Luckily all the patients in this report survived until discharge from the hospital .Likewise, Yorke et al. reported a case of intestinal obstruction due to an intraluminal foreign body. In this case, a patient underwent a laparotomy to treat ruptured acute appendicitis. A laparotomy towel was left behind during the operation . In addiA similar course of events was noticed in the post-myomectomy case reported by Naiem et al. in 2021 which presented with acute abdominal signs after almost 6 months of the primary operation and it was then discovered to be due to infected missed surgical gauze that was then extracted with good patient outcome .For such cases and once the diagnosis has been made, management includes investigations, parenteral antibiotics, intravenous fluids, and emergency laparotomies. In addition, laparoscopic retrieval may also be carried out if the diagnosis is done early , 14.Medical practitioners, especially surgical staff, must be aware of the risk factors that cause retained sponges and take deliberate steps to avoid them , 15, 16.One of the promising solutions to decrease the rate of Gossypiboma is the use of tagged surgical gauze which can be detected by regular x-ray. This is expected to decrease the rate of error associated with the use of manual counting Table .Gossypiboma should be considered even though it is rare in patients with intestinal obstruction, especially if there is a history of abdominal surgery, as it can have serious consequences. To reduce its occurrence and medicolegal ramifications, standard surgical precaution and prevention measures should always be followed, including pre- and post-operative sponge counting, the use of radio-opaque markers, and ongoing staff training.


A 4-year-old male child presented to us with a paraspinal pseudo-tumor over the mid-back region with pain being his only symptom. On initial ultrasonography, it was presumed to be a nerve sheath tumor, but on an excision biopsy and histopathology, it proved to be a subcutaneous cysticercosis. Furthermore, an MRI of the brain showed a ring enhancing lesion with vasogenic edema, which confirmed the diagnosis of a neurologically symptomless neurocysticercosis. We treated the patient with albendazole and a short course of dexamethasone. There was complete resolution of the painful subcutaneous swelling, and the patient remained neurologically symptomless at all subsequent follow-ups. Resolution of the brain lesions was seen in the 6-month MRI follow-up. Although rare, orthopedic surgeons should consider the possibility of parasitic infections when dealing with small near-asymptomatic soft tissue paraspinal swellings of uncertain etiology. A thorough investigation in such cases can be lifesaving. Benign spinal and paraspinal soft tissue disorders are very common. They can range from herniated or sequestrated disks, synovial cysts, and degenerative arthritis to rare infectious conditions like cysticercosis .In developing countries like India, cysticercosis has become a major health concern. It is a parasite-borne disease caused by cysticercus cellulosae, which is the larval form of pork tapeworm, Taenia Solium , 3. It pWe present the case of a 4-year-old male child with dorsal paraspinal swelling, which initially seemed to be a case of an isolated subcutaneous cysticercosis, with no apparent neurological symptoms.A 4-year-old male child, brought by his parents, presented to the orthopedic outpatient department of our hospital with swelling over the mid-upper back region . The sweOn examination, we appreciated a pea-sized rounded mass with normal overlying skin. The swelling had no local rise of temperature and was non-tender, non-fluctuant, and non-reducible. The swelling was well-defined, firm, and in the subcutaneous plane. Clinically, the dimensions were 2 × 1 cm over the left paraspinal region, at the level of upper thoracic vertebrae.X-ray chest and dorsal spine seemed within normal limits . UltrasoTo confirm our diagnosis, we went ahead with an open biopsy. Under general anesthesia, with adequate aseptic precautions, a longitudinal incision of 4 × 1 cm was made over the swelling. The superficial fascia was dissected, and the swelling was found to be in the subcutaneous plane with a small component of paraspinal muscular infiltration. The mass along with its sac was removed, which was soft to firm with a jellylike consistency . After aThe histopathology report revealed the presence of a parasite composed of cuticle, subcuticular cells along with muscle, and chronic inflammatory infiltrate with a final impression of cysticercosis . After tAt 1-month follow-up, the patient had complete resolution of pain and swelling. Local USG back showed no evidence of any remnant lesion. At the 6-month follow-up, an MRI of the brain was done that showed a major reduction in the size of the lesion and resolution of perilesional edema . At 1-yeHuman cysticercosis is a parasitic infection caused by the larval stage of pork tapeworm, Taenia Solium . It is eInfection takes place by consumption of uncooked pork, vegetables, or water contaminated with human feces containing encysted larvae of Taenia Solium , 8. HumaAfter cysts are ingested by humans, gastric secretions in the human stomach break the outer wall of the cyst, and the head of the parasite (scolex), are released. The scolex anchors to the small intestinal mucosa and matures to form an adult tapeworm in 5–12 weeks. The tapeworm then sheds proglottids and eggs into the human faces, which remain undestroyed in the soil for days together, because of its thick covering shell. When food contaminated with this soil is ingested by humans, the breakdown of the eggshell by human stomach gastric secretions releases oncospheres (embryos). These oncospheres invade the intestinal wall, enter the mesenteric veins via the bloodstream and get lodged into various body tissues, and develop into cysticerci. Cysticerci can be found in any part of the body, but the brain, eyes, subcutaneous tissue, and muscles are where they most frequently appear , 8, 9 F.When skeletal muscles are involved, they present as palpable cysticerci in the subcutaneous tissue. It can cause myositis and present as a palpable swelling or can have varied presentations depending on the site , 11. Wheet al. [Most isolated muscular and subcutaneous cysticercosis is symptomless and goes undiagnosed throughout the life of the patient. In a few rare instances, there can be a trauma to the cyst or the parasite inside it may die, releasing antigens that set off an immune reaction and inflammation, causing the cyst to become symptomatic . Intereset al. , in theiClinical judgment of cysticercosis is very tough unless it is kept in the list of differential diagnoses. Pseudotumors causing a similar presentation include neurofibromas, lipomas, tuberculous lymphadenitis, pyomyositis, or epidermoid cysts , 15. DesPrior to the development of high-resolution sonography, USG was not frequently utilized in the diagnosis of muscle cysticercosis; however, it is now able to diagnose such disorders. The nonionizing and noninvasive nature of USG helps in establishing the possibility of such cases without the need for invasive techniques like a biopsy, which can then be managed conservatively with medications . AccordiMedical therapy with praziquantel or albendazole is effective in reducing the size of the cystic lesions in neurocysticercosis . The risOur study showed a similar result with a complete clinical and radiological resolution of the paraspinal lesion seen at the 1-month follow-up and thereafter.To the best of our knowledge, our case is the only documented case report of neurocysticercosis presenting as an isolated subcutaneous swelling over the back with no neurological or ophthalmic manifestations seen typically in this condition, in a pediatric child.In an endemic zone like ours, neurocysticercosis may present as an asymptomatic isolated peripheral pseudotumor of uncertain etiology with absent neurological symptoms. High-resolution USG is a well-documented safe, cost-effective, and widely available method to document cysticercosis, and such cases should not be missed. Although rare, orthopedic surgeons should consider the possibility of parasitic infections when dealing with small soft tissue paraspinal swellings. This case report also shows how a thorough systemic investigation in such cases can be lifesaving.This letter describes individual contributions by the authors. Swapnil Keny , Nihar Modi , Aryan Keny , Nikhil Gokhale , Saurabh Yadav , and Kalpana Azad (Review and editing)None declared.None declared.


Paragangliomas are rare neuroendocrine tumors. While paragangliomas of the spine are rare, those located in non-cauda equina areas with spinal canal extension are even rarer.We present a case of a 23-year-old female of African descent with a primary thoracic paraganglioma with intervertebral extension resulting in displacement and compression of the spinal cord and extensive local invasion of the surrounding structures. This paraganglioma was functional with typical symptoms of catecholamine excess. Despite the aggressive nature of the paraganglioma, the patient only had isolated sensory symptoms in the left shoulder. Adequate alpha and beta-blockade were instituted prior to her undergoing surgery with near-total resection and complete preserved neurology. There was no underlying pathogenic genetic mutation found.Even though rare, paraganglioma should be considered in the differential diagnosis of spinal tumors. Genetic testing should be performed in patients with paragangliomas. One should exercise extreme caution in treating such rare tumors that may cause neurological deficits and careful surgical planning should be undertaken to avoid possible catastrophic complications. Pheochromocytomas (PCC) arise in the adrenal medulla . When foThe majority of parasympathetic PGLs are found in the head and neck region along the cranial nerve branches of the vagus and glossopharyngeal nerves . In addiPrimary PGLs of the central nervous system are extremely rare . AccordiWe present a case of a young African female with a functional PGL occurring in the paravertebral space of the thoracic spine, with local invasion and displacement of the spinal cord.A 23-year-old female of African descent, recently diagnosed with hypertension, was referred to the endocrine clinic for investigation. She had a background history of human immunodeficiency virus (HIV) infection with a recent absolute cluster of differentiation 4 (CD4) count of 390 cells. She was virally suppressed on a first-line fixed-dose combination treatment of tenofovir-lamivudine-dolutegravir. There was no other significant past medical, surgical, or family history of note. On further history, the patient reported paroxysmal episodes of headaches, palpitations, and sweating. She did not have any focal neurological symptoms. On physical examination, she had a tachycardia of 110 beats per minute and a sustained elevated blood pressure with an average of 160/90 mmHg. There were no palpable neck or abdominal masses or any skin lesions. The rest of her systemic examination was unremarkable.On biochemical investigation, she had significantly elevated urine catecholamine metabolites with normetanephrine levels of 50,060 nmol/24 h (562–2129 nmol/24 h), (Table 68Ga DOTATATE (68 Ga) 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)–Octreotate scan showed DOTA receptor avid uptake in the left posterior mediastinal mass  of the abdomen was normal. Subsequent CT chest imaging showed a large avidly enhancing left posterior mediastinal T1–T3 paraspinal soft tissue mass abutting the apical-posterior segment of the left upper lobe of the lung. Medial extension into the second thoracic vertebral body, and even further extension into the intervertebral neural foramen, resulted in spinal cord abutment  demonstrated extension into the epidural space via the left neural foramina of T1/T2 and T2/T3 and with resultant displacement and compression of the spinal cord at the T2 level; however, no spinal cord edema was noted. There was additional infiltration of the posterior left parietal pleura with encasement of the left subclavian artery and abutment of the left common carotid artery, brachiocephalic trunk, and aortic arch posterior walls  and a beta blocker (atenolol) prior to surgery. After 14 days of the alpha blockade and 72 h of beta blockade, our patient underwent emergency surgery, having a T2–T4 laminectomy and posterior resection of the PGL lesion. The surgery was uncomplicated and upon postoperative assessment, the patient had preserved neurology.Histology confirmed the typical nested  growth pattern of the tumor with invasion into the surrounding capsule and a focus of lymphovascular space invasion Fig. A and B. As genetic testing for PPGLs was not yet available in South Africa, a sample was sent to an internationally accredited commercial laboratory. The sample yielded no key pathogenic DNA mutation.Postoperatively she remained symptomatic; her blood pressure remained elevated. At 6 weeks, postoperation urine sampling and imaging were conducted. The 24-h urine metanephrines were still positive with a urine normetanephrine level of 66,124 nmol/24 h (562–2129 nmol/24 h). A postoperative meta-iodobenzylguanidine (MIBG) scan revealed that there was still avid disease in the left upper thoracic region, representing residual disease  is the preferred functional imaging method and specific diagnostic technique, when DOTA is not available [68Ga-DOTA PET/CT in the detection of PPGLs, it has become the primary functional imaging technique for PPGLs [Imaging modalities usually confirm the diagnosis with a discoverable mass, and nuclear medicine scans are extremely helpful to detect whether the mass is active. Scintigraphy with vailable . Based oor PPGLs .Once a diagnosis is confirmed, total surgical excision of the tumor is the primary goal as this provides a better long-term outcome . Prior tCases of recurrence, when the tumor was not totally resected, have been described in the literature . ChemothSpinal PGLs are exceedingly rare, and herein we present a case of a young female of African descent, with a functional thoracic PGL with spinal canal extension and compression. There was no underlying pathogenic genetic mutation found in the patient. It is important that the management of cases involve a multidisciplinary team. Even though rare, PGLs should be considered in the differential diagnosis of spinal tumors. Genetic testing should be undertaken in the investigation of patients with PGLs for pathologic mutations. Malignancy should be suspected, with multiple and/or unusually located lesions. One should exercise extreme caution in treating such rare lesions that cause neurological deficits and undertake careful surgical planning to avoid catastrophic complications.


Meningiomas are mostly benign brain tumors with minimal malignant cases. Anaplastic meningioma has malignant morphological characteristics and a World Health Organization grade of III.The present study reports a case of an occipital meningioma in a patient who initially chose observation and follow-up after diagnosis. The patient ultimately underwent surgery due to the enlargement of the tumor and the development of visual field defects after a decade of imaging follow-up. The postoperative pathology slides indicated the presence of an anaplastic meningioma .The patient’s diagnosis was established through cranial magnetic resonance imaging, which revealed an irregular mixed mass in the right occipital region with isointense T1 and hypointense T2 signal, irregular lobulation, and a maximum diameter of approximately 5.4 cm. Heterogenous enhancement was observed in the contrast-enhanced scan.The patient opted for surgical intervention to remove the tumor, and the pathology slides of the tumor sample confirmed the diagnosis of anaplastic meningioma. The patient also received radiotherapy (40Gy/15fr).No recurrence was observed during the 9-month follow-up.This case highlights the potential for low-grade meningiomas to undergo malignant transformation, particularly in the presence of irregular lobulation, peritumoral brain edema, and heterogeneous enhancement on contrast-enhanced scans. Total excision (Simpson grade I) is the preferred treatment option, and long-term imaging follow-up is recommended. The present study reports a case of an occipital meningioma in a patient who initially elected for a strategy of observation and monitoring following the initial diagnosis. However, due to the enlargement of the tumor and the emergence of visual field defects over a period of 10 years of imaging follow-up, the patient ultimately underwent surgical intervention. The postoperative pathology analysis revealed the presence of anaplastic meningioma . To the best of our knowledge, this represents a case of anaplastic meningioma with the longest documented imaging follow-up interval since the initial diagnosis. While there is currently no consensus on the time frame for malignant transformation in low-grade meningiomas, it is acknowledged that there is a risk of malignant transformation. Therefore, it is recommended that patients receive intervention as soon as possible following the identification of a space-occupying lesion at the initial imaging diagnosis. Total excision is considered the preferred treatment option, and long-term imaging follow-up is required postoperatively.Meningiomas are a prevalent type of brain tumor, with the majority of cases being benign in nature.The present study reports on a case of an occipital meningioma in an 80-year-old female patient. In 2012, a space-occupying lesion was identified in the right occipital region with an elliptical shape measuring approximately 3 cm in diameter. Based on imaging, the diagnosis of meningioma was considered .The pathology analysis of the tumor sample revealed a predominance of atypical spindle tumor cells with extensive multifocal necrosis and partial readily-visible nuclear division. Immunohistochemistry results were PR , EMA , S-100 , CD34 , P53 , and Ki-67 . Collectively, this led to the diagnosis of anaplastic meningioma (WHO-grade III)  and there was no evidence of recurrence during the 9-month follow-up period. According to the 2021 WHO classification system, central nervous system tumors are classified into 15 subtypes under grades I, II, and III. The majority of meningiomas are histologically benign and can be effectively treated through surgical resection. Atypical (WHO-grade II) and anaplastic meningiomas (WHO-grade III) have a tendency to recur. Anaplastic meningiomas (WHO-grade III) can be broadly categorized into 2 groups: cases diagnosed by pathology slides during the initial surgery, and cases that have transformed from low-grade meningiomas. The 5-year survival rate of anaplastic meningiomas (WHO-grade III) ranges from 8 to 61%. In the current case, the interval from initial imaging diagnosis to surgery was 10 years, indicating a slow progression. It is plausible to suspect that the anaplastic meningioma (WHO-grade III) in this case was transformed from a low-grade meningioma (WHO-grade I). Factors that may contribute to this transformation include radiotherapy, surgical stimulation, viral and chromosomal variations, patient age, and tumor location. Imaging findings, in this case, revealed an irregularly lobulated tumor with peritumoral brain edema, and heterogeneous enhancement on contrast-enhanced scans, which are typically indicative of malignancy. Total tumor resection (Simpson grade I) and adjuvant radiotherapy have been shown to be beneficial in extending survival.Meningiomas are tumors that arise from arachnoid cap cells and are among the most prevalent intracranial tumors, often observed in regions with abundant arachnoid granulations.There is currently no consensus on the time frame for the malignant transformation of meningiomas. This particular case, with a 10-year follow-up period, represents one of the longest follow-up periods reported in the literature and serves as a valuable reference in the field of neuro-oncology. However, even after the malignant meningioma is removed at a Simpson grade I level, recurrence may still occur with adjuvant radiotherapy. Therefore, it is recommended that intervention be initiated as soon as possible upon the initial diagnosis of meningioma. Total excision (Simpson grade I) is the preferred course of treatment, and long-term imaging follow-up is recommended. For patients who opt for imaging follow-up after the initial diagnosis, a trend of tumor enlargement should prompt consideration of further intervention, particularly in cases that present with irregular lobulation, peritumoral brain edema, and heterogeneous enhancement on contrast-enhanced scans, as these may indicate malignant transformation.Conceptualization: Xiaoqin Qu, Jingcheng Jiang, Lihua Qiu, Yong Yi.Data curation: Xiaoqin Qu, Jingcheng Jiang, Han Wang, Chao Zhang, Qingshan Deng, Xiaoping Xu, Shijun Zhou.Formal analysis: Jingcheng Jiang.Investigation: Jingcheng Jiang.Supervision: Lihua Qiu, Yong Yi.Validation: Yong Yi.Writing – original draft: Xiaoqin Qu, Jingcheng Jiang, Han Wang, Chao Zhang, Qingshan Deng, Xiaoping Xu, Shijun Zhou.Writing – review & editing: Lihua Qiu, Yong Yi.


Placental abruption, a rare but life-threatening obstetric emergency, presents substantial risks to maternal and fetal well-being. This case report documents the clinical journey of a 35-year-old woman with multiple risk factors who presented at 30 weeks gestation with symptoms suggestive of placental abruption, including colicky lower abdominal pain and vaginal bleeding. Notably, her late initiation of prenatal care and a history of pregnancy-induced hypertension added complexity to the clinical picture. The case revealed a Couvelaire uterus, an uncommon and challenging complication of placental abruption, further emphasizing the need for early recognition and swift intervention. A multidisciplinary approach played a pivotal role in managing this high-risk obstetric case. Imaging and laboratory tests facilitated diagnosis and assessment, guiding surgical intervention and post-operative care. Despite the severity of the condition, the patient experienced a positive outcome for herself and her fetus, highlighting the critical importance of timely and comprehensive medical care. This case report contributes to medical knowledge by shedding light on the rare Couvelaire uterus. It underscores the significance of early diagnosis, coordinated healthcare teams, and patient education in mitigating risks associated with placental abruption. Ultimately, it reinforces the vital role of healthcare providers in safeguarding the lives of expectant mothers and their infants in obstetric emergencies. Placental abruption, an infrequent yet perilous obstetric emergency, poses substantial threats to the well-being of both mother and fetus . This caPlacental abruption is a critical obstetric complication characterised by prematurely separating the placenta from the uterine wall before the delivery of the fetus. This condition can lead to significant maternal and fetal morbidity and mortality if not promptly recognised and managed. Therefore, it is essential to understand the signs, symptoms, and potential complications associated with this condition .Abruptio placenta typically presents symptoms such as colicky lower abdominal pain and vaginal bleeding. Recognising these clinical manifestations promptly is crucial, as they often necessitate immediate medical attention. Moreover, understanding the gestational age at which placental abruption occurs can significantly impact maternal and fetal outcomes. Therefore, this case report will explore the gestational age differences and their implications .Placental abruption, defined as the premature detachment of the placenta from the uterine wall after 20 weeks of gestation, represents a condition fraught with grave consequences for both the expectant mother and the developing fetus .This case report offers a comprehensive account of the patient's clinical journey, encompassing her initial presentation with alarming symptoms and deteriorating vital signs, culminating in surgical exploration that resulted in the delivery of the fetus and placenta. Additionally, we delve into the patient's post-operative recovery, emphasising the importance of a multidisciplinary approach in addressing the intricate interplay of factors in cases of severe placental abruption. The favourable outcome underscores the significance of early diagnosis, prompt surgical intervention, and vigilant post-operative care, emphasising the pivotal role of healthcare professionals in handling such high-stakes obstetric scenarios .A 35-year-old woman, gravida three para one, presented to the emergency department during the late night hours when she was at 30 weeks gestation in her second pregnancy. She complained of colicky lower abdominal pain and vaginal bleeding, which had been ongoing for six hours. During the history-taking process, it was revealed that she had previously used one sanitary pad, which was only mildly soaked. Her medical history included one full-term normal vaginal delivery complicated by pregnancy-induced hypertension one year earlier. Notably, she had not received prenatal care at our hospital and was only booked for care at 21 weeks in a private facility. Until this point, she had been relatively asymptomatic, with two antenatal visits. It's noteworthy that she declined maternal serum screening for chromosomal and aneuploidies. Additionally, a fetal anomaly screening at 21 weeks had shown no signs of fetal anomalies.Upon examination, the patient's vital signs were concerning, with maternal tachycardia of 110 beats per minute and a blood pressure reading of 90/70 mmHg. Abdominal examination revealed a contracted and tense abdomen that felt woody-hard. A speculum examination showed active bleeding through the cervical os, and a small clot was evacuated during the examination.Subsequently, the patient was admitted to the hospital for further monitoring. Initial blood tests revealed a haemoglobin level of 8.4 g/dL, a low platelet count of 90,000/cumm, and a deranged coagulation profile characterized by prolonged prothrombin time (PT). They activated partial thromboplastin time (aPTT). An abdominal ultrasound showed a heterogeneous area anterior to the placenta, suggesting blood products, indicating placental abruption.Given the patient's deteriorating condition and the need to explore the unique aspects of this case, we opted for an explorative laparotomy. Under general anaesthesia, a lower segment hysterotomy was performed via a Pfannenstiel incision. This approach allowed us to gain crucial insights into the condition of the patient's uterus and the complications arising from the Couvelaire uterus, a relatively rare and severe manifestation of placental abruption.During the laparotomy, our observations unveiled several noteworthy findings. Notably, we encountered a Couvelaire uterus Figure , a condiAs we proceeded with the surgery, we encountered the fetus and an entirely separated placenta. One of the major complications associated with a Couvelaire uterus is hemoperitoneum, a condition characterised by blood accumulating within the abdominal cavity. Unfortunately, this case presented with hemoperitoneum, which was evident during the procedure. The blood loss is approximately 800 mL Figure , emphasiThe appearance of the uterus during the laparotomy remained consistent with a Couvelaire uterus, and we undertook the necessary steps to ensure hemostasis. The uterus was closed in two layers with meticulous attention to detail, ultimately achieving successful bleeding control Figure .The patient's recovery was satisfactory after the surgery, with blood product replacements administered. Her coagulation profile returned to normal, and on the third post-operative day, her haemoglobin level was measured and found to be 9.2 g/dL, indicating a positive response to treatment. She was discharged in good health three days after the surgery. Subsequent histopathological examination of the placenta confirmed the presence of retroplacental and intramembranous haemorrhage with intervillous haemorrhage, consistent with placental abruption.This case illuminates an exceptionally rare complication: the presence of a Couvelaire uterus, characterized by the extensive infiltration of blood into the myometrial tissue. This condition often accompanies severe placental abruption, rendering surgical intervention a formidable challenge. Identifying this condition during the surgical procedure underscores the significance of a comprehensive intraoperative assessment and unwavering vigilance ,6. EffecCurrently, no established diagnostic clinical criterion exists for placental abruption. The New Jersey-Placental Abruption study  reports Highlighting the urgency of early diagnosis in cases of placental abruption is imperative. In this instance, the delay in seeking medical attention and the tardiness in hospital booking may have exacerbated the severity of the abruption. Therefore, promoting awareness among pregnant women regarding timely prenatal care and recognising warning signs is paramount in averting such adversities . DiagnosDespite the intricacies of the case and the emergence of a Couvelaire uterus, the patient's expeditious surgical intervention and comprehensive post-operative care culminated in a favourable outcome for both the mother and the fetus. This serves as a poignant reminder of the indispensable role played by a well-coordinated healthcare team in safeguarding the lives of expectant mothers and their offspring .This case report enriches the body of medical literature by shedding light on the rare complication of a Couvelaire uterus within the context of placental abruption. It underscores the imperativeness of early diagnosis and swift intervention in managing high-risk obstetric scenarios, emphasizing the need for continuous medical education and heightened awareness among healthcare providers. Furthermore, this case underscores the importance of patient education about prenatal care and recognizing warning signs during pregnancy. Healthcare systems should prioritize initiatives to augment patient awareness to mitigate delays in seeking essential medical attention.In conclusion, the placental abruption presenting with a Couvelaire uterus in our case report not only underscores the challenges and complexities faced by healthcare providers in managing obstetric emergencies but also brings to light the unique aspects and novelty of this clinical scenario. Our case offers a distinctive perspective by shedding light on the intricate interplay of factors contributing to the development of a Couvelaire uterus, including the delayed presentation of the patient and the ensuing hemoperitoneum - a complication not extensively documented in previous literature. This novel insight into the pathophysiology of a Couvelaire uterus and its association with hemoperitoneum adds to the body of knowledge surrounding this rare condition. Furthermore, our report serves as a testament to the critical role of early diagnosis, a multidisciplinary approach, and comprehensive care in achieving favourable outcomes in high-risk obstetric situations. By presenting this unique case, we aim to highlight the significance of prompt recognition and timely intervention in placental abruption cases with atypical presentations, ultimately emphasizing the critical importance of healthcare professionals in ensuring the well-being of both mothers and infants in such challenging clinical scenarios.


Genetic evaluation has not been performed in our patient. The physiopathology of giant insulinomas remain unexplained, however with possible relationship with type 1 multiple endocrine neoplasia, sporadic somatic YY1 mutations and possible transformation of bulky non-functional pancreatic neuroendocrine tumors to a functional phenotype, with slow insulin secretion. While giant insulinomas remain rare in the literature, multicentric genetic analysis of tumor samples might reveal unique features of this rare subtype of neuroendocrine pancreatic tumors. Insulinomas of large size tend to have greater malignancy and higher rates of invasiveness. Careful follow-up, especially for liver and lymph node metastases, must be performed using functional imaging techniques to avoid disease relapse.Insulinomas, with an incidence of 4 cases per million individuals per year, remain amongst the most frequent functional neuroendocrine tumors. The usual diameter of insulinomas usually remains under 3 cm of major axis. However, 44 exceptional cases of “giant insulinomas”, have been reported worldwide, generally exceeding 9 cm in major axis. In this article, we report the case of a 38-year-old woman whom suffered from chronic hypoglycemia despite treatment with diazoxide. Abdominal CT-scan revealed a 88 x 73 mm mass located at the tail of the pancreas. Following surgical excision, histopathological analysis confirmed G1 neuroendocrine tumor, with focal cytoplasmic expression of insulin in tumor cells. After a 16-month follow-up period, the patient didn’t address any specific complaint, and no disease recurrence and/or metastasis were observed. A  InsulinAs a general rule, most patients with insulinoma present with hypoglycemia, however diagnosis can be challenging in smaller tumors, given that the average size of these tumors is no greater than 3 cm of diameter in 95% of cases , 7. In sManagement of insulinomas include curative surgery, and medical treatment such as the use of diazoxide or somatostatin analogs  to alleviate symptoms and induce tumor regression , 10. OthInsulinomas are commonly considered as benign tumors, however malignancy could be associated with tumors of greater size with higher metastatic rates , 15. DesIn this article, we report the case of a 38-year-old female patient suffering from a non-metastasizing insulin-secreting giant pancreatic neuroendocrine tumor (PanNET) and discuss the pathogenesis and current knowledge regarding giant insulinomas.2A 38-year-old female patient was admitted to the University Hospital of Dijon for multiple episodes of malaise, fatigue and fainting at home for the last 3 months. The episodes of fainting were experienced by the patient before noon or by the end of the afternoon, usually before meals. Increased food intake at specific timepoints before meals alleviated the symptoms. Past medical history includes appendectomy and use of a contraceptive intrauterine device. Family history includes prostate cancer in one of the grandfathers. The patient was not on any specific medication by time of the diagnosis, however regular tobacco use was noted.68Ga-DOTATATE-PET scan was performed 6 months after surgery, which came back normal.The patient was soon referred to the Department of Endocrinology, as fasting capillary blood glucose measurements (CBGM) were as low as 1.99 mmol/L (35.8 mg/dL). At admission, the patient weighted 58.2 kg. Concomitant fasting insulin and C-peptide assays revealed inappropriate insulin secretion, with C-peptide at 2.01 ng/mL, pro-insulin at 91.56 pmol/L and insulin levels at 13.6 mIU/L. Liver function tests, hemoglobin (13 g/dL), albumin levels (37 g/L), creatinine (63 µmol/L) and calcium (2.44 mmol/L) levels were otherwise normal. Total bilirubin (26 µmol/L) either conjugated or free was slight increased . CRP levels were low. The TSH (0.65 mIU/L), T4 (16.5 pmol/L), ACTH (29 ng/L) and cortisol levels remained within normal range. The PTH, IGF1 and prolactin levels were within normal range. Genetic analysis for MEN1 gene has not been performed. An abdominal CT-scan was performed, which showed a heterogenous 88 x 73 mm bulky mass of the left hypochondrium located between the tail of the pancreas and the splenic hilum, without evidence of tissue infiltration or peripheral lymph node invasion Figure 1368Ga-DOTATATE-PET scan to predict prognosis and detect small-sized metastatic sites  and showing variable phenotypic spectrum even in identical monozygotic twins  pathway might explain overgrowth and potential transformation in giant insulinomas . Giant iIn conclusion, giant insulinomas are very rare tumors showing unique histopathological features, with very scarce knowledge about their pathogenesis. “Giant” insulinomas have a higher recurrence of metastasis, malignancy, and tissue invasion than smaller tumors, therefore indicating the need for careful follow-up to avoid the appearance of metastatic recurrence, especially metastatic liver disease. Further international integrated studies involving transcriptomic analysis and cell culture of giant insulinomas might explain the pathogenesis of these overgrowing tumors, usually presenting with a worse prognosis and requiring risky surgical procedures for safe and complete removal.4The resection specimen was handled for gross examination according to standard guidelines . The tumThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.Writing and editing: GT, LM, J-MP, BB, AR. Resources: A-CL, GT, LM, BB, J-MP, AR. HA, PR, KG, RL. Investigation: GT, LM, J-MP, BB, AR, HA, PR, RL, KG. All authors contributed to the article and approved the submitted version.


Adolescent idiopathic scoliosis is a coronal plane spinal deformity which most commonly presents in adolescent girls from ages 10 to 18 (A). Diagnosis is made with full-length standing posteroanterior (PA) and lateral spine radiographs. Treatment can be observation, bracing, or surgical management depending on the skeletal maturity of the patient, magnitude of deformity, and curve progression. In scoliosis cases, surgical intervention is typically considered when the curvature progresses to a certain degree or when it causes significant pain, respiratory problems, or other complications . The goal of scoliosis surgery is to correct the curvature and stabilize the spine. However, despite surgical intervention, there is a small risk of recurrence or progression of the deformity. Factors that may increase the risk of recurrence include inadequate surgical correction, incomplete fusion of the spinal segments, failure of implants or instrumentation, and continued growth of the spine in skeletally immature individuals. Here, we report a rare presentation of operated case of adolescent idiopathic scoliosis at dorsal spine with recurrence of deformity (D). Recurrence of deformity is very uncommon (<0.5 %). A 22-year-old female patient was brought to the orthopedics outpatient department (OPD) with complaints of pain and deformity in his upper back region since 5 years which were increasing over the period of time (E). On examination, there was scar of previous surgery present over midline approximately 15 cm in length at dorso lumbar level, recurrence of deformity over right side convex curve and no neurodeficit present and power in bilateral upper limb and lower limb v/v.


Dedifferentiated liposarcoma is defined as a malignant tumor that changes its shape from a well-differentiated liposarcoma to a non-liposarcomatous form. Most paratesticular liposarcomas manifest as an inguinal, painless, slow-growing mass. The standard treatment is extensive surgical excision, radiotherapy being proposed for cases with positive margins, those with recurrence, or in cases of the existence of unfavorable prognostic factors.We present the case of a young patient diagnosed initially with left hydrocele, which after 2 years proved to mask a differentiated liposarcoma of the spermatic cord. The initial clinical manifestations were represented by the increase in volume of the left groin-scrotal region and pain at this level.Microscopic examination in hematoxylin-eosin staining highlighted the presence of lipoblasts and fibroblasts in association with areas of hemorrhage and tumor necrosis. The performed immunohistochemical tests confirmed the diagnosis of dedifferentiated liposarcoma. To support and confirm the presence of the mouse double minute 2 homolog gene mutation, chromogenic in situ hybridization analysis was performed.The initial treatment was the surgical one. After 2 weeks, the patient received zolendronic acid for hypercalcemia which was caused by the osseous metastasis.The patient died secondary to acute renal failure caused by hypercalcemia despite the treatment received.This case underlines the importance of both the correct management of oncological patients, as well as immunohistochemical and genetic tests in the identification of prognostic factors, with the ultimate goal of administering an appropriate oncological treatment. Liposarcoma is a tumor originating in the mesenchymal cells, the most frequent location being the retroperitoneal one. Other rare locations are spermatic cord, mediastinum, head and neck, and trunk. According to the latest edition of the World Health Organization (2020), liposarcoma is classified as well-differentiated, dedifferentiated, myxoid, pleomorphic, and myxoid pleomorphic liposarcoma. Most paratesticular liposarcomas manifest as a painless, slow-growing inguinal mass. These tumors are often misdiagnosed as hydrocele, lipoma, funicular cyst, testicular tumor, or inguinoscrotal hernia. The standard treatment is extensive surgical excision, radiotherapy being proposed for cases with positive margins, those with recurrence or if they are associated with negative prognostic factors.In adults, over 75% of primary paratesticular tumors form in the spermatic cord and represent 7 to 10% of all intrascrotal tumors. Of these, 20% are liposarcomas.A 42-year-old patient presented to the hospital for an increase in the volume of the left inguinal-scrotal region and pain at this level. Two years before presenting to the hospital, he was diagnosed with a minimal amount of left hydrocele, which is why he did not undergo any treatment for this pathology. On palpation, a painful fluid collection was identified. Paraclinically, carcinoembryonic antigen and human chorionic gonadotropin had normal values. Imagistically, computed tomography highlighted a left scrotal cavity with an enlarged projection area with heterogeneous content by the presence of a fluid accumulation and a relatively well-defined nodular lesion with polylobate contour, native hypodense, with heterogeneous structure by the presence of non-capturing hypodense areas and isodense, iodophilic areas with vascular pathways included. Numerous areas of secondary determinations of osteolysis have also been identified, as well as paraaortic lymphadenopathy with adenopathic block formation.The patient was treated surgically by the resection of the left inguinoscrotal region without excision of the adenopathies and discharged in a good clinical state. After 2 weeks, the patient returned to the hospital with tonic-clonic seizures caused by hypercalcemia . Due to the manifestations at the time of hospitalization, magnetic resonance imaging (MRI) was performed. It highlighted the presence of metastases at the level of the frontal bone. The MRI examination identified a relatively well-defined nodular lesion, with a maximum diameter of 2 cm and hyperintensity in T2-weighted image , the pTNM staging was: pT4 pM1. The patient was in stage IV of the disease. Considering the fact that the lymph nodes were not sent for examination, their invasions could not be assessed and, as a result, reported.The following immunohistochemical markers were performed: Ki-67, mouse double minute 2 homolog (MDM2), glial fibrillary acidic protein, smooth muscle actin, vimentin, p16, and p53 Fig. . The immGenetic testing by chromogenic in situ hybridization (CISH) of the examined cells (x400 magnification) showed nuclear 4 to 8 individually arranged chromogenic signals, with an average of 5.48 on 50 cells. The examined cells revealed the presence of a high degree amplification of the MDM2 gene , spermatic cord (76%), and vaginal tunic (20%). It is difficult to identify the origin given the size of the tumor and the degree of adhesion. Most occur in adults between the ages of 50 and 60. Data on the exact pathogenic mechanism are scarce, but it is known to be formed de novo from connective tissue and not by malignant transformation of a preexisting lipoma.Soft tissue sarcomas are a rare disease, accounting for approximately 1% of all adult malignancies and approximately 20% of mesenchymal malignancies. In general, these tumors are asymptomatic for many years, with symptoms lasting between 1 week and 5 years.The typical clinical presentation is inguinal edema or unilateral scrotal mass, which may or may not be painful, occasionally accompanied by hydrocele. Due to nonspecific manifestations, it is mandatory to differentiate preoperatively by inguinal hernia, hematocele, hydrocele, lipoma, epididymitis or orchiepididymitis, tuberculosis, and malignant lesions of the testicle.In our case, it is a 42-year-old man, whose manifestations began at the age of 40, a decade earlier than the average age cited in the literature. His symptoms were initially represented by hydrocele, evolving in the next 2 years until the significant increase in the volume of the left inguinoscrotal region, and pain. Distant metastases were also present at the time of diagnosis. The typical appearance on ultrasound is represented by hypervascular and heterogeneous with hyperechoic areas, depending on the amounts of intratumoral adipose tissue, but it is not possible to differentiate between a lipoma and a liposarcoma, especially if it is well-differentiated.,8 Computer tomography with contrast substance is the most used and most useful primary imaging method to diagnose a possible soft tissue sarcoma developed in the trunk and pelvis. Magnetic resonance imaging is reserved for patients allergic to iodinated contrast agents. Also, CT is useful for establishing localization, staging, and post-therapeutic follow-up.Usually, the inguinal and scrotal masses are evaluated by ultrasound to differentiate the intratesticular location from the extratesticular one and the solid masses from the cystic ones.In our case, because the suspected diagnosis was hydrocele, a CT was performed. It revealed a nodular lesion with a heterogeneous structure by the presence of non-capturing hypodense areas and isodense, iodophilic areas. The presumptive diagnosis was liposarcoma. The imaging appearance of the inguinal-scrotal region in association with adenopathies and secondary bone findings led to the establishment of the initial surgical treatment: the resection of the left inguinoscrotal region without the excision of the lymph nodes.,10 Retroperitoneal lymph node dissection is usually performed in cases with present metastases. In Kamitani’s study, he showed that the 3-year survival rate without recurrence was significantly higher in patients treated with high inguinal orchiectomy (79.8%) than in those treated with tumorectomy alone (54.1%). The 3-year survival rate was 54.2% for those with positive margins and 88.6% for the cases with negative margins.Radical orchiectomy with high ligation of the spermatic cord, without positive microscopic edges, is the essential surgical treatment.Due to the increased risk of recurrence after surgical treatment, there is evidence that all spermatic cord tumors should be treated with adjuvant radiotherapy, regardless of histological grade and type. Chemotherapeutic treatment is initiated with anthracyclines, usually doxorubicin in association with ifosfamide. However, dedifferentiated liposarcoma shows chemoresistance, with radiographic response in less than a third of patients.Some studies have shown that postoperative radiation therapy can significantly reduce the recurrence rate at 10 years in patients with high-grade tumors. It is recommended in cases of high-grade tumors, lymphatic invasion, positive margins, or relapses. Regarding chemotherapy, the data in the literature are limited, without a definitive role in the management of liposarcomas.MDM2 is a major target in oncology treatment, with substances blocking the interaction between MDM2 and p53, restoring the wild-type activity of p53. One of these molecules is Nutlin-3A, which inhibits the interaction between the 2 genes and stabilizes p53, the disadvantage being the very low clinical efficacy and the limitation of the therapeutic dose secondary to severe thrombocytopenia. The dedifferentiated subtype is the most worrying variant in terms of aggressive evolution and early recurrence. The areas of dedifferentiation have various aspects, but most frequently resemble undifferentiated pleomorphic sarcoma and high-grade or intermediate-grade myxofibrosarcoma. In our case, areas with a fascicular appearance, with a “Herringbone” pattern, accentuated pleomorphism and the presence of multinucleated giant cells were identified.Dedifferentiated liposarcoma is a malignant tumor that changes its shape from a well-differentiated liposarcoma to a non-liposarcomatous form. Dedifferentiation is a time-dependent process in 10 to 15% of well-differentiated forms, the average period being 7.7 years, and the 5-year survival rate is 28%. In our case, both the immunohistochemical expression and the amplification of the MDM2 gene confirmed the diagnosis of dedifferentiated liposarcoma.From a cytogenetic point of view, dedifferentiated liposarcoma is characterized by a supernumerary ring and giant marker chromosomes. They contain amplified seventy 12q13-15, but also other co-amplified chromosomal regions. Region 12q13-15 includes genes such as MDM2, CDK4, and HMGA2. MDM2 binds to p53 and regulates it negatively by preventing nuclear transcription and translocation, but also by supporting its degradation through ubiquitin E3 binding. Currently, immunohistochemical evaluation of MDM2 and CDK4 may help screen for 12q13-15 amplification. Horvai et al observed that dedifferentiated liposarcomas have a higher total number of amplification.The epigenomic initiators of dedifferentiation are poorly known, and more studies are needed. The molecular pathogenesis of dedifferentiation is a poorly understood process, although the genomic profile of this tumor is characterized by a low mutational burden. The amount of 12q13-15 amplification and MDM2 upregulation seems to be associated with the degree of dedifferentiation. P53 mutations were associated with the dedifferentiation process from well-differentiated to dedifferentiated liposarcoma. The location of the tumor has an important role in this process. In retroperitoneal localization, MDM2 amplifications and p53 mutations are mutually exclusive, but in non-retroperitoneal localizations of dedifferentiated liposarcoma, TP53 mutations appear in the presence of MDM2 amplification. The MDM2-p53 axis is regulated by multiple oncogenic signaling pathways involved in sarcomogenesis and represents a possible therapeutic target. Also, inhibitors of the co-activators of the MDM2-p53 pathway, such as inhibitors of mTOR, were studied. Most of the targeted therapies studied for dedifferentiated liposarcoma had clinically inferior results compared to anthracycline-based chemotherapy. For this reason, most of the studied inhibitors are not recommended as adjuvants to systemic therapy.The tumor suppressor protein p53 is an essential regulator of cell division, DNA repair, apoptosis, and cellular senescence. The activity of this protein is primarily regulated by MDM2. Thus, the amplification of MDM2 leads to a decrease in p53 activity. According to Cai D et al, genetic mutations of p16 led to a decrease in overall survival. The high frequency of p53 gene mutations tends to determine the decrease in disease-free survival in sarcomas.Rekhi B et al studied the expression of p16 in 16 cases of dedifferentiated liposarcoma, all having a diffusely positive immunoexpression.In our case, we identified a large number of amplifications of the MDM2 gene. We also observed the presence of p53 gene mutation and p16 overexpression. This association justifies the fulminant evolution of the presented case, the death occurring within 3 weeks from the time of diagnosis. In the study by Ballo et al 5-year recurrence rates at the loco-regional, hematogenous, and pelvic lymph nodes were 19.4%, 11.1%, and respectively 5.5%.The main way of metastasis of such a tumor is by contiguous extension through the inguinal canal into the abdominal cavity, the extension by hematogenous and lymphatic route being rarer.In the case of our patient, he presented at the time of diagnosis bone metastases that occur by hematogenous route, but also secondary lymph nodes involvement. Contiguous extension at the level of the adjacent organs was not identified. Wang et al observed that age <50 and incomplete surgical resection are predictive factors of non-recurrent survival and overall survival. Contrary, Dotan et al reported tumor size and the absence of metastases at the time of diagnosis are the only significant predictors of disease-specific survival. Stojadinovic et al also claim that positive surgical margins significantly increase the risk of local recurrence in addition to increasing the risk of metastasis and disease-related death.Negative margins are an essential factor for non-recurrent survival. The total disease-specific survival at 5 and 10 years in cases of spermatic cord sarcoma is 75% and 55%.The postoperative and post-diagnostic management consists of imaging follow-up performed at 3, 6, 12, and 24 months, all the more so as this category of malignancies presents a risk for local recurrence, follow-up up to 10 years being mandatory.In the present case, following the evolution of the patient after diagnosis and surgical treatment, was not possible because of the occurrence of death within three weeks of the establishment of the diagnosis.Although the dedifferentiated liposarcoma of the spermatic cord is a rare entity, whose evolution is unfavorable, extending mainly by contiguity, in this case, the extension of tumor proliferation took place by hematogenous and lymphatic routes, the last ones being rarer ways of metastasis of sarcomas. This aspect is one of the main features of the case. Another defining aspect is the age of onset of the manifestations, which is lower than the average age reported in the literature.This case highlights the importance of a quick diagnosis, starting with appropriate imaging investigations. The final diagnosis is guaranteed only by corroborating the histopathological and immunohistochemical aspects with the clinical ones. The CISH test has a complementary role, also confirming the diagnosis established in the usual staining. It also draws attention to the unfavorable evolution of sarcomas, which can lead to death through the biochemical effects determined by the occurrence of metastases.Conceptualization: Mariana Aschie, Gabriela-Izabela Baltatescu.Supervision: Mariana Deacu.Validation: Madalina Bosoteanu.Writing – original draft: Cristian Ionut Orasanu, Raluca Ioana Voda.Writing – review & editing: Sorin Vamesu, Georgeta Camelia Cozaru.


Deep endometriosis, defined as external adenomyosis, is a late stage of endometriosis. Associated with very severe pain, in addition to probably being a cofactor of infertility, with a low prevalence, the diagnosis is integrated by high clinical suspicion and confirmed with imaging studies. Deep infiltration can reach sigmoid colon, which would have surgical indication as resolving treatment. We report the case of deep infiltrating endometriosis affecting sigmoid colon of a 42-year-old woman, who was diagnosed with colicky pain in the left lower quadrant and chronic constipation. Colonoscopy revealed a 90% stenosis in the proximal portion of sigmoid colon, as well as mural thickening proximal to the site of stenosis, reported by computed tomography with oral contrast, for which it was decided to perform robot-assisted sigmoidectomy, with a 6-month follow-up and with imaging control, patient continues asymptomatic and without the presence of lesions suggestive of recurrence, and there is no functional impairment. Endometriosis is a very common disease in women, defined by the presence of endometrial tissue outside the uterine cavity, a process that induces a chronic inflammatory reaction in tissues and organs . It is eWe present the case of a 42-year-old woman who was diagnosed with chronic constipation that had lasted 5 years. Her chief complaint was absence of stool, intense colicky abdominal pain localised at the left lower quadrant and hypogastrium, nausea and vomiting on five occasions. She consulted her primary physician, who prescribed oral trimebutine, rifaximin, omeprazole and pinaverium bromide with lysine clonixinate; this partially resolved the symptoms. Upon arrival to our medical unit, we conducted laboratory and imaging studies which yielded the following relevant results: leukocytosis (11 400 leukocytes) with neutrophilia (8500 neutrophils), hyperbilirubinemia, . The rest of the blood laboratory findings were within normal limits. The urinalysis reported a density of 1015, pH 5.5, ketones +, bilirubin 2 +, positive nitrites, leukocytes of 6–10 and erythrocytes 0–2 per field. Due to persistence of the patient’s symptoms, 2 days later, an abdominal computed tomography (CT) scan with oral contrast was performed. The findings were of a thickened sigmoid colon with associated stenosis. After 3 days, we performed a colonoscopy with sigmoid biopsy . The resThe patient completed the postoperative period with adequate evolution, and hospital discharge 5 days later with no complications.et al., it was found that there is no significant correlation between symptoms and degree of intestinal wall infiltration [Deep intestinal endometriosis presents as a clinical picture similar or imitating a colorectal neoplasia; given this similarity in the clinical presentation, physicians must keep in mind the possibility of deep intestinal endometriosis as a differential diagnosis in women diagnosed with constipation, rectal bleeding, changes in bowel habits and intestinal obstruction. In a study conducted by Rossini ltration . In otheltration . The estltration . Dependiltration . This deltration . The degltration . CT scanltration , 14.According to several studies, laparoscopic rectal and sigmoid resection for deep endometriosis is safe, with low rates of severe complications and a short recovery time , 14. Rob


Lambl’s excrescences (LE) are mobile filiform lesions, mostly found on the left-sided heart valves. Histologically, they have a mesenchymal origin with a single endothelial layer. They have the potential to detach, resulting in catastrophic thromboembolic events. Their rarity often leads to them being misdiagnosed as vegetations of endocarditis with patients failing to improve on conventional therapy.A 48-year-old female with a history of hypertension presented to the Emergency Department with a one-week history of sharp left upper quadrant pain. She was vitally stable; the only lab abnormality was revealed to be a mildly elevated white cell count. CT abdomen revealed a splenic infarct involving 25% of the parenchyma. Patients had no history of abdominal trauma, coagulation disorders, exogenous estrogen use or IV drug abuse. Subsequent investigations failed to reveal any cause of hypercoagulability. An extensive cardiac workup revealed no arrhythmias, but transesophageal echocardiogram showed a mobile echo density on the ventricular side of the aortic valve attached at the coaptation zone, approximately 2.7 cm long and 0.1 cm wide, suggesting a very prominent Lambl’s excrescence. In the absence of any other findings, the patient’s splenic infarct was determined to be secondary to an embolic event from the aortic valve lesion. Rivaroxaban was initiated and the patient subsequently improved.Existing literature describes most LEs as being asymptomatic and discovered incidentally on echocardiograms. This case illustrates the need to develop a criterion for prompt identification of LEs and differentiating them from the vegetations of endocarditis. It also brings forth the question of prophylactic treatment of these lesions while highlighting the lack of guidelines regarding the management of embolic phenomena secondary to LE. Lambl’s excrescences (LE) were first described by Vilém Dušan Lambl in 1856 -4. The LA 48-year-old lady with a history of hypertension and smoking presented to the Emergency Department complaining of sharp left upper quadrant abdominal pain for one week. Patient was hemodynamically stable, afebrile and saturating well on room air. Physical examination demonstrated tenderness of the left upper quadrant. Labs showed mild leukocytosis and a normal complete metabolic profile.Computed tomography (CT) abdomen revealed splenic infarct Figure  involvinShe underwent extensive cardiac workup to eliminate an embolism of cardiac origin as the cause of splenic infarction. 30-day Holter monitor did not show any evidence of atrial fibrillation or other arrhythmia. Transesophageal echocardiogram (TEE) showed mobile echodensity on the ventricular side of the aortic valve attached at the coaptation zone, 2.7 cm long and 0.1 cm wide, suggesting very prominent Lambl’s excrescence  titre of 1:80 (speckled), negative rheumatoid factor and normal complement levels. Blood smear showed normal red blood cell (RBC) morphology. Hepatitis C virus (HCV) antibodies were normal. Embolic event from the aortic valve lesion was the most plausible explanation for the patient's splenic infarction. Rivaroxaban was initiated for management.LEs are often asymptomatic and identified incidentally during routine echocardiograms. They can often be found on valve closure lines as a papillary extension . These hOur patient’s lesion was present on the aortic valve like the case described by Lambl et al. , howeverThe pathogenesis behind development of these lesions seems to be repeated trauma from the passage of blood causing microtears in the endothelium. This results in fibrin deposition and fibrous scar formation that is later covered by an endothelial layer .Echocardiogram is used to identify the lesions, with TEE being favored over transthoracic echo (TTE). However even with TEE the sensitivity and specificity are low at 68% and 85% respectively [LEs are often mistaken for vegetations caused by endocarditis, papillary fibroelastoma and aortic valve fenestration . HistopaLEs are rarely associated with ischemic stroke ,8,12-14 Given the rarity of this phenomenon, there are no guidelines on treatment of patients with LE. Currently based on the available case reports treatment varies from antiplatelet therapy with single or dual agents in patients with single embolic phenomenon -20. In cIn conclusion, existing literature reports an association between the presence of LE to ischemia/embolic events. However, there is scant evidence for the clinical significance of the presence of these lesions. A paucity in the literature has made it difficult to determine the guidelines for management of patients with such ischemic/embolic events. There is a need to determine the clinical relevance of these lesions and their management.


Renal angiomyolipoma (AML), which is a rare solid kidney tumor with benign characteristics, also known as a renal hamartoma, can exhibit various clinical symptoms and severe consequences may arise if the lesion becomes large.A 58-year-old woman was admitted to a hospital, with general fatigue, abdominal swelling, and epigastric fullness. Upon examination, a large mass was palpated, which occupied almost the entire right abdomen. The abdominal computed tomography scan revealed a large right renal mass measuring 22 × 18 × 8 cm, which was exophytic and heterogeneous with a large fat component and an enhancing solid part. The tumor was successfully excised through a generous right subcostal incision with left-side extension. The total weight of the resected specimen was 2500 g, which appears to be the largest angiomyolipoma ever resected in Ethiopia.Renal AML, a benign tumor derived from mesenchymal components, is sometimes referred to as a “hamartoma” due to its variable makeup. The most common complaints of patients with renal AML are lower back pain, hematuria, and physical finding of hypotension (shock), though patients with giant AML, as in this case, may also experience gastrointestinal symptoms due to the mass' compression.Although treatment options requiring contemporary medical technologies and skilled manpower are difficult to offer in set ups of resource-limited countries, such as the one we reported from, giant renal angiomyolipoma can be treated safely with open nephrectomy. •Giant renal AML is a rare solid tumor.•Most renal AMLs are asymptomatic and identified incidentally with imaging.•Giant renal AMLs carry significant risk of bleeding.•Partial or total nephrectomy is recommended treatment for giant AMLs. Although the preponderance of cases remain asymptomatic, certain tumors may elicit sudden abdominal pain or hypotension, due to substantial intra lesion hemorrhage or retroperitoneal invasion. The management of patients presenting with renal angiomyolipoma is largely determined by tumor size. Tumors with a diameter of less than four centimeters (cm) are typically asymptomatic and can be managed with close monitoring, whereas larger tumors require the use of one or more of the available treatment modalities, including radiofrequency ablation, transarterial embolization, and surgical intervention .Herein, it is our intention to present a highly uncommon case in which the patient expressed dissatisfaction with abdominal fullness, ultimately leading to the diagnosis of a sizable renal angiomyolipoma. This medical anomaly was effectively resolved through the implementation of surgical excision. It is noteworthy that this particular case report adheres strictly to the esteemed SCARE criteria .2A 58-year-old female patient presented with general fatigue, abdominal swelling, epigastric fullness, early satiety, progressive bloating sensation, and reddish discoloration of urine lasting for six months before her presentation.The abdominal swelling started as a small mass in the right flank area, which gradually increased to occupy almost the entire abdomen over months' period. Furthermore, the patient experienced a weight loss of about 6 kg, with a weight of 54 kg at presentation compared to 60 kg, six months prior. Upon examination, a smooth, round, soft, and painless mass was palpable on the entire abdomen, with the dominant portion localized on the right side. Further examination and investigations were conducted to determine the underlying cause of the symptoms presented by the patient, which included abdominal distension, weight loss, and reddish urine.The complete blood count revealed a moderate level of anemia, indicated by a hemoglobin level of 8.0, while the other parameters fell within the normal range. Urine microscopy revealed microscopic hematuria, but renal function test results were unremarkable.Following ultrasound examination, a hyper echoic mass measuring approximately 18 cm in size was identified in the right abdominal area, possibly originating from the right kidney. Additionally, computed tomography (CT) revealed a large right renal mass measuring 22 × 18 × 8 cm, which was exophytic and heterogeneous with a large fat component and an enhancing solid part . There wExploratory laparotomy was performed via a subcostal incision on the right side. However, it was not possible to achieve full exposure through this incision; thus, we extended it to the left side, resulting in a chevron incision. The abdominal muscles were then divided using electrocautery, and the peritoneum was entered. As shown in Histopathological analysis revealed proliferation of bland adipocytes intermixed with cells with eosinophilic cytoplasm and cigar-shaped nuclei . The fin3First documented in 1951, renal angiomyolipoma (AML) is a nonmalignant neoplasm originating from mesenchymal elements . As a reThis substantial tumor, possessing thick-walled blood vessels, is susceptible to vascular ruptures and hemorrhaging. The occurrence of compression symptoms and bleeding from rupture is heightened owing to the development of hemorrhagic aneurysms accompanying the expanding AML , which mFor tumors that are less than 4 cm in size, most cases are asymptomatic, and can be followed with conservative management , or radi4Although treatment options requiring contemporary medical technologies and skilled manpower are difficult to offer in set ups of resource-limited countries, such as the one we reported from, giant renal angiomyolipoma can be treated safely with open nephrectomy.Before data collection, written informed consent was acquired and the laboratory procedure was done with the essence of beneficence and data were kept confidential. The written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of written consent is available for review by the Editor-in-Chief of this journal on request.The study is approved by the Research Review Committee of the institution. Before data collection, informed consent was acquired and the laboratory procedure was done with the essence of beneficence and data were kept confidential.There is no funding received for this work.Tilahun Deresse: Writing – original draft, review & editing.Mandante Bogale: Writing – original draft, review & editing.Dawit Alemayehu: Review & editing.Megbar Dessalegn: Review & editingMarta Seid: Review & editingTilahun Deresse.Not applicable.There is no conflict of interest.


Few reports of laser coagulation for foetal bronchopulmonary sequestration (BPS), a rare congenital malformation characterised by the absence of tracheobronchial connection and the presence of a systemic feeding artery, have been published. Additionally, very few of them focus also on the postnatal management, with results limited and controversial. Postnatal treatment of residual malformation remains debated, hence the need to share our experience of a combined pre- and postnatal approach to complicated extra-lobar BPS. We report the case of a female foetus with the diagnosis of a pulmonary lesion. Due to mediastinal shift, unilateral compressive hydrothorax, ascites, and hydrops, a foetal treatment with ultrasound-guided laser coagulation of the anomalous vessel was performed. At birth, due to the persistence of the malformation, an elective delayed thoracoscopical surgery was performed. Prenatal laser ablation for complicated BPS is a life-saving procedure not always resulting in lesion disappearance. Thoracoscopical surgical exploration in case of persistent lesions at birth offers the possibility of a minimally invasive sequestrectomy feasible and safe. Bronchopulmonary sequestration (BPS) is a rare congenital malformation characterised by the absence of tracheobronchial connection and the presence of a systemic feeding artery .Some BPSs, above all cases without foetal fluid effusions, spontaneously regress during pregnancy and can be managed expectantly , and othTo date, few studies reported in the Literature documented how complicated BPSs are successfully treated prenatally with laser ablation of the feeding artery –6, but vWe report a case of large foetal extra-lobar BPS treated with prenatal laser ablation followed by successful thoracoscopic elective resection.A pregnant women was referred to our attention with a female foetus with diagnosis of the left inferior pulmonary lesion at 22 weeks of amenorrhea (WA). Ultrasonographic follow-up showed an anomalous systemic vessel of 3 mm in diameter originating from the abdominal aorta and a progressive increase in size of the lesion with mediastinal shift, compressive hydrothorax, ascites, and hydrops.A foetal MRI confirmed a heterogeneous mass in the left lower lung lobe and the presence of concomitant left hydrothorax and right mediastinal shift shown in A foetal treatment was performed at 26 WA.Briefly, intrauterine ultrasound-guided laser coagulation (USLC) of the feeding artery was performed under maternal spinal anaesthesia and foetal intramuscular anaesthesia. An 18 G needle was introduced percutaneously, directly into the amniotic cavity. Under ultrasound guidance, the needle was directed through the foetal thorax to the lung mass and to the main feeding artery. The 400-micron laser fibre was inserted and, at a power of 15 Watts, contacted the aberrant artery intermittently for 15 s achieving coagulation. Color Doppler demonstrated cessation of blood flow shown in The complete procedure lasted 30 minutes. No intraoperative complications were observed.Serial ultrasound showed normal foetal growth, regression of anasarca, and stability of the size of the sequestration.At the control MRI at 32 WA, the size of the BPS was stable with 2/3 of the mass devascularized.The baby was delivered vaginally at 38 weeks, with a birth weight of 2550 g, poor Apgar scores, and respiratory distress that required mechanical ventilation and oxygen support.Chest X-ray at birth showed the persistence of a solid mass in the left lower lung lobe. The patient was closely monitored, and an elective surgery was scheduled.A preoperative chest CT scan with contrast showed stability of the extra-lobar BPS; thus, the patient underwent thoracoscopy (at 11 months).In the right lateral decubitus, a 3 mm trocar was inserted under the tip of the scapula. Two additional trocars were inserted. At the inspection, a macroscopically viable and perfused mass was rapidly identified, with the feeding vessel coming from the subdiaphragmatic aorta. The adhesions between the visceral and the parietal pleura were soft and easily removed by gentle smooth dissection. The feeding vessel was identified, closed with 3 Hem-o-Lock clip, and divided by Ligasure. The lesion was extracted intact through the posterior port with an endobag OR)AND((laser)OR(ablation))AND((sequestration)ANDAND(thoracoscopy)).” All papers were screened based on title and abstract. All papers reporting at least one case of BPS treated with prenatal laser coagulation requiring postnatal surgical treatment due to the persistence of the lesion were reviewed.For each case, when available, the following information was collected: GA at the time of the procedure, GA at birth, postnatal imaging, type of surgery (thoracotomy or thoracoscopy), and pathologic findings . Data regarding all the cases of BPS treated with USLC with persistent lesions at birth requiring postnatal management were collected and summarised as shown in A review of Literature identified 6 studies reporting at least one case of BPS treated prenatally with USLC requiring postnatal management , 7–12 . No case of antenatal death has been reported. The mean gestational age at birth was 36.83 ± 3.9 WA (range: 29–39). Regarding postnatal management, all cases included in our series required surgery after birth due to the persistence of the lesion, as indicated previously. In 16 cases, no information about postnatal radiological investigation was available, 6 received an MRI, and 11 underwent chest CT.Postnatal sequestrectomy was performed in 34 patients (100%).The surgical approach was open in 5 cases (15%), thoracoscopic in 4 (12%), and not specified in the others 25 (73%).In all the thoracoscopic cases, the presence of significant, numerous, and strong adhesions was reported.A percentage of foetuses with extra-lobar BPS can undergo potentially fatal complications, commonly due to hydrothorax, that may cause a mediastinal shift, decreased venous return, and increased central venous pressure leading to foetal hydrops . Like foIn case of complicated extra-lobar BPS, prenatal treatment might be mandatory to avoid progression to hydrops, intrauterine, and neonatal death.Since the first case of complicated foetal BPS successfully treated with intrauterine ultrasound-guided laser coagulation of the feeding artery was presented in 2007 , few repThere is a general consensus about how complicated BPS can commonly prenatally be treated with satisfactory outcomes , 4, but In fact, essentially due to the rarity of the disease, only small series or case reports have been published in Literature to date, and very few of them focus also on the postnatal management, with results sometimes incomplete, limited, and partly controversial, including extremely good results without any need for postnatal surgery as well as cases with large residual masses after birth –6, 9–12.Detailed surgical reports, with precise descriptions of the procedure, operative images, or videos describing the appearance of the thorax and the potential thoracic changes, are still lacking, hence the need to share our experience.To the best of our knowledge, only two other authors (from the same institution) presented their experience in thoracoscopic sequestrectomy after foetal laser coagulation, focusing on operative findings, for a total of 3 case reports present to date in Literature , 8.Both authors will describe the thoracoscopic appearance of the residual lesions mainly characterised by the presence of extensive severe adhesions among them, lung, and chest wall. They both detail how dissection of these adhesions was challenging with moderate bleeding , 8.Discordantly, we found smooth adhesions, and their dissection was easily conducted without bleeding. In all the cases described, the feeding artery was well evidenced intraoperatively and well recognisable in its proximal part arising from the aorta. In one case, the anomalous systemic vessel was cut with Just-Right 5-mm stapler after ligature with Hem-o-Lock clip due to its huge dimension . We perfIn all cases even when the postnatal CT did not show the anomalous systemic vessel, at the moment of surgical exploration, the vascular structure was present. This was probably related to the phenomenon of revascularization of the anomalous vessel after laser coagulation and supports us in sustaining that persistent lesions at birth should undergo elective thoracoscopic resection to avoid the potential risks of leaving a residual BPS in situ. Probably, this phenomenon should let us consider the need for systematic surgical exploration of these cases.BPS can occasionally present with prenatal complications correlated to foetal or neonatal death. Prenatal laser ablation for complicated BPS does not always result in lesion disappearance. Thoracoscopic surgical exploration in case of persistent lesions at birth offers the possibility of a minimally invasive sequestrectomy feasible and safe.


Liver cysts are common benign lesions with rare malignancy potential. Distinguishing between benign and malignant tumors within liver cysts is challenging. We present the case of a patient with a chronically expanding hematoma within a liver cyst that was resected under suspicion of liver cystadenocarcinoma. A 73‐year‐old female patient presented with elevated hepatobiliary enzyme levels, no viral hepatitis, elevated tumor marker levels, and preserved liver capacity (Child–Pugh grade A). Abdominal ultrasonography revealed a large cyst (>10 cm) occupying the right lobe and a 25‐mm mass lesion with mixed echogenicity inside the cyst. Contrast‐enhanced computed tomography showed atrophy of the parenchyma of the right lobe and dilation of the right intrahepatic bile duct due to the large cyst. Moreover, in the arterial phase, a point‐like high‐density area was observed inside the nodule, which increased from 25 to 35 mm over 3 months. Diffusion‐weighted magnetic resonance imaging revealed a high‐intensity signal within the nodule; however, positron emission tomography did not show an increased accumulation of fluorodeoxyglucose in the same area. Considering the risk of peritoneal dissemination if the cyst was punctured and found to be malignant, we performed a right hepatectomy. Pathological findings revealed a brownish fluid‐filled cyst containing a dark reddish nodule diffusely filled with hematoma, confirming the absence of a malignancy. To date, the patient has not experienced recurrence. We encountered a case of a chronic, expanding hematoma originating from a liver cyst that was difficult to distinguish preoperatively from a liver cystadenocarcinoma.  These benign lesions typically exhibit minimal or no changes in size or shape over time. However, some liver cysts can cause hemorrhage, which may be triggered by external factors like bruises and falls. Hematomas resulting from liver cysts are rare, comprising approximately 10% of all cases.2A 73‐year‐old woman was referred to our hospital following a physical examination that indicated elevated hepatobiliary enzyme levels in her blood sample. Additionally, an abdominal ultrasound scan revealed a cystic lesion occupying the right lobe of the liver. She was asymptomatic and had no history of smoking or alcohol consumption. Furthermore, she had a history of acute appendicitis and left‐sided breast cancer; however, she had no history of falls or trauma. Her older sister died of cholangiocellular carcinoma, and she was undergoing treatment for bilateral metachronous breast cancer. Blood test results showed a slight elevation in biliary enzyme levels ; however, hepatic enzyme levels were within the normal range. The patient was assigned a Child–Pugh score of A (5 points), and the indocyanine green test score at 15 min was 5%, indicating a good reserve capacity of the liver. Furthermore, hepatitis virus markers were negative, and tumor markers , carbohydrate antigen 19‐9 [CA19‐9]) were within the normal range.Contrast‐enhanced computed tomography showed that the cyst had almost completely replaced the right lobe of the liver; however, there was no obvious evidence of distant metastasis Figure . The sizDespite considering the possibility of a hematoma within the liver cyst, the increase in the nodule size and the patient's family history of cancer made it challenging to rule out liver cystadenocarcinoma. Although we considered a diagnosis through the puncture of the hepatic cyst, we were concerned about the potential risk of needle seeding in case the cyst was malignant. Thus, we decided to perform a surgical diagnostic resection. Preoperative computer simulations indicated that even after removing the hepatic cyst, the residual liver volume remained >800 mL. Therefore, an open‐right hepatectomy was planned.Ultrasonography during surgery showed that the nodule had a consistently high echogenicity Figure , and a rOverall, the 900‐g large liver cyst was soft Figure , with a 3In the present case, surgical resection was the treatment of choice for the liver cyst because of the difficulty in preoperatively determining its benign or malignant nature. This uncertainty was partly attributed to the infrequent appearance of nodules within liver cysts and limited number of reported cases.Echinococcus parasitic infections are known to have similar imaging findings. These tumors are very difficult to distinguish through imaging. Given their prevalence among middle‐aged and older women, achieving an accurate diagnosis can be extremely difficult, even if their frequency varies. The diagnosis should be based on histopathological findings.First, we considered differences in the frequency of occurrence. Liver cystadenocarcinoma accounts for only 0.12% of all primary liver malignancies,This also raises the question of how CEA and CA19‐9 levels in the cystic fluid affect diagnosis. In a previous study, CEA and CA19‐9 levels were measured in the cystic fluid of 40 patients with benign liver cysts and 32 patients with liver cystadenocarcinomas. In those with benign liver cysts, the CEA and CA19‐9 levels were 4.21 ± 2.91 (0.27–36.21) ng/mL and 21.37 ± 14.35 (0.60–85.92) U/mL, respectively, whereas in those with liver cystadenocarcinoma, the corresponding levels were 6.83 ± 2.43 (0.15–23.11) ng/mL and 21.37 ± 14.35 (0.60–85.92) U/mL, respectively, showing a higher tendency toward elevation in liver cystadenocarcinoma.en bloc surgical resection remains the first choice of treatment and diagnosis for nodules within liver cysts. However, if the disease is benign, as in the present case, there is little need for surgical resection, which would be an overinvasive hepatic resection. The timing of treatment and the balance between its advantages and disadvantages must be carefully considered. Liver cystadenocarcinoma has been reported to have a better prognosis than primary liver cancers, such as hepatocellular carcinoma and intrahepatic cholangiocarcinoma, with a 5‐year survival rate of >70% after complete resection.Thus, considering the limitations of imaging and potential risk of puncture, Kodai Abe: Conceptualization; resources; writing – original draft. Shunsuke Tomita: Data curation; validation. Shohei Suzuki: Formal analysis; visualization. Yu Kigasawa: Formal analysis; investigation; visualization. Hironobu Kashiwagi: Methodology; resources; visualization. Michihito Nishioka: Methodology; validation; writing – review and editing. Yasuo Kabeshima: Project administration; supervision.Not applicable.The authors declare that they have no conflict of interest.All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.