Melanocytic lesions, whether benign or malignant, are extremely rare in the cervix and, more particularly, in the endocervical mucosa.Cervical melanosis is a benign entity, most often discovered by incidental findings on a histological study of a surgical specimen resected for another reason. The microscopic examination allows the diagnosis with certainty after ruling out any potential malignancies.The etiopathogenesis remains poorly understood; however, a number of theories have been put forward, such as excessive migration of pigmented cells from the neural crest, trauma, or chronic irritation situations.We report the case of a 40-year-old female patient followed in the gynecology department for a polymyomatous uterus. She underwent a total hysterectomy. The histological and immunohistochemical examinations concluded an incidental finding of cervical melanosis lesions associated with leiomyomas. Melanosis lesions are benign and can affect the uterine cervix  such as,Endocervical melanosis is a very rare entity with an incidence of 0.05% , which iThis case report has a double interest: The rarity of the lesion will enable us to review the situation regarding this entity, after ruling out other differential diagnoses, essentially malignant melanic lesions, which are highly aggressive.We describe the case of a 40-year-old female patient who was seen in gynecology for well-defined, confluent uterine lesions very suggestive of myomas. A total hysterectomy was done through laparotomy. The specimen was processed for histopathological study. Macro- and microscopic examination of the total hysterectomy specimen confirmed the diagnosis of uterine leiomyomas. The uterine cervix was free of macroscopically detectable lesions.Microscopic examination of the cervix, after staining with hematoxylin and eosin, revealed an endocervical mucosa lined by a regular mucosecretory columnar epithelium, overlying a chorion containing numerous round, ovoid, or spindle-shaped cells, which contained brownish intracytoplasmic pigments without showing cytonuclear atypia or mitosis .The exocervix consisted of a regular squamous epithelium showing no architectural organisation or signs of HPV infection, overlying a chorion with congestive remodeling and a few scattered lymphocytes and plasma cells. To confirm the highly suspicious melanocytic nature of the intracytoplasmic pigments at the endocervical mucosa, a Fontana staining was performed and came back positive at the level of these deposits Figure .An immunohistochemical study was also done with SRY-box transcription factor 10 (SOX10) antibody and was also positive Figure .In light of all these data, the diagnosis of cervical melanosis was retained.Particularly when it occurs in the endocervix, cervical melanosis is a very uncommon benign disease. In cases of endocervical localisation, it is characterised by localised or diffuse melanin pigment deposits in the chorion. However, in cases of exocervical localisation, it is characterised by hyperpigmentation of the basal layer of the epithelium, with or without accompanying basal melanocytes . The patIt must be highlighted that any hyperpigmented lesion must be biopsied and histopathologically examined to rule out a malignant neoplasm, especially a mucosal melanoma, which is in turn rarely observed .The pathogenesis of this entity remains poorly elucidated; however, the most widespread theory explains the presence of melanosis lesions at the cervical level as well as at other locations (laryngeal , colonicHistologically, it is a matter of intracytoplasmic melanin pigment deposits in histiocytes and melanocytes located in the endocervical chorion. These cells do not show cytonuclear atypia or mitosis, with the absence of ulceration and necrosis. Special staining and/or immunohistochemical study is mandatory to confirm the melanocytic nature of these pigments. If available, electron microscopy is always beneficial .The particularity of our case lies in the rarity of endocervical melanosis, especially since, to our knowledge, this is the third case discovered incidentally during the management of a polymyomatous uterus .Cervical melanosis lesions are usually asymptomatic and are discovered incidentally on a surgical specimen resected for tumoral or other reasons. When a hyperpigmented lesion is observed clinically, several differential diagnoses arise, and histopathological examination is required. When these patients are followed up after pathological confirmation, no progression to malignancy has been observed.However, it is important to point out that the etiopathogenesis of these lesions is not clearly studied due to the rarity of the reported cases, and a well-codified follow-up protocol must be programmed.


The clinical manifestations of GTN include amenorrhea, abnormal vaginal bleeding, and increased serum human chorionic gonadotropin level, which are also common clinical features of ectopic pregnancy. The diagnosis of typical GTN is not difficult. However, some patients with atypical clinical manifestations and a lack of specificity in their B-ultrasound images are easy to misdiagnose, especially when the lesions are located in special parts outside the uterus and lack specific imaging features.Gestational trophoblastic neoplasia (GTN) refers to the hydatidiform mole tissue that invades the myometrium or even penetrates the uterine wall to the broad ligament or abdominal cavity, and a few have distant metastases through blood transport. According to the World Health OrganizationA 41-year-old woman who presented 3 months after having an abortion with severe abdominal pain that lasted 15 hours.CT showed massive blood accumulation in the abdominal cavity and the pelvic cavity. Uterine lesions? Transvaginal uterine ultrasound reveals: a right intrauterine mixed mass (approximately 83 * 66 mm mixed echo mass), a possible pregnancy, and a rupture pregnancy (right pregnancy). abdominal effusion (large) and clots, maximum front and rear diameters of 95 mm, pelvic effusion, and about 20 mm deep. HCG levels in the blood were 17,452 IU/L and hemoglobin levels were 81 g/L. Admission diagnosis: Abdominal pain investigation: ectopic pregnancy? Bleeding shock.Laparoscopy and laparotomy followed by hysterectomy, treated by chemotherapy.Hysterectomy was required due to intraoperative hemostasis difficulties, and the patient lost her uterus forever.Continued reporting of these cases are important so that the gynecologists are aware about the possibility of ruptured invasive mole and it should be kept as a differential diagnosis in all the pregnant women presents with acute onset lower abdominal pain. In particular, GTN patients with extrauterine lesions are more likely to be misdiagnosed with EP. GTN is mainly treated with chemotherapy, while EP is treated with surgery or drug therapy, and misdiagnosis will lead to an incorrect treatment strategy for patients. Timely diagnosis and diagnosis of gestational trophoblastic tumors are the key factors to avoid unnecessary surgery. We present a case of invasive mole which gradually eroded in the uterus and the uterine vasculature, leading to sudden rupture of uterus, massive hemoperitoneum and shock, mimicking EP. Share this case in order to reduce the probability of an erosion hydatidiform mole being misdirected as an EP and improve the diagnosis rate of an erosion hydatidiform mole.Gestational trophoblastic neoplasia (GTN) is a group of diseases caused by the abnormal proliferation of trophoblast cells in the placenta, which include benign mole and malignant trophoblast diseases; GTN can be secondary to any type of pregnancy, but has a low incidence ranging from 1 to 3/1000 pregnancies for hydatidiform mole to (1–9)/40,000 pregnancies for choriocarcinomaA 41-year-old woman presented to the emergency department 3 months after an abortion with sudden onset abdominal pain for 15 hours on April 16, 2020.The patient complained of having had an early induced abortion in the local hospital for an early pregnancy on January 14, 2020, and the intraoperative clearance object was not sent for pathological examination. Blood HCG was not reviewed after surgery due to recent severe travel difficulties with COVID-19. She had no sexual history for nearly 1 mouth. On April 25 PM, 2020, she complained of pain to syncope once, accompanied by nausea and vomiting 3 times, and the vomit was gastric content. The patient had regular menstruation, menarche at 13 years old, menstrual period 5 days, cycle 30 days, last menstrual November 28, 2019 menstrual volume normal, no dysmenorrhea, had been married, G4P3A1, had 2 previous vaginal births, 1 cesarean section in 2014, and 1 abortion. There were no special diseases in the past. There is no history of alcohol or drug abuse. No genetic history. Considerations for diagnosis in other hospitals “Abdominal pain checks cause: residual uterine horn pregnancy? “Intrauterine pregnancy tissue residue?” It was suggested that the patient be transferred to the superior hospital for further treatment. The patient was sent to our emergency department by ambulance from another hospital. Physical examination: temperature: 36.8°C, pulse 120 times per minute, breathing 20 times per minute, 80/50 mm Hg; conscious, passive position, painful face, poor examination, flat admission; abdominal tension, whole abdominal tenderness, positive rebound pain, mobile turbidity (+). The vulva development was normal, the vagina was unobstructed, there were no abnormal secretions inside, no odor, cervical lifting pain, or swing pain, according to a pelvic examination. The abdominal wall was thick, the patient had poor coordination, uterine tenderness, obvious tenderness in the bilateral appendage area, and no touch of the mass. CT showed massive blood accumulation in the abdominal cavity and the pelvic cavity. Uterine lesions? Transvaginal uterine ultrasound reveals: a right intrauterine mixed mass (approximately 83 * 66 mm mixed echo mass), a possible pregnancy, and a rupture pregnancy (right pregnancy). abdominal effusion (large) and clots, maximum front and rear diameters of 95 mm, pelvic effusion, and about 20 mm deep , be a high-risk patient, The patient was treated with standard chemotherapy and discharged from the hospital after being cured. There was no abnormality after 2 years of follow-up.Laparoscopic surgery was performed on the patient. Suction part blood and blood clots, exposed pelvic cavity, uterine enlargement, see the right uterus near the uterine horn bulge, the surface is purple blue earthworm filling, the right galloping tube lower mechanical and right broad ligament visible tablet hard nodules, surface is also purple blue, range about 6 * 3 cm, the right upper sacral ligame Laparotomy was immediately transferred, and laparoscopy exploration was moved to open total hysterectomy + right adnexectomy + left salpingectomy; When the uterus was pulled, a purple blue earthworm filled and ruptured the right uterine horn, and several blister-like tissues of various sizes overflowed.Fig. . The proApproval for the study protocol was not necessary because our institutional review board does not require approval for case reports. We obtained written informed consent for treatment of the patient.; Because the cases are so rare, it is unlikely that gynecologist sees such challenging cases in a lifetime; thus, reliance on ultrasound could lead to misdiagnosis; Therefore, when the patient has an acute clinical gynecological abdomen and severe bleeding, the patient should be asked about the medical history in detail; HCG level normalized.A review of domestic and foreign literature found that GTN misdiagnosed as EP was reported in few literatures. Only 65 cases of gestational trophoblast cells being mistaken for EP have been reported in the medical literature; 11 cases were uterine perforation of pregnant trophoblast cells, and 8 cases were hysterectomy, permanently losing the possibility of the uterus and reproduction. Our case is in line with these 8 cases because delayed diagnosis leads to surgery and hysterectomy. but we succeeded in saving the live of the patient. With the development of hydatidiform moles, early diagnosis and early treatment are the keys to improving the cure rate. In this case, there is no chance of early treatment; COVID-19 is widely spread worldwide, seriously affecting the daily lives and health of humans. However, the impact of COVID-19 patients on other human diseases besides respiratory symptoms cannot be ignoredThere was no regular reexamination of blood HCG after surgery, which increases the difficulty of diagnosis in these patients. In addition to histology, molecular genetic studies can help in the diagnostic pathway. Earlier detection of molar pregnancy by ultrasound has resulted in changes in clinical presentation and decreased morbidity from uterine evacuation; Pathological examination and color ultrasound review are critical. Surgery may have an important role in the management of GTN. Hysterectomy can be considered in uncontrolled uterine bleeding, So our case is in line with hysterectomy.Within 14 weeks after evacuation in 95% of these patients.Gestational trophoblastic disease has a potential for myometrial and vascular invasion, leading to uterine perforation and massive hemorrhage. Therefore, to avoid adverse consequences it is necessary to Pathological examination after abortion and regular reexamination of blood HCG. Continued reporting of these cases are important so that the gynecologists are aware about the possibility of ruptured invasive mole and it should be kept as a differential diagnosis in all the pregnant women presents with acute onset lower abdominal pain. Although this is a rare case, it is a single case report that lacks the support of statistical data, more cases and studies are still needed.Conceptualization: Su Zhen Jiang, Hong Xia Gong.Data curation: Su Zhen Jiang.Formal analysis: Su Zhen Jiang.Supervision: Hong Xia Gong.Writing – original draft: Su Zhen Jiang.Writing – review & editing: Su Zhen Jiang, Hong Xia Gong.


Adrenal lymphangioma is a rare benign tumor of lymphatic origin, usually incidentally detected from various imaging studies taken for an unrelated purpose. We present a case of a right adrenal lymphangioma treated successfully with surgical intervention.A 36‐year‐old previously healthy woman was referred to our urology department for a right adrenal mass, discovered during a routine health checkup. The tumor had no endocrinological activity, and the patient opted for surgical resection following a concern for malignancy. A laparoscopic right partial adrenalectomy was performed, and on histological examination, the tumor was diagnosed as right adrenal lymphangioma.Adrenal lymphangiomas lack disease specific radiological characteristics that allow for a definitive diagnosis from imaging alone. To rule out tumors of potentially malignant nature, surgical intervention should be considered. CTcomputed tomographyH&Ehematoxylin and eosinMRImagnetic resonance imagingAdrenal lymphangioma is a rare benign tumor of lymphatic origin. This tumor has no disease‐specific characteristics that allow for diagnosis solely from imaging studies. Here, we report a case of right adrenal lymphangioma successfully treated with laparoscopic partial adrenalectomy.Adrenal lymphangioma is a rare benign tumor of lymphatic origin. Whereas most lymphangiomas are found during infancy, usually in the cranial region, adrenal lymphangiomas are mostly detected incidentally during adulthood from various imaging studies. Here, we report a case of a right adrenal lymphangioma successfully treated with laparoscopic partial adrenalectomy.A 36‐year‐old previously healthy woman was referred to our hospital for a right cystic adrenal mass, which was discovered incidentally during her routine medical checkup. A contrast CT scan showed a poorly enhanced 5 cm solitary mass on the right adrenal gland, with a polycystic appearance with some calcification Fig. . On MRI,The patient opted for surgery from her concerns about a possible malignancy, or future hemorrhage.The surgery was performed under general anesthesia in the left semi‐lateral decubitus position. A 12 mm laparoscopic port was positioned slightly lateral from the right midclavicular line, 3 cm caudal from the ribcage. A 5 mm port was placed on the same axial plane, on the right midclavicular line for the right‐hand access, and on the anterior axillary line for the left hand. A 5 mm assistant port was placed caudally from the xyphoid.The tumor had a round, polycystic appearance, with clear visible margins with the adrenal gland Fig. . The lacHistologically, on H&E staining, fibrotic cysts containing calcifications were observed, with clear borders with the normal adrenal tissue Fig. . On immuLymphangiomas are benign tumors originating from the lymphatic system, majority of which are found during infancy, commonly in the cranial and axillary regions.et al. observed that these tumors are more frequently found in women, and more commonly seen in the right adrenal gland.Adrenal lymphangiomas are therefore a rare occurrence, although there is an increase in its reported incidence, presumably owing to the advancement and availability of various imaging modalities.As it was the case for this patient, on a histological level, lymphangiomas are often seen on H&E staining as polycystic lesions lined with endothelium‐like cells.Immunohistochemistry is also a very useful tool to confirm the tumor's lymphatic origin. We utilized CD31 and D2‐40, which are specific markers used to detect tissues of lymphatic linage. Other useful markers may include CD34, factor VIII‐related antigen, and PROX1.Lymphangiomas lack specific radiological characteristics that allow for differentiation on imaging alone.Surgical excision may be the management of choice for symptomatic or large adrenal lymphangiomas.Due to its rarity, the precise malignancy potential of a cystic adrenal mass is not well established, and few retrospective case series have been published. Chien reported 7 out of the 25 surgically treated cystic adrenal lesions were associated with a neoplasm , of which two were malignant.The prognosis of adrenal lymphangiomas post‐surgery seems to be extremely good, as we were unable to find cases that reported post‐surgical relapse.We report a case of a cystic adrenal lymphangioma successfully treated with laparoscopic partial adrenalectomy. This rare and benign tumor of lymphatic origin should be included in the differential diagnoses of adrenal tumors. The potential malignant nature of a tumor should always be considered during the assessment of adrenal cystic tumors.Heisuke Iijima: Writing – original draft. Taisho Noda: Validation. Kosuke Uchida: Validation. Yasuhiro Hakamata: Validation. Akira Fujisaki: Validation. Shin Imai: Validation. Yoshiro Otsuki: Validation. Tatsuaki Yoneda: Conceptualization; supervision; writing – review and editing.The authors declare no conflict of interest.Not applicable.Not applicable.Not applicable.


Superficial angiomyxomas of the skin are rare benign cutaneous tumors of soft tissue composed of myxoid matrix and thin-walled blood vessels. They can be sporadic or develop in conjunction with the Carney complex. These tumors have a predilection for the trunk, lower limbs, head, neck, and genitalia. Herein, we report a case of superficial angiomyxoma of the axilla in a 42-year-old man. The pedunculated polypoidal mass showed a maximum diameter of 4.5 cm and intra- and extra-lesional vascularity on Doppler, and the histopathology report was suggestive of myxoid matrix with scattered bland stellate and spindle cells and long thin-walled branching blood vessels and inflammatory infiltrate consisting of mainly neutrophils. Smooth muscle actin (SMA), S100, and desmin were found to be negative on immunohistochemistry, but CD34 was discovered to be positive. It was possible to make the diagnosis of superficial angiomyxoma using these histological and immunohistochemical characteristics. Wide local excision, being the preferred treatment, was performed, and the patient was followed up for six months with no signs of recurrence. Superficial angiomyxomas (SA) are benign, infrequent cutaneous tumors that can be either sporadic or develop in conjunction with the Carney complex, particularly if they affect the external ear. They are composed of a distinct myxoid matrix and numerous thin-walled blood vessels. This is more frequently observed in men and has a predilection for the trunk, lower limbs, head, neck, and genitalia, with an incidence of approximately 0.008%-3% ,2. TreatA 42-year-old male reported to the clinic with a history of swelling in the left axilla for one month, gradually progressing in size. The swelling was not associated with pain. There was no history of similar swelling elsewhere in the body and no history of pigmentation of the skin. There was no relevant medical history or family history. Physical examination revealed two flesh-colored, polypoidal masses noted in the left axilla, each measuring roughly 2x3cm in dimension, non-tender with normal skin surrounding it. Figure DiagnosisHistopathology of the specimen is suggestive of multilobulated polypoidal tumor tissue overlined by flattened keratinizing stratified squamous epithelium and comprised of hypocellular myxoid matrix containing scattered bland spindle and stellate cells and long branching thin-walled blood vessels. Mitotic activity is rare; acellular mucin cysts, entrapped strands of squamous epithelium, and tiny keratinous cysts are evident. Stroma also shows mixed inflammatory infiltrate consisting of neutrophils, lymphocytes, and plasma cells. Immunohistochemistry markers were negative for S100, smooth muscle acin (SMA), and desmin and positive for CD34. In Figure TreatmentThe preferred treatment is wide local excision of the lesion, which the patient underwent without any complications. An elliptical incision was taken around the swelling in the axilla, with a margin of 5mm, and deepened in layers to excise the swelling. Care was taken to avoid too much dissection to avoid seroma formation. After achieving hemostasis, closure was done in two layers. The postoperative course was uneventful, and the patient showed no signs or symptoms of recurrence after six months at the time of writing this report. Figure The patient presented with complaints of swelling in the left axilla of one month duration, for which the derived differentials were fibroma, papilloma, and localized neurofibroma. Generally, superficial angiomyxomas invade into the subcutaneous tissue, and an increase in this depth is directly related to an increased risk of recurrence and aggressiveness. The tendency of lesions to recur also increases with the presence of epithelial components, with a recurrence rate of 68% compared to 13% in lesions without epithelial components . ReporteIn summary, a rare case of superficial angiomyxoma with an unusual location was reported in a 42-year-old male who underwent wide local excision and the diagnosis was confirmed by histopathological and immunohistochemical investigations. It has been differentiated from the other differential diagnosis by immunohistochemistry. For any lesion with a polypoidal appearance, flesh-colored and firm in consistency, the diagnosis of superficial angiomyxoma needs to be ruled out. Since local recurrence is common, the patient needs to be kept under close follow-up.


Schwannomas are tumors originating from Schwann cells, about 45% of them are located in the head and neck region, including the parapharyngeal space (PFS). Vagus nerve schwannomas (VS) and cervical sympathetic chain schwannomas (CSCS) are most commonly found in this region. We present a case of CSCS located in the PFS of a middle-aged female patient who had surgery with the endoscopic endonasal approach (EEA). There have been no earlier reports of CSCS resection utilizing EEA, according to our literature search. To our knowledge, there is no scientific record of CSCS resection using EEA.  Schwannomas are tumors originating from Schwann cells, described by Verocay in 1908. Despite appearing in various parts of the body, about 45% of them are located in the head and neck region, including the parapharyngeal space (PPS). Vagus nerve schwannomas (VS) and cervical sympathetic chain schwannomas (CSCS) are most commonly found in this region [The post-styloid compartment of PPS encases principal neurovascular structures, such as the cervical sympathetic chain; cranial nerves IX, X, XI, and XII, as well as the internal carotid artery (ICA), and internal jugular vein (IJV).We present a case of CSCS located in the PPS of a middle-aged female patient who underwent surgery via the endoscopic endonasal approach (EEA). There are no reports in the literature on CSCS resection using EEA.Anamnesis and physical examinationA 43-year-old female patient was referred by the head and neck surgery team after a transoral biopsy of a palpable lesion in the right cervical region. The patient reported that for 18 months, a palpable and painless cervical mass was present on the right side of the neck with progressive growth. The patient denied having dysphonia, dysphagia, hoarseness, or any other symptoms associated with Horner syndrome (HS).NeuroimagingA well-delimited expansive growth in the right parapharyngeal cavity, with homogeneous contrast uptake, estimated to be 5.6 cm, which extended to the rhino pharynx, was seen on the magnetic resonance imaging (MRI) of the skull. The lesion described displaced the IJV and ICA in the same posterolateral direction to the right Figure .Surgical techniqueGiven the upper parapharyngeal location, we decided to perform surgical resection through the EEA endonasal route with the aid of neuronavigation and ICA monitoring was performed with the aid of Doppler ultrasound.Initially, right turbinectomy was performed, followed by posterior septectomy, bilateral sphenoethmoidectomy, and finally increased antrostomy. The sphenopalatine foramen was identified, as well as the sphenopalatine and palatovaginal arteries, both of which were resected. Afterward, the resection of the posterolateral aspect of the maxillary sinus was performed which revealed the posterior outlook of the pterygopalatine fossa. The transpterygoid approach was performed by removing the inferior portion of the periosteum around the vidian nerve which allowed access to the base of the pterygoid processes. Extensive removal of the pterygoid process and medial and lateral pterygoid plates provided complete exposure of the upper portion of the PFS. In the right PFS, a yellowish fibroelastic lesion was identified whose posterolateral limits were closely related to the ipsilateral ICA. An ultrasonic aspirator was used to perform tumor debulking Figure . ConsidePostoperative evolutionThe patient reported mild dysphagia on the first postoperative (POD), without any evidence of HS or first bite syndrome (FBS), and was discharged on the fourth POD.The pathology examination of the lesion revealed that it was a schwannoma, and after three months and 12 months, the control MRI of the skull revealed a full excision of the lesion with no evidence of tumor recurrence. At the 12 months follow-up, the patient remained free of complaints or complications Figure .The vagus nerve is the most frequent origin of schwannoma found in the head and neck region. When large, they can cause compressive symptoms, such as pain and paresthesia, as well as dysphagia and hoarseness. Graffeo et al. [2[ compiled data from investigations which identified several patterns that can be used to differentiate these tumors from CSCS Table . The folA review that studied 1,143 PPS tumors showed that most of them are benign (82%). The most common subtype according to the aforementioned review is salivary gland tumors (45%), followed by schwannomas (41%). Surgical treatment is the conventional therapy for tumors located in the PFS, and it has as its main objective, the complete excision of the tumor while maintaining the surrounding noble structure [In cases with PFS tumors, the transcervical approach (TCA) has historically been the most used route. TCA is advantageous because it allows direct access to the lower portion of the PFS, as well as a good visualization of the cranial nerves and control of the great vessels, reducing the risk of facial nerve injury and bleeding, respectively . EEA hasTo our knowledge, there is no scientific record of CSCS resection using EEA. Understanding the endoscopic anatomy of the PFS can lead to improvements in morbidity associated with tumor resection in this dense neurovascular region, as well as reduce surgery time.


Bladder rupture is an uncommon injury that leads to significant morbidity and mortality. Though occurring mostly due to trauma, this life-threatening pathology may also occur spontaneously or after a procedure such as transurethral resection of bladder tumor (TURBT). Computed tomography (CT) cystography is the standard imaging modality for diagnosis. However, this test is unlikely to be ordered in a patient with undifferentiated abdominal pain unless there is specific suspicion for this diagnosis. In our emergency department, a 48 year-old male with history of bladder cancer and TURBT two weeks prior to arrival presented with severe abdominal pain and difficulty urinating for 3 days. Point of care ultrasound (POCUS) revealed an irregularly shaped bladder, likely site of bladder rupture, and large amount of abdominal free fluid with sediment. These findings prompted an expedited diagnostic CT scan with cystography. Emergent exploratory laparotomy ultimately confirmed a small bladder defect with 2.5 L of urinary ascites. The diagnosis of non-traumatic bladder rupture can be overlooked in patients presenting with a peritonitic abdominen. The typically ordered test for such patients is standard CT, which carries a high false-negative rate for bladder rupture. This case highlights the utility of POCUS in facilitating a rapid diagnosis. Bladder rupture is an uncommon injury associated with life-threatening peritonitis. Gross hematuria is the most common symptom, with an incidence of 77-100% Bladder rupture occurs most commonly from blunt 67-86%) and penetrating 14-33%) trauma 7-86% and-33% trauTrans-urethral resection of bladder tumor (TURBT) is the procedure of choice for the initial diagnosis, risk stratification, and management of bladder cancer The American Urological Association (AUA) reports that computed tomography (CT) cystography  is the diagnostic imaging test of choice to evaluate for bladder injury Here we present the first known case of an iatrogenic bladder rupture diagnosed by point of care ultrasound (POCUS), as well as the first known case where delayed diagnosis of any bladder rupture was made using POCUS. This rapid bedside diagnosis led to prescient ordering of CT cystography and expedited definitive surgical management.A 48 year-old male with history of bladder squamous cell carcinoma was triaged to the ED with worsening abdominal pain and difficulty urinating for 3 days. Triage vitals signs were notable for an elevated blood pressure of 178/89 mmHg and tachycardia to 110 beats per minute. Otherwise, the patient was afebrile with a temperature of 99.1°F, breathing at 20 breaths per minute, with an oxygen saturation of 98% on room air. As the patient looked uncomfortable upon arrival to the patient care area, he was attended to immediately by the physicians, while the nurse obtained intravenous access and blood tests. A brief history revealed that he had undergone TURBT six weeks earlier for initial evaluation and treatment of his bladder cancer, then another repeat TURBT two weeks prior to arrival for restaging and removal of the remaining tumor.On physical examination, the patient was ill-appearing, tachycardic, and in significant distress due to abdominal pain. His abdomen was diffusely distended, tense, and tender to palpation with involuntary guarding. The rest of the physical examination (including genitourinary) was unremarkable.An electrocardiogram from triage showed beginnings of a sine wave pattern, prolonged QRS interval to 160 msec, and peaked T waves altogether suggestive of hyperkalemia, for which appropriate medications were ordered. Given the patient’s urinary retention and history of prostate cancer, immediate foley catheter insertion was planned in order to drain an expected markedly distended bladder. However, POCUS performed at the bedside in the supine position revealed an irregularly-shaped, non-distended bladder containing anechoic fluid and floating sediment . Disruption of the hyperechoic bladder dome was seen superiorly leading directly to intra-abdominal free fluid, indicating a likely site of bladder rupture . The patient was then tilted into the Trendelenburg position to increase POCUS sensitivity for gravitationally-dependent free fluid. This evaluation revealed large volume of heterogenous free fluid throughout the right upper quadrant, as well as moderate bilateral hydronephrosis . Altogether, this raised concern for intraperitoneal bladder rupture. The Urology service was consulted immediately and reviewed the POCUS images. Placement of a foley catheter drained cloudy yellow urine, and both services expedited CT scan of the abdomen and pelvis with cystography . The suspected diagnosis was confirmed, and the patient was emergently taken directly from CT to operating room prior to any laboratory tests having resulted. During exploratory laparotomy, 2.5 liters of urinary ascites were evacuated from the peritoneal cavity, and the bladder wall defect was sutured closed. By this time, the initially drawn blood samples resulted with blood urea nitrogen of 180 mg/dL, creatinine of 12.4 mg/dL, potassium of 7.5 mEq/L, and anion-gap metabolic acidosis with pH of 7.23. Postoperative course was uneventful, acute kidney injury improved, and the patient followed up in clinic five days later for pelvic drain removal.This is the first known case report in which an iatrogenic bladder rupture, and also a delayed rupture from any etiology, was diagnosed at bedside using POCUS. Based on POCUS findings, the clinicians specifically ordered CT cystography due to its higher sensitivity for bladder injury, instead of standard CT with intravenous contrast. This decision expedited definitive diagnosis and subsequent exploratory laparotomy by the Urology service. ED management saved the patient from significant risk of morbidity and mortality. In the large retrospective study of patients who underwent TURBT, two of the fifteen patients with bladder perforation who died from septic shock and multiorgan failure had prolonged time of 21 days from TURBT to diagnosis Most prior cases of bladder rupture diagnosed by ultrasound occurred in the setting of trauma using the Focused Assessment with Sonography for Trauma (FAST) examination The contour of a distended bladder would appear using 2D ultrasound as a roughly anechoic ellipsoid (not a circle), which explains why estimated bladder volume obtained from three dimensions is often multiplied by a correction coefficient factor of 0.72 Intraperitoneal bladder ruptures most commonly occur at the bladder dome, the weakest and most mobile part of the bladder A bladder rupture occurs rarely and even less often from a non-traumatic etiology. A conventional CT scan ordered for a patient with an undifferentiated acute abdomen carries a high false-negative rate for this diagnosis. To order the gold standard CT cystography in the ED thus requires having a high level of suspicion. This case report highlights the utility of POCUS for rapidly identifying a bladder injury at the bedside, thereby leading to expedited appropriate follow-up imaging and transition to definitive surgical evacuation of free fluid and bladder wall repair.Informed consent was obtained for use of the associated images and clips.HL, EL, and SA have no conflicts of interest to disclose.Video S1Video S2Video S3Video S4


Surgical drains are commonly used to manage intraperitoneal fluid after major surgeries, but their prophylactic use has been controversial due to potential complications. One rarely reported complication is small bowel obstruction (SBO), primarily seen in post-colorectal surgeries. We present a case of SBO following open radical cystectomy due to surgical drain placement, a complication not previously reported in urologic surgeries. The case highlights the importance of considering the risks and benefits of prophylactic drain placement. It emphasizes the need for a higher index of suspicion for SBO in patients with surgical drains who develop post-operative nausea and distention. Timely radiological imaging and clinical examination are crucial for accurate diagnosis and proper treatment. Surgical drains are commonly placed within the abdominal and pelvic cavity after major surgeries, including cystectomy, for drainage of excess intraperitoneal fluid collection. However, the use of prophylactic drainage has been a controversial topic due to potential complications such as leaks and infections . A rarelA 79-year-old male with an extensive past medical history, including prostate cancer treated with radiation in 2008 and carcinoma in situ of the bladder first diagnosed in 2016, underwent treatment with BCG, followed by mitomycin, before being lost to follow-up. In November 2022, he underwent a blue light cystoscopy, which revealed a large lobulated lesion on the left trigone of the bladder. The patient had undergone transurethral resection of a large lesion and left ureteral stent insertion of left hydroureteronephrosis seen on retrograde pyelogram. The pathology resulting from this procedure revealed high-grade urothelial carcinoma invading the muscularis propria. The patient was duly informed of the risks, benefits, and alternative treatment options available for muscle-invasive bladder cancer. After considering these, the patient chose to proceed with a radical cystoprostatectomy with urinary diversion.The patient underwent an open radical cystoprostatectomy, bilateral pelvic lymph node dissection, and the creation of an ileal conduit with ileal-ureteral anastomosis on January 16, 2023. The final pathology report revealed an ulcerated, high-grade urothelial carcinoma that invaded through the muscularis propria of the bladder, with surgical resection margins being negative. Additionally, bilateral lymph nodes were examined and were found to be negative for metastatic carcinoma. As part of the standard post-operative care, bilateral ureteral stents were inserted through the ureteral anastomosis, and a Foley catheter was inserted per urethra for pelvic drainage. A 19 French Blake surgical drain was introduced into the pelvic cavity through a stab incision in the left lower quadrant via the lateral abdominal wall, and a nasogastric tube (NGT) was placed. The positioning of all tubes was confirmed, with a post-operative abdominal X-ray demonstrating proper placement. All drainage output was monitored daily.The NGT was removed on post-operative day 2 due to a low output of 50 cc in 24 hours, with the patient reporting minor flatus and managing to ambulate around the hospital hallways. By post-operative day 3, the patient could tolerate sips of water but reported hiccups and a lack of appetite. On post-operative day 4, he began to feel more distended, and an examination revealed hypoactive bowel sounds, prompting a repeat abdominal X-ray. Imaging demonstrated multiple segments of dilated air-filled small bowel measuring up to 4.5 cm, concerning for SBO. The decision was made to reinsert the NGT with low continuous wall suction (LCWS) on post-operative day 4 for abdominal decompression, returning 1450 cc of brown bilious fluid. On post-operative day 6, the patient’s abdominal symptoms resolved, and he began passing flatus again, prompting a NGT clamp trial followed by NGT removal. However, that night, the patient experienced increasing abdominal pain and distension, accompanied by nausea and 100cc of bilious vomiting. This led to the reinsertion of the NGT, which immediately yielded 800cc of bilious fluid. A CT abdomen and pelvis (CTAP) with oral contrast through NGT was ordered and performed on post-operative day 7. This showed a 5.4 cm distension of the small bowel with a transition point in the left lower quadrant (LLQ) indicative of an SBO at the surgical drain site. Per radiology, the surgical drain is seen traversing the small bowel loop at the transition point, causing compression (Figure This case highlights a rare but potentially severe complication of surgical drain placement: the development of SBO. Although SBO is a common gastrointestinal complication post major abdominal surgeries, including urological surgeries, SBO caused by surgical drain placement has only been reported a few times. Most of the published case reports are from general surgery cases involving colorectal procedures that involve loops of bowels wrapping around the drain . In urolAnother factor that should be reviewed in this case is using prophylactic surgical drains after urological procedures. The use of prophylactic surgical drains has been a common practice for centuries due to their relative safety and low-risk profile. However, there is an ongoing debate among physicians about using prophylactic surgical drains, as no standardized guidelines surround this topic. The primary benefits of a surgical drain include the removal of excess intraperitoneal fluid that can accumulate after surgery and lead to complications like infection, wound dehiscence, and seroma formation. Moreover, a surgical drain can facilitate the earlier detection and management of potential complications, such as bleeding or leakage from surgical anastomoses, which are critical in urological surgeries for the timely detection of urinary leaks. Untreated urinary leakage can cause severe complications, including chemical peritonitis, urinoma formation, and sepsis . DespiteIt is crucial to carefully evaluate the advantages and disadvantages of using prophylactic surgical drains. In cases where intraoperative drainage tubes are used, the placement and condition of the drain should be closely monitored. If symptoms of post-operative ileus occur, the possibility of SBO should be considered and promptly investigated, including the differential diagnosis of surgical drain-related SBO. Suppose a confirmed SBO or conservative treatment fails to alleviate the patient's abdominal obstructive symptoms before performing an invasive procedure. In that case, removing the percutaneous drain should be considered and carried out.


Wilms tumor (WT) is a rare form of cancer that typically affects children and is usually confined to the kidneys. Extra-renal Wilms tumor (ERWT) is even rarer and develops in other areas of the body, such as the retroperitoneum and inguinal regions, and occasionally at the level of the spinal cord. We present a case report of a 4-year-old boy diagnosed with spinal ERWT, who was also affected with a spinal dysraphism. Our case-based systematic review of pediatric ERWT showed that a multimodal therapeutic approach  is important, but an international standardization of the staging approach and therapeutic protocols is needed to define the best clinical management in these children: indeed, there is a lack of clinical studies focused on pediatric ERWT and international trials are needed to achieve these objectives. Our research emphasizes the importance of timely diagnosis and treatment and, possibly, standardized medical approach, in order to improve the outcome of these very rare pediatric malignancies, whose clinical management is even more problematic in developing countries. Wilms Tumor (WT) is one of the most common renal tumors in the pediatric population. Occasionally, WT can primarily develop outside the kidneys . Most pediatric ERWTs develop in the abdominal cavity and pelvis, whereas the occurrence of this tumor in other extra-renal sites represents a minor part of ERWT cases. In addition to describing a case of spinal ERWT  in a 4-year boy , we performed a case-based systematic literature review on pediatric ERWT. We retrieved 72 papers providing enough information on the diagnosis, treatment, and outcomes of 98 ERWT pediatric patients. Our research highlighted that a multimodal approach involving both chemotherapy and radiotherapy, after partial or complete tumor resection in most cases, was typically used, but there is no standardized therapeutic approach for this pediatric malignancy. However, this tumor may be potentially treated with a better success rate if the diagnostic confirmation is not delayed, the mass can be totally resected, and an appropriate and, possibly, tailored multimodal treatment can be promptly established. In this regard, an international agreement on a unique staging system for (pediatric) ERWT is definitely needed, as well as the development of international research, which may be able to gather several children diagnosed with ERWT and, possibly, lead to clinical trials which should also include developing countries. Wilms tumor (WT), or nephroblastoma, is one of the most common solid malignancies in children. It represents around 95% of renal tumors in the pediatric age, and, indeed, it arises almost exclusively from the kidneys . HoweverThe clinical presentation of ERWT is unspecific and can vary according to the primary location and size of the mass. Useful diagnostic investigations are ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI); however, the radiological features of ERWT are also nonspecific: therefore, these imaging techniques alone cannot provide a final and safe diagnosis for this tumor; surgery and eventual histopathological examination are required to reliably distinguish ERWT from other malignancies, which may enter into the differential diagnosis  ,5.We report a 4-year-old child diagnosed with ERWT arising in the spinal canal, an extremely rare location; moreover, this patient was also affected with spinal dysraphism. Additionally, we provide a systematic case-based review of pediatric ERWT cases described in the medical literature so far, in order to summarize and discuss the main diagnostic and therapeutic aspects and challenges.A 4-year-old boy  presented to the regional hospital because of intermittent limp and back/left leg pain for 2 months. According to his parents, such a problem appeared after falling on his back. No fever or other complaints were reported at that time. Family history was negative for any relevant diseases, including malignancies and congenital malformations.In the regional hospital, the child underwent MRI of the spinal cord, which revealed a mass at the level of T12-S3 vertebrae; notably, this exam also revealed a spinal dysraphism (posterior spina bifida), which was not suspected or known before. However, any further medical assistance was refused until six months later, when they again brought their child to the same hospital after he had already developed paraplegia and other neurological dysfunctions . A second MRI of the spinal cord revealed an intramedullary mass of the thoracic and lumbar spinal cord, with signs of extramedullary growth. Parents gave their consent for a biopsy of this mass, and the procedure was performed without any complications; unfortunately, mass excision was not possible.After histopathological confirmation of malignancy, this patient was transferred to our referral national center for Pediatric Oncology, where the diagnostic work-up was completed, including brain, spinal cord, abdomen, and pelvis MRI with contrast medium, and chest CT, according to the recommendations of the Republic of Kazakhstan national medical protocols for patients diagnosed with any malignancy. The previously obtained histopathological material was also sent to our Pathology Department for further examination and analyses (see later), which supported the diagnosis of ERWT. Laboratory examinations showed no significant abnormalities except for mild anemia; however, bone marrow examination did not show any tumor infiltration. The levels of plasmatic α-fetoprotein, β-human chorionic gonadotropin, and neuron-specific enolase were within the normal range. A cerebrospinal fluid examination was not performed due to the contraindication represented by the extensive intraspinal tumor.The main steps of the diagnostic timeline are reported in As mentioned, the MRI of the spinal cord was performed upon admission to our medical center: it revealed an irregularly shaped solid mass infiltrating the spinal canal at the T9-S4 level. The dimensions of the formation were up to 39 × 36 mm × 205 mm. At the T12-S1 level, the tumor spread paravertebrally on both sides (size: from 11 × 10 mm to 29 × 23 mm) along the nerve roots. Moreover, at the C1-C2 level, along the right-anterior surface of the spinal cord, an oval-shaped mass  was also described see A. FinallThe main radiological findings during the clinical course and follow-up are also summarized in The histopathological examination revealed a tumor mass represented by blastemal, epithelial, and stromal components. The blastemal component was characterized by foci of medium-sized cells having round and oval hyperchromic nuclei and poor cytoplasm; multiple mitoses were noted. The epithelial component was characterized by formations resembling renal tubules lined with cuboidal epithelium with rounded nuclei and light cytoplasm, and primitive glomerular structures. The stromal component was represented by patches of fibrous tissue .The immunohistochemistry of tumor cells was WT1—diffuse positive, Pan-cytokeratin epithelial cells—focally positive, CD99—positive, NSE—stroma positive, Desmin—negative, and S100—negative. In addition, the proliferative activity of tumor cells (Ki-67) reached 90%.Thus, the morphological and immunohistochemical characteristics were consistent with nephroblastoma and, thus, spinal ERWT  was finally diagnosed.2), carboplatin (200 mg/m2), cyclophosphamide (450 mg/m2), and doxorubicin (50 mg/m2). Additionally, the patient underwent radiation therapy, receiving 25.5 Gy in 17 fractions on the craniospinal axis and an additional sequential booster dose of 25.5 Gy in 17 fractions on the main tumor site. The overview of the clinical course and therapeutic management is summarized in After the final ERWT diagnostic confirmation, chemotherapy was started according to the protocol of the International Society for Pediatric Oncology (SIOP WT 2001), stage III, in the high-risk group (due to the presence of metastases). Nine courses of chemotherapy were performed, consisting of etoposide , due to the lack of significant response, a second and more extensive tumor biopsy was performed. Histopathological and immunohistochemical examination of tumor cells once again confirmed the diagnosis of ERWT. Positron emission tomography-computed tomography (PET-CT), performed before this second biopsy, also confirmed a metabolically active mass in the spinal canal; notably, cervical, left axillary, and right inguinal lymph nodes uptake with low metabolic activity were also detected.After this diagnostic reassessment, the patient was discharged from the hospital due to a break between chemotherapy courses, but he returned to our medical center only four months later. The spinal MRI described an increased size of the mass, as shown in 2; carboplatin: 500 mg/m2; and etoposide: 100 mg/m2), which was interrupted due to the rapid deterioration of the clinical condition. The patient died in the intensive care unit around two years after his initial ERWT diagnosis.This unfortunate patient started a palliative course with ICE chemotherapy  until 31 December 2022.A total of 421 items were retrieved from the medical literature in the electronic database; after excluding duplicated records and inappropriate manuscripts , and after screening the article abstracts, 237 titles were discarded. Thus, 184 titles were considered for eligibility: a total of 72 full-text accessible papers were selected since these included at least one pediatric EWTW and provided minimal clinical, diagnostic, therapeutic, and follow-up information. The PRISMA flowchart describing all the stages of this systematic literature search is shown in After a critical assessment and selection of the articles according to the PRISMA guidelines, data extraction was done by one investigator and was checked by a second investigator following these main inclusion criteria: any case report/series articles including pediatric patients diagnosed with ERWT, which could provide sufficient information on clinical, diagnostic, therapeutic and follow-up aspects, according to the objectives of the data extraction, as described below.The following information was extracted: first author’s last name, publication year, patient’s gender and age, ERWT location, time of diagnosis, tumor stage, treatment, relapse, metastasis, follow-up, and outcome.n = 59) and small case series (n = 13). Notably, no clinical studies investigating or focused on ERWT pediatric patients (including data in aggregated form) were retrieved.The final output of this systematic case-based literature review consisted of 72 papers, including case reports (n = 51), inguinal region , female genital tract , (para-)vertebral/spinal regions , pelvis , bladder (n = 3), scrotum (n = 3), chest wall (n = 1), colon , mesentery (n = 1).The main patient’s data extracted from case reports and series are schematically summarized in n = 50; males, n = 47; gender information was not available for one pediatric patient). Age information was available for 92 patients (out of 98): overall, the age of these pediatric ERWT patients at diagnosis was 4.02 ± 3.83 years (mean ± standard deviation).Overall, the gender ratio of this pooled population was 1.06:1 , three cases were diagnosed as stage I, 11 cases as stage II, 12 cases as stage III, and 2 cases as stage IV. According to the SIOP staging system (n = 5), one case was at stage I, three cases at stage III, and one case at stage IV. Additionally, according to the United Kingdom Children’s Cancer Study Group (n = 2), both patients were categorized as stage III. Lastly, based on the TNM  system (n = 2), these patients were classified as stage I and stage III, respectively.Clear staging information for pediatric ERWT was available for only 42 patients (out of 98). Among these 42 cases with ERWT staging information, 28 were staged according to the National Wilms Tumor Study (NWTS) for intrarenal Wilms tumors. In two cases, the United Kingdom Children’s Cancer Study Group protocol was used for staging. In five cases, the staging system, according to the International Society of Pediatric Oncology (SIOP), was used. In two cases, staging according to the TNM staging system was applied. In the remaining five cases, the staging system was not clearly specified. According to the NWTS . A minority of patients (n = 12) underwent surgery only. Overall, almost all patients (n = 93) underwent partial or complete resection of the tumor, except three children who received only tumor biopsy; moreover, no clear information is given about two patients.Information about the therapeutic management was available for the majority of ERWT children. Most patients were treated using a multimodal approach . Among these relapsed patients, local recurrence was described in five cases, whereas seven patients developed metastases distant from the primary tumor site . In four patients, both local relapse and metastases were concomitantly diagnosed (as occurred in our case report).± 2.05 years, based on data from 78 patients; indeed, unfortunately, no follow-up period is available for the remaining 20 ERWT cases. This period varied between one month and 10.8 years. As regards the outcome analysis, 77 patients were alive at the end of the follow-up, and death was reported in five cases. Finally, there is information on the time elapsed between symptoms onset and ERWT diagnosis for 47 patients: the estimated median time was approximately 12–13 weeks, but unfortunately, some patients needed several months to be diagnosed .The mean follow-up was 2.49 Since our case report described a child affected with ERWT located in the spinal cord, we performed a subanalysis of these patients, as shown in Pediatric ERWT is a rare malignancy; indeed, all available articles are case reports or small case series, as shown by our systematic literature research. The primary site is extremely variable since this malignancy can develop anywhere along the cranio-caudal migration pathway of primitive mesonephros and metanephros cells . RetropeMoreover, we also highlighted that there is no standardized treatment protocol for ERWT in children; however, the therapeutic approach is multimodal, although it is firstly based on the surgery, which is also essential for the diagnostic confirmation . AccordiDespite such a therapeutic heterogeneity, patient’s death was reported in only five cases (6.1%) at the end of 2.5-year median follow-up; therefore, the lack of a longer follow-up does not allow us to know if there were mid/long-term relapsed cases and, thus, the actual mortality rate. According to two international multidisciplinary cooperative consortia—the Children’s Oncology Group (COG) Renal Tumour Committee, previously known as the National Wilms Tumour Study Group (NWTSG), and the International Society of Paediatric Oncology (SIOP) Renal Tumour Study Group (RTSG), despite different treatment approaches, the overall survival of WT patients is approximately 90% . In patiThe knowledge of two effective drugs (vincristine and actinomycin D) in WT may have further improved the survival of ERWT children. This combination of drugs was developed by the SIOP and the NWTS in the 1970s and 1980s, and was shown to be highly effective in treating renal WT. As a result, this combination has been widely used in treating nearly two-thirds of children diagnosed with this disease ,82, inclTherefore, even though no general conclusion can be made in terms of optimal therapeutic management , the recommendation for a total surgical resection (whenever this is possible) is the therapeutic mainstay of pediatric ERWT inside a multimodal and personalized therapeutic plan, which should take into consideration the tumor site, histological details, and staging. As regards the chemotherapy, vincristine, actinomycin D, and doxorubicin were among the most used drugs to treat pediatric ERWT, as also discussed by Liang et al., who reported the largest monocentric case series (five patients) so far ; howeverAs specifically regards the staging, our literature research definitely highlighted the lack of a uniform approach. The use of different staging systems  was observed. The staging system for renal WT was developed by the National Wilms Tumor Study Group (NWTS) and updated by the Renal Tumors Committee of the Children’s Oncology Group (COG). SIOP is another European Group that has provided a different WT staging system since 1971: this differed from COG regarding the concept of giving preoperative chemotherapy to all patients > 6 months of age . NeoadjuAs an additional completion of our analysis, we also focused on pediatric ERWT arising from the spinal cord region, starting from our direct experience with our patient. As summarized in In perspective, clinical studies are crucial for developing new treatments for rare tumors, including ERWT. Of course, conducting clinical trials for rare tumors is challenging due to the small patients’ population and, thus, the related logistic issues to include study participants from different areas of the world, along with the hesitancy from the pharmaceutical industry to specifically invest in “small markets” clinical research . MoreovePediatric ERWT is a rare form of cancer that must be diagnosed and treated with a multimodal approach. Currently, there is no standardized therapeutic approach for this pediatric malignancy, as is highlighted by the present article. However, this tumor could be potentially treated with a good success rate if the certain diagnosis is not delayed, the mass can be totally resected, and an appropriate and, possibly, tailored multimodal treatment can be promptly established. In this regard, an international agreement on a unique staging system for (pediatric) ERWT is definitely needed, as well as the development of international research, which may be able to gather a number of children diagnosed with ERWT and lead to clinical trials, which should also include developing countries.


Head and neck tumors are among the most common malignancies . In thisIn general, tumors originating from the minor salivary glands often show a higher degree of malignancy than tumors of the major salivary glands  . ConsequThe clinical features of ACC in the head and neck region are often variable. Typically, a swelling of the respective facial region that progresses quickly or slowly, depending on the growth pattern, is often associated with diffuse pain . FurtherMost ACC usually show a slow growth pattern with a histologically highly differentiated cell picture, but markedly infiltrative growth behavior . HistoloIn advanced ACC, even conventional radiation therapy can sometimes only achieve limited improvement with regard to the long-term outcome of ACC given the low mitotic aspect . DiagnosTypically, ACC can show increased uptake of contrast medium agent with an infiltrative spread pattern in the respective anatomical region  3]. How. How3]. Histopathologically, ACC can show a cribriform (most common), tubular, or solid growth pattern . FurtherThe therapy of ACC in the head and neck region is sometimes challenging and depends in particular on the progression of the disease and the specific localization.The treatment of choice, especially in localized tumor stages, consists of complete resection of the ACC with a sufficient safety margin (2–3 cm) and is usually supplemented by a neck dissection . Due to In addition, it must be noted that a sufficient safety margin sometimes cannot be achieved in the case of tumors in the head and neck region due to the anatomical conditions. Consequently, this leads to an increased risk of recurrence and/or residual disease in many malignancies of this region . FurtherIn addition, in sensitive locations with pronounced infiltration , adjuvant radiotherapy in the form of proton therapy can be helpful after surgical tumor resection , 9. YounA two-stage surgical procedure with initial tumor resection and epithesis treatment can sometimes be advantageous in therapy planning and plastic reconstruction with the above-mentioned distant flaps after adjuvant proton therapy . HoweverIn general, the prognosis for ACC is acceptable with regard to 5-year survival of up to 80% . HoweverIt should be noted that head and neck ACC can occur in different anatomical regions. In principle, ACC grow slowly and consequently often cause a lack of clinical symptoms.Their perivascular and perineural growth pattern can present therapeutic challenges, particularly in the head and neck region. The treatment of ACC in the head and neck region consists of surgical tumor resection with subsequent neck dissection and one- or two-stage plastic defect reconstruction. Severe ACC often require adjuvant radiotherapy. Proton therapy, as a special form of radiotherapy, seems to have decisive advantages with regard to the long-term survival of this highly malignant tumor originating from the small salivary glands.


Despite the current advances in antenatal care and imaging methodologies in obstetrics, cases of advanced abdominal pregnancies are still reported, mostly in low- and middle-income countries where frequently only a few perinatal checks are performed and where these methodologies are sometimes not adopted in obstetrical outpatient settings.We report the video of a case of a 20-year-old I gravida Ivorian patient, sent to CHU de T reichville in Abidjan, Ivory Coast, for management of abdominal 39 weeks pregnancy after routine antenatal care. She was asymptomatic with a live foetus in transverse lie position. The anamnesis revealed four prenatal checks without ultrasound evaluation, the first one at 24 weeks of pregnancy. Emergency median longitudinal sub-umbilical laparotomy incision was performed. Foetal extraction was realized by transplacental incision due to omental placental implantation. A live female baby weighting 3350 grams was delivered, presenting bilateral clubfeet and an enlarged neck. The release of the adherent placenta required a partial omentectomy and left adnexectomy and was carefully removed following active bleeding from its detached margins. The newborn died of respiratory distress on the first day after birth. No autopsy was performed. Postoperative morbidity for the woman was minimal and she was discharged on the seventh post-operative day in good general condition.Abdominal pregnancies with a normal live foetus at such an advanced gestational age are extremely rare, and there are no available videos in the extant literature of the surgical procedure performed. Standardization of treatment principles, pre-operative preparation with imaging techniques  and adequately equipped and staffed neonatal units are necessary to optimize the foetus-maternal outcomes. Despite advances in diagnostic imaging and focused antenatal care, cases of undiagnosed abdominal pregnancies at term are still reported in obstetric practice, mostly in low- and middle-income countries , 2. TheyWe report a case of a 20-year-old I gravida Ivorian patient, sent to CHU de Treichville in Abidjan, Ivory Coast, for management of abdominal 39 weeks pregnancy after a routine antenatal care consultation and ultrasound at term of gestation. She was asymptomatic with a live foetus in transverse lie position. The anamnesis revealed four prenatal checks without ultrasound evaluation, the first one at 24 weeks of pregnancy.The diagnosis of abdominal pregnancy was confirmed at the CHU after a new obstetrical evaluation and a TA ultrasound. TV ultrasound showed a non-pregnant uterus regular in morphology and volumetry. Antenatal nonstress test (NST) revealed only a persistent tachycardia with baseline fetal heart rate between 160–180 bpm. Emergency median longitudinal sub-umbilical laparotomy enlarged to para-umbilical incision was performed. Foetal extraction was realized by trans-placental incision due to abdominal placental implantation. A live female baby weighting 3350 grams and measuring 51 cm was delivered, with an Apgar score of 3-5-5 at the 1st, the 5th and the 10th minute respectively and presenting bilateral clubfeet and enlarged neck. It was not possible to perform cord pH to evaluate signs of neonatal acidemia. No following imaging investigations were performed on the newborn.The placenta adhered to the epiploon, left ovary and salpinx and its release required a partial omentectomy and left adnexectomy. The placenta was carefully removed following active bleeding from its detached margins. The uterus appeared normal in morphology, with a size of 12 gestational weeks. The patient was transfused with a total of 3 units of red cell concentrate  during and after surgery. The newborn died on the first day after birth of respiratory distress. No autopsy was performed. Postoperative morbidity for the woman was minimal with transient paralytic ileus on the second post-operative day. Her recovery was otherwise uneventful and she was discharged on the seventh postoperative day in good general condition. Follow up evaluations of the mother at 2 weeks, 6 weeks, and 6 months postpartum were uneventful.Abdominal pregnancy with a normal live foetus at such an advanced gestational age is rare. Our survey of the literature revealed fewer than 10 postdated reported cases of abdominal pregnancy , mostly In this specific case, the patient did not perform any ultrasound during the poor prenatal check-ups she did, which meant that the diagnosis of abdominal pregnancy was made late in the 39th week of gestation.Both maternal and foetal mortality rates in such cases are high, as well as the malformation rate among the affected foetus . In a moTreatment is surgery. Immediate termination of pregnancy can be offered if the diagnosis is made before 20 weeks of gestation . PatientGiven the documented low survival rates of neonates in such cases, neonatal units must be adequately equipped and staffed to support them. The issue of removing the placenta during the operation is controversial. Treatment of the remaining placenta with methotrexate has recently been abandoned in favor of the clinical and instrumental monitoring of the patient in the short and long term. Where available, interventional radiology procedures allowing for preoperative embolization of placental vessels are helpful in preventing severe intraoperative blood loss  and imagThese pre-operative procedures would make the surgeon aware of what to expect at surgery and reduce the associated maternal morbidity and mortality.Supplementary Material DetailsClick here for additional data file.Supplementary Material DetailsClick here for additional data file.


Acute cholecystitis is responsible for 44 % of emergency admissions to the emergency services with multiple complications such as empyema a necesitatis (EN). EN has a close relation with cholecystitis when the perforation of the gallbladder (GB) can lead to the formation of a biliary fistula. Patients can be asymptomatic, with late consultations, thus being a diagnostic challenge. Different techniques are described for cholecystitis and secondary abscess, therefore, the choice of the appropriate procedure should be the best one to reduce the high associated morbidity.We present a case of an 89-year-old patient, admitted for a sensation of a mass in the right hypochondrium with abdominal pain. He was taken to the operating room, finding a vesicular plastron with piocholecyst and perforation into the abdominal wall with abscess and fasciitis. Subtotal cholecystectomy was performed laparoscopically and an open approach in the abdominal wall, drainage of the abscess and debridement, leaving a negative pressure system.EN affects elder patients with high rates of morbidity, also GB empyema, which is related with its perforation and posterior fistulization, its external spontaneous perforation is much less frequent. Fistulas originated from the biliary tract are well described in the literature, with low incidence. They are related with improved diagnostic investigations and earlier implemented treatment by antibiotics and surgery.Biliary EN represents a very unusual complication of acute cholecystitis, its atypical presentation represents a diagnostic challenge, with very few cases documented and high mortality rates. Its management represents a challenge for the general surgeon, finding different approaches and surgical behaviors to take. •There are multiple complications associated with this entity, one of them, is empyema a necesitatis.•Perforation is a complication of cholecystitis, it can be generated by carcinoma or spontaneous and can lead to fistulization.•The management on the acute phase, consists of analgesics, antibiotics and common treatment for acute cholecystitis.•There are several surgical options such as cholecystectomy, cholecystostomy or abdominal drainage. There aWe present the case according to the SCARE guidelines .2We present a case of an 89-year-old male patient with multiple comorbidities , who was admitted due to an approximate two-month history sensation of a mass in right hypochondrium, associated with soft abdominal swelling, no redness or other skin changes. Clinical evaluation showed a tender palpable round mass in the upper right quadrant , with noWithin extension studies, a CT scan of the abdomen with contrast was performed, which showed an image compatible with acute perforated cholecystitis, with an associated multiseptated collection, with spontaneous drainage to the thoracoabdominal wall .Fig. 2CTWith these findings, he was taken to the operating room, finding a vesicular plastron with piocholecyst and perforation of the gall bladder into the abdominal wall, with abscess and fasciitis of the wall involving fascia and subcutaneous tissue. Subtotal cholecystectomy was performed laparoscopically and openly at the level of the abdominal wall, drainage of the abscess and debridement, leaving a negative pressure system on the abdominal wall . HistoloIn the immediate postoperative period, the patient presented a torpid evolution, including septic shock managed in the intensive care unit  that req3Empyema a necesitatis (EN) is a clinical entity barely described in the literature that affects elder patients with high morbidity rates that is tightly related with its perforation and posterior fistulization as a complication of gallbladder empyema . GallblaFistulas originated from the biliary tract are well described in the literature, with low incidence nowadays related to improved diagnostic research and earlier implementation of antibiotic and surgical treatments . They caHaving cholecystitis is a predisposing factor for peritoneal adhesions formation with the parietal peritoneum. With the concomitant inflammation and distension of the gall bladder, it adheres itself to the parietal peritoneum of the anterior abdominal wall ,12. ThisEscherichia coli, Coliforms and Klebsiella pneumoniae are the most common organisms found), malignant transformation of the fistulous tract and necrotizing soft tissue infections, as presented in our case, that might lead no necrotizing fasciitis [Clinical manifestations are highly variable, patients with empyema a necesitatis  can be asymptomatic, with late admission to the emergency room (ER) while mildly symptomatic , making asciitis ,17.Management of this condition is still controversial as it leads to more than 40 % risk of septic complications increasing mortality rates . ManagemThe incidence of these pathologies has decreased due to the advent of diagnostic methods, the use of antibiotics and early surgical management of biliary tract disease ,14.Biliary empyema a necesitatis represents a very unusual complication of acute cholecystitis, its atypical presentation represents a current diagnostic challenge, with very few cases documented in the literature and high mortality rates. The management represents a challenge for the general surgeon, tasked with finding different approaches and surgical behaviors to consider establishing successful management. Considering what was previously described and the outcome of our patient, a more conservative management could be recommended in these patients, in whom the control and response to septic shock and surgical blow could lead to death. We decided on a more aggressive and less conservative treatment as the best option for the patient considering it provided a definitive treatment to the underlying etiology, and because he was on stable clinical condition during hospital admission. However, in the case of an octogenarian patient such as this one that is frail and who suffers from multiple comorbidities, a two-stage procedure treatment may have been the preferable option.ENempyema a necesitatisGPgallbladder perforationERemergency roomICUintensive care unitWritten informed consent was obtained from the family of the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval for this study  was provided by the Ethical Committee of Universidad del Rosario, Bogotá, Colombia on 30 March 2023.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Luisa Trujillo-Guerrero: Make substantial contributions to conception and design, acquisition of data, analysis and interpretation of data.Edgar Javier Aguirre- Salamanca: Participate in drafting the article and revising it critically for important intellectual content.Camilo Ramírez-Giraldo: Participate in drafting the article and revising it critically for important intellectual content.Camilo Ramírez-Giraldo.Not applicable.All authors declare no conflicts of interest.


Hydroceles of the canal of Nuck are rare, and have not been described in relation to pregnancy.A 34-year-old Caucasian female patient had bilateral groin swelling debuted during her pregnancy. A preoperative magnetic resonance imaging scan found bilateral hydroceles of the canal of Nuck. Operative findings and histological examinations revealed a left-sided inguinal hernia and a right-sided hydrocele. The patient was discharged well and without signs of postoperative complications or hernia recurrence.In this case, a hydrocele and a hernia sac were morphologically identical in terms of preoperative appearance and development. Given the morphological correlation, it was surprising to find different operative findings confirmed by the histopathological examination.This is the first ever report of the synchronic development of two morphologically identical cystic processes, with one being a hydrocele and the other a hernia sac. In addition, the hydrocele developed during pregnancy, making this case even more unique. Hydroceles of the canal of Nuck are rare, and have not been described in relation to pregnancy . Groin hA 34-year-old Caucasian female patient, a former professional athlete, was referred to our outpatient clinic with intermittent swelling and localized discomfort in both groin regions over a period of 2 years. Symptoms exacerbated during strenuous exercise and heavy lifting, and impaired her daily routines.Swelling debuted during her pregnancy, and remained unchanged after delivery. The pregnancy was a first time, single-fold, with natural delivery of a healthy child. The patient was healthy, age equivalent, and a non-smoker.Physical examination found bilateral swelling of the inguinal canal without tenderness. The swellings did not disappear upon manipulation. A magnetic resonance imaging (MRI) scan of the hip and lower abdomen was performed, although ultrasound normally would be first choice image diagnostics. The MRI revealed cystic protrusions located subcutaneously in both groin areas. The cystic processes measured 83 × 37 × 48 mm on the right side and 67 × 30 × 30 mm on the left side, without communicating with other anatomical structures. The overall MRI concluded bilateral hydroceles of the canal of Nuck Fig. .Fig. 1PrUnder general anesthesia, a bilateral excision of the cystic mass was performed. In both sides a groin exploration was performed, and the cysts were freed from their surroundings.Intraoperative findings included a hydrocele on the right side, measuring 120 × 40 × 30 mm, without communication with the peritoneal cavity. The hydrocele was punctured, producing clear water-like fluid, and excised according to its origin . Histopathological examinations found on the left side flattened soft tissue with minor chronic inflammation lined with mesothelium without atypia.The patient was discharged shortly after surgery. After follow-up 1 month and 3 months after surgery, the patient was well without signs of postoperative complications or hernia recurrence. The patient’s written consent was received and data were anonymized due to guidelines from the ethical committee.et al. analyzed groin hernias during pregnancy, and did not find any acute complications of hernia during pregnancy. A spontaneous remission was observed in 10 of 25 patients. In conclusion, a watchful waiting strategy was recommended [In women, the prevalence of inguinal hernia is 3–5.8% , whereasDue to relatively high complication rates, the watchful waiting strategy is not recommended in groin hernias in women, with the exception of hernias debuting during pregnancy .Hydroceles of the canal of Nuck are a rare condition, only previously described as case reports , 5. ThesIn this case, preoperative MRI findings concluded bilateral type I hydrocele of the canal of Nuck. However, the operative findings were different, as only the right side was a type I hydrocele of the canal of Nuck, while the left side represented a M1 hernia. An abdominal bulge, not able to be repaired, was further diagnosed with ultrasound. When a cystic process has been identified, both hydrocele and inguinal hernia must be considered. Such diagnostic challenges can be supplemented with MRI or diagnostic laparoscopy to detect intraperitoneal communication. A confirmed inguinal hernia should be treated with reparation repair. If no mesh was implanted as recommended, the rationality should be argued. In this case report no mesh was implanted due to the very small defect, suitable for repair with suture only. The assessment to suture strategy were based on hernia size and medial type hernia, whereas it had not been possible in case of femoral hernia.et al., patients were included from medical journals, including “bulge” or “hernia,” whereas some differential diagnosis (including cysts) may have been overlooked, and further classification was not made [et al.’s study [Hydroceles in the canal of Nuck have not been described during pregnancy until now. In Oma not made . In our ’s study . Our finIt is recommended that a groin bulge debuting during pregnancy is treated by watchful waiting . Such reA hydrocele of the canal of Nuck is considered a safe condition, with no reports of complications . ConsideIn this case, a hydrocele and a hernia sac were morphologically identical in terms of preoperative appearance and development. Given the morphological correlation, it was surprising to find different operative findings confirmed by histopathological examination.Our findings suggest a possible connection between the occurrence of hydroceles and hernia sacs. Such a connection has not yet been described in the literature.This is the first ever report of the synchronic development of two morphologically identical cystic processes, with one being a hydrocele and the other a hernia sac. In addition, the hydrocele developed during pregnancy, making this case even more unique.


Teaching Point: AMLEC is a rare subtype of an angiomyolipoma (AML) and not a primary cystic lesion. A 51-year-old man presented to his general physician with persistent mild abdominal pain. His prior history and family history were unremarkable. The patient did not use medication. Clinical examination and routine peripheral blood tests were normal. A screening abdominal ultrasound examination was requested to reassure the patient and showed no relevant findings regarding the abdominal pain. However, a hyperechoic 22 mm well-circumscribed donut-like lesion was visualized in the upper pole of the left kidney, with presence of a central cyst (Angiomyolipomas (AMLs) are the most common benign renal tumours and are composed of vascular, smooth muscle and fatty elements. The presence of macroscopic fat within a lesion is the hallmark feature of AMLs on all modalities, but the amount of fat in these lesions may vary. Therefore, AMLs are radiologically divided into fat-rich, fat-poor, and fat-invisible subtypes. Due to these subgroups, imaging can differentiate between benign lesions (fat-rich) and lesions that require more careful evaluation (fat-poor and fat-invisible) .In our case a benign fat-rich AML was diagnosed complicated with an epithelial cyst. Care should be taken not to confuse this AML with a primary cystic renal lesion, as the management and therapeutic options between an atypical renal cyst and AML differ significantly. Cysts are managed according to the Bosniak classification, while the AML approach depends on the symptomatology, the size of the lesion (cut-off 4 cm), and the diagnostic certainty on imaging. When possible, conservative treatment with active surveillance is preferred to maintain as many nephrons as possible. In other cases, AML can be treated with surgery, embolization, and ablation or in selected hereditary cases also with medication (mTOR inhibitors) .


Anastomotic recurrence of colorectal cancer is rare, but reoperation improves prognosis. However, there is no clear evidence regarding the extent of dissection, and there are few reports on the details of surgery. We used intraoperative lymphatic flow imaging with indocyanine green (ICG) fluorescence as a reference to determine the range of additional resection.The patient was a 75-year-old man who underwent laparoscopic right hemicolectomy and extracorporeal functional terminal anastomosis for ascending colon cancer 4 years ago. Histopathological examination revealed a well-differentiated tubular adenocarcinoma, T4aN0M0, pathological stageIIB. During follow-up, anemia was observed, and colonoscopy indicated anastomotic recurrence, so additional laparoscopic resection was performed. Intraoperatively, ICG was injected into the anastomotic site, and the operation proceeded under near-infrared light observation. Lymphatic vessels along the middle colonic artery were visualized down to the root of the vessel. Using this as an indicator, the vessel was ligated from the root. Using the fact that the lymphatic vessels were also depicted in the small intestinal mesentery on the oral side of the anastomosis as an indicator, the small intestine and mesentery were resected about 7 cm from the anastomosis.The optimal surgical approach for anastomotic recurrence of colorectal cancer has not been defined. Intraoperative ICG fluorescence imaging can provide images of lymphatic flow from the site of recurrence and may be an indicator of lymph node dissection in the case of anastomotic recurrence. Anastomotic recurrence is relatively rare among local recurrences after colorectal cancer surgery , 2. Thisand his cancer defined as RAS wild tumor. The distance to the tumor at the resection margin was pathological proximal margin (PM0) at the proximal dissected edge of 90 mm, pDM0  at the distal dissected edge of 133 mm, and no cancer invasion on the lateral dissected surface, indicating a curative grade A.A 75-year-old patient underwent laparoscopic right hemicolectomy for ascending colon cancer 4 years ago. The patient underwent laparoscopic resection of the ileocecal artery and the right branch of the middle colonic artery with D3 dissection. Functional end-to-end anastomosis (FEEA) was performed using automated anastomosis devices. Histopathological findings of the primary tumor were type 2, well-differentiated ductal adenocarcinoma, pSE, (pT4a), INFβ, ly1, v2, pN0, pH0, pP0, pM0, and pStage IIB, After that, he was referred to our hospital because of a neoplastic lesion near the anastomosis between the ileum and the transverse colon detected by computed tomography colonography.Colonoscopy Fig. a revealeThe patient was diagnosed with anastomotic recurrence 4 years postoperatively and underwent additional laparoscopic resection. ICG was diluted to 5 mg/ml and administered at the beginning of the procedure with an endoscopic 25-gauge needle, 1 ml of ICG was administered from the serosal surface to the submucosa on the anal side about 10 mm of the mass of the anastomotic site, and the operation proceeded with near-infrared light observation (Fig. Macroscopically, a 3.8 × 3.6 cm raised lesion was observed at the anastomosis (Fig. In the sites of recurrence after curative resection of all colorectal cancers, intestinal anastomosis is relatively rare, accounting for about 1% . AccordiThe possibility of pushing intestinal floating cancer cells into the submucosa during needle insertion  has longAlthough there is no established guideline for additional resection at the time of anastomotic recurrence , 10, it Regarding horizontal dissection, previous reports indicate that the frequency of cancer cells detected in the intestinal mucosa prior to anastomosis for colorectal cancer was 12.5% for oral and 21.2% for anal incision , 11, 12.There are many case reports of reoperation for colorectal cancer that recurred at the anastomosis after initial FEEA –17. HoweOn the other hand, current intraoperative use of ICG is limited, and is generally intended primarily to assess perfusion of the colonic facet to reduce the risk of anastomotic leakage. Besides, it is also used as a valuable tool to clarify lymphatic drainage when performing iliac lymph node chain and lateral lymph node dissection .Although this method has not been shown to be useful in determining the extent of lymph node dissection, we believe it can help clarify drainage of lymphatic flow from the anastomosis and help determine the extent of dissection during additional resection of anastomotic recurrences.In reviewing past reports of colon anastomotic recurrences, many considered a causal relationship to the initial surgery, but none mentioned the appropriate range of additional resection. Intraoperative imaging with ICG fluorescence may help to evaluate lymphatic flow in the vicinity of the tumor and to determine the appropriate horizontal and vertical dissection area for additional resection.


This is the first case report of 43-year-old lady with a myxoid hepatic adenoma which demonstrated significant contrast uptake during hepatobiliary phase imaging. This highlights the potential for a missed diagnosis and likely subsequent malignant transformation in a young patient in whom it was initially presumed to be focal nodular hyperplasia with no further surveillance. A 43-year-old female had a palpable incidental liver mass identified during an abdominal examination at the time of consultation for pelvic floor weakness. She did not have any gastrointestinal symptoms, changes in bowel habits, nor systemic features of malignancy or infection. She reported excessive alcohol consumption, drinking a bottle of wine every night for the last 10 years, but displayed no evidence of liver cirrhosis. She had no significant family history of liver disease or malignancy.−1, international normalised ratio of 0.9 and plasma ammonia of 32 μmol l−1. Liver function tests were unremarkable including an albumin of 50 g l−1, bilirubin of 17 μmol l−1, normal transaminases, alkaline phosphatase of 63 U l−1 and gamma-glutamyl transferase of 32 U l−1. Tumour markers including carcinoembryonic antigen, cancer antigen 15–3, cancer antigen 125, cancer antigen 19–9 were within normal limits. Hepatitic screen for hepatitis B surface antigen and hepatitis C antibodies were negative.Laboratory investigations revealed normal full blood examination panel, with normal platelet count of 224 × 10^9  lCT scan of the liver demonstrated a segment 5/6 large exophytic solid mass with multiple central hypodensities on the unenhanced imaging. On arterial phase, there was hypervascular curvilinear and nodular internal enhancement with hypoenhancing hypodense components. On the portal venous phase, there was some degree of gradual enhancement of the hypodense areas , which d®, Bayer-Schering, Berlin, Germany) was performed. At MRI, a large heterogeneous mass (9.4 × 6.1 × 8.4 cm) with multiple internal septations which demonstrated intermediate T1 and low T2 signal was evident in S5–S6. There were areas of increased diffusion restriction corresponding to low T2 signal structures. There were also internal circumscribed T2 hyperintense structures with elevated apparent diffusion coefficient value. There was no evidence of lipid or fat content, however, on T1 weighted opposed-phase sequence, there were areas demonstrating a mild signal increase compared to low signal on T1 weighted in-phase sequence. This can be seen in haemosiderin deposition due to prior haemorrhages. On dynamic sequences, there was moderate peripheral enhancement in the arterial phase, with minimal centripetal filling in the portal venous phase and no washout. At the 20 min delayed hepatobiliary phase (HBP), there was uptake of Gd-EOB throughout the mass   are a rare variant of hepatic neoplasms They are described to lack Gd-EOB uptake at HBP imaging. Typically on MRI, FNH are iso- or hypointense on T1 weighted images, hyper- or isointense on T2 weighted images, and have a hyperintense central scar which enhances in the delayed phases of contrast-enhanced imaging. The scar enhancement is typically visible using extracellular, aspecific gadolinium chelate contrast agents and less evident when using Gd-EOB due to the peculiarity of gadolinium chelate which is lacing an interstitial distribution with fast biliary and renal excretion. Gd-EOB is actively transported into functioning hepatocytes via the organic anion transporting polypeptide 1B3 (OATP1B3). HBP enhancement is seen in masses with functioning hepatocytes like FNH, and it is this feature that is used to differentiate it from HCA. However, it is recognised that a minority of HCA demonstrate Gd-EOB uptake to varying degrees at HBP imaging and it has been suggested that the degree of the uptake can be used for HCA subtyping, although there is a paucity of literature to address these features. Variable degrees of Gd-EOB uptake can be seen in β-catenin-mutated HCAs, thought to be due to the relationship between the activation of the β-catenin pathway and OATP1B3 expression. Previous case reports on MHN specifically describe no uptake of Gd-EOB. In this case, both areas of high T2 signal within the mass, presumably reflecting myoxid material, as well as intermediate T2-signal structures at the periphery demonstrated uptake in the hepatobiliary phase. Therefore, ‘pooling’ into the myxoid components (no hepatocytes within) may be present, but solid components also demonstrated uptake of hepatobiliary contrast. Mutational analysis was not performed in this case to search for β-catenin mutation.The previously described MRI appearance of MHN includes markedly increased T2 signal with internal septations and a heterogeneous, progressive, largely centripetal enhancement pattern.This case report aims to highlight the unusual uptake of Gd-EOB on HBP in a patient with myxoid hepatic adenoma.This highlights the potential for a missed diagnosis and likely subsequent malignant transformation in a young patient in whom it was initially presumed to be FNH with no further surveillance.The differentiation between benign and malignant MHN may not be possible at imaging.This case report will further expand the clinical and radiological findings of MHN in the literature.