Hydrometrocolpos (HMC) is a rare condition where fluids or secretions accumulate in the vagina (hydrocolpos) or up to the uterus (hydrometrocolpos). This case series study reports three infants with different etiologies and presentations of HMC and aims to review literature for proper workup upon initial diagnosis. The first neonate antenatally presented with a huge cystic mass. HMC secondary to imperforate hymen was proved, and hymenotomy was performed at 2 days of age. The second participant presented with persistent urogenital sinus and hematopoietic chimerism, possibly due to transfusion from her twin brother via placenta anastomoses. At 2 months of corrected age, she had difficult defecating, and sonogram revealed HMC with normal appearance of uterus and ovaries. Regular follow-ups and surgical reconstruction will be conducted before puberty. The third patient had cloacal malformation and multiple congenital anomalies at birth. Vesicovaginal fistula-related HMC was detected and managed with surgical drainage in the neonate stage. The girl began menstruation with dysmenorrhea at 12 years. The image studies demonstrated hematometrocolpos secondary to left-side hemivaginal septum, uterine didelphy, and ipsilateral renal agenesis, indicating Herlyn–Werner–Wunderlich syndrome. HMC can be diagnosed easily via sonogram. Careful external genitalia examinations help to identify persistent urogenital sinus or cloacal malformation. Occasionally, the HMC may be part of syndrome manifestations or associated with sex chromosome anomalies. Clinicians may conduct surveillance of renal, cardiac, and skeletal systems as well as chromosome study for early diagnosis and management. Hemato/hydrometrocolpos is a rare condition caused by distal vaginal obstruction with accumulation of blood or mucus secretions in the vagina and uterus. The reported incidence of hydrometrocolpos is around 0.006% . Hemato/We herein report three infants of congenital HMC with different anatomical causes and clinical presentations.Case 1 was born at 36 weeks of gestation. An 8 cm cystic mass in the lower abdomen was detected on antenatal ultrasound from 32 weeks of gestation. The patient presented with a bulging mass over the vulva area. Magnetic resonance imaging (MRI)  showed aCase 2 was a twin A, conceived with in vitro fertilization (IVF), born at 29 weeks of gestation. Antenatal ultrasound showed that the female fetus was a donor and the male fetus was a recipient of twin–twin transfusion syndrome (TTTS) at 20 weeks of gestation. Laser therapy was performed at 22 weeks of gestation. Cordocentesis of twin A revealed the karyotype of 46, XY, which conflicted with the female genitalia appearance and a donor of TTTS. Thus, the chromosome study of peripheral lymphocytes was rechecked and reported 46, XY (82%)/46, XX (18%). The sex-determining region of the Y-chromosome (SRY) gene was positive. The external genitalia presented with normal anus and a single genital opening, suspecting a common sheath of urogenital sinus .The patient presented with defecation difficulty at 2 months of corrected age. The ultrasound  and MRI Case 3 was a female infant born at 34 weeks of gestation. The antenatal ultrasound showed fetal ureteral obstruction and oligohydramnios. She had a poorly developed vestibule with a small orifice near the clitoris and high-type imperforate anus, indicating cloacal malformation. A double-barrel colostomy and drainage of 30 mL turbid urine of the orifice of the common channel, possibly from the distended vagina, was performed at 5 hours of age. Abdominal ultrasound at 1 day of age showed a 7.5 cm cystic mass in the lower abdomen, but it decreased in size on the next day. Water instillation via urinary catheter visualized the urinary bladder and enlarged the cystic mass on real-time ultrasound, suggesting HMC with vesicovaginal fistula. The patient received spinal lipoma excision at 8 months of age for the lipomyelomeningocele, and repair for tetralogy of Fallot at 1 year of age. Posterior sagittal anorectovaginourethroplasty using the Pena method was performed at 1 year, 8 months of age, and the distal vagina was replaced by a 5 cm length of rectum. She began menstruating at 12 years, 10 months, which was associated with cyclic abdominal pain, and the MRI detected uterine didelphys with left hematometrocolpos, hemivagina, and left renal agenesis . HysteroThe three infants in this study had different clinical presentations and were diagnosed at different times . The strPresentations of HMC depend on the degree of compression of the surrounding structures. Frequently, the urinary tract is compressed causing varying degrees of hydronephrosis as in case 1 and 3, as previous reports mentioned ,12,13; pWe suggest a peripheral blood chromosome study for patients with HMC for disorders of sexual development and a sex chromosome anomaly survey. HMC had been reported associated with 47, XXX, 45, X/46, XX mosaicism and 45, X ,26. GeneSurgical intervention of HMC varied from surgical drainage to correction of genital malformations according to the complexity of anomaly . Huge HMHydrometrocolpos in infants is a rare condition. The presentations include an intraabdominal cystic mass, which may be evident in utero, and mass-related compression effects such as hydroureteronephrosis, urinary retention, constipation, and bowel obstruction. Associated structural anomalies in the urinary tract  and anorectal tract  should be clarified for surgical planning. In addition, the hydrometrocolpos is sometimes part of syndromic manifestations. Careful evaluation of skeletal anomalies , congenital heart diseases, and renal anomalies  and chromosome studies are important for early diagnosis and proper management.


A phosphaturic mesenchymal tumor (PMT) is classified into four histological subtypes: mixed connective tissue, osteoblast-like, non-ossifying fibroma-like, and ossifying fibroma-like. The ossifying fibroma-like subtype being extremely rare. Most PMTs are benign, with a minimal number becoming malignant after recurrence. In this study, we report a case of recurrence and malignant transformation of PMT-ossifying fibroma-like subtype in the left hip bone.Here, we report the clinical manifestations, histology, pathological features, and treatment of a 57-year-old Chinese woman with a recurrent and malignant ossifying fibroma-like subtype PMT of the left iliac bone. The tumor was first discovered 3 years ago when the patient underwent surgery to remove the tumor. Precisely 2 years and 6 months after the operation, the pain in the left hip reappeared. After 6 months, the patient went to our hospital for treatment. After the tumor resection, the postoperative symptoms improved significantly, and the serum alkaline phosphatase level returned to normal. Based on clinical manifestations, evaluation of serum biochemical indicators, X-ray examination, computerized tomography scan of the pelvis, and histopathological examination of the two operations, the patient was finally diagnosed with a recurring and malignant transformation of the left iliac bone phosphaturic mesenchymal tumor-ossifying fibroma-like subtype. No tumor recurrence was found during the follow-up 15 months after the operation.This case increases the awareness of a rare malignant subtype of PMT and provides a valuable reference for the diagnosis of this disease. A phosphaturic mesenchymal tumor (PMT) is a rare abnormal growth that is classified into four histological subtypes: mixed connective tissue, osteoblast-like, non-ossifying fibroma-like, and ossifying fibroma-like . The mixA 57-year-old Chinese woman came to our hospital for treatment. The patient indicated that the pain and soreness in the left hip had lasted for 6 months, accompanied by swelling in the left groin area, and gradual difficulty in walking. These symptoms could be relieved via rest and painkillers were needed at times. The patient’s personal and family history was not unusual, but the previous medical history showed that the patient had also experienced pain in the left hip 3 years before admission. At that time, she was diagnosed with a left iliac bone tumor in her hometown hospital and underwent tumor resection After treatment, the symptoms were relieved.Physical examination showed that the patient’s left groin was swollen, and an old surgical scar about 8 cm in length was visible on the left hip. A mass of about 10.0 8.0 cm in size could be palpated. The boundary was unclear, with no tenderness, medium texture, normal superficial skin temperature, no varicose vessels and skin ulcers, normal limb sensation, normal muscle strength of the limbs, unrestricted activity, and no abnormalities in the neurological examination.Upon admission, an evaluation of the serum biochemical indicators indicated high serum alkaline phosphatase (211 U/L) and normal serum calcium (2.510 mmol/L) and phosphorus (1.150 mmol/L) levels. The serum levels of the following tumor markers were normal: Carbohydrate antigen 199, carbohydrate antigen 125, carcinoembryonic antigen, and alpha-fetoprotein. No results were available for serum fibroblast growth factor (FGF-23), serum 1-α,25-dihydroxyvitamin D3 -D3) levels, or urine phosphate.X-ray of the pelvis Fig.  indicateComputerized tomography of the pelvis showed a 9.5 × 8.4 × 7.6 cm uneven mass in the bone destruction area protruding into the pelvic cavity and compressing the left internal iliac and psoas muscles Fig. a, b. TheTo further clarify the nature of the tumor, we observed the tumor tissue sections of the patient from 3 years ago. The histology at the time showed that the ossifying fibroma-like area of the tumor was mainly composed of mild spindle cells Fig. a-d. The According to the surgical plan, the patient underwent left iliac wing tumor resection, pelvic bone grafting, and plate internal fixation. After successful anesthesia, the patient was positioned on her right side, a herringbone incision was made with the lateral iliac crest of the left iliac bone as the highest point, and a herringbone incision was made. The anterior incision extended to the midpoint of the inguinal ligament, extending outside. We used an electric knife to make an incision along the medial and lateral subperiosteal of the iliac bone, and gradually peeled off the muscles toward the deep surface without cutting the iliopsoas and sartorius muscles, and peeled each muscle from the attachment point of the pelvis one by one to expose the iliac wings. The dissection range was about 4 cm from the tumor. Osteotomy was used to cut the anterior superior iliac spine and the iliac bone about 1 cm above the sacroiliac joint. All the left iliac wing and the tumor were removed and sent for pathological examination. The hand field was then soaked in sterilized distilled water to stop local bleeding. An appropriate size of the artificial bone block was selected and pressed on the remaining ilium osteotomy screen, two steel plates were placed and fixed with screws. The C-arm fluoroscopy and internal fixation were excellent. During the operation, we found that the left iliac wing was extensively invaded by the tumor. The tumor traversed the iliac wing, the size was about 10 × 10 cm, the capsule was intact, and nourishing blood vessels were growing into it. The structure of the left iliac bone was destroyed, and tumor-infiltrating growth was observed in the bone Fig. a, b.FigThe histology of the patient’s tumor showed tumor cells were composed of oval, spindle, and star-shaped cells, with small nuclei and nucleoli, increased density, and a fibrous histiocytoma-like structure Fig. a, b. TumBased on the histopathology and immunohistochemistry of the two surgical specimens, the pathological diagnosis of a recurring malignant left ilium PMT-ossifying fibroma-like subtype was confirmed. Post-surgery, the patient’s left hip soreness improved and the alkaline phosphatase levels returned to normal Table . The patHerein we reported the clinical manifestations, histological, and pathological features of a 57-year-old Chinese woman with recurrent and malignant transformation of an ossifying fibroma-like PMT in the left iliac bone. She was successfully treated and did not show recurrent manifestations in the 15-month follow-up period.PMT is a rare interstitial tumor. The main clinical manifestations are osteomalacia, hypophosphatemia, hematuria and neoplastic lesions . The disIn clinical practice, Honda et al. found that patients with PMT are usually associated with a history of osteomalacia, and the patients showed typical features of osteomalacia in the early stage, including generalized fatigue, bone pain, musculoskeletal weakness and incomplete fractures. The clinical manifestations include hypophosphatemia and decreased serum 1,25(OH)2-vitamin D3 levels . DetectiIn 1987, Weidner . Among tIn most cases, tumor excision can alleviate PMT clinical symptoms and restore the levels of biochemical indicators . In casePMT is a rare and unique mesenchymal tumor with heterogeneous but recognizable histology. Due to the increased secretion of FGF23, it often causes clinical paraneoplastic syndromes, which consist of hypophosphatemic hyperphosphorylation osteomalacia. Patients usually show progressive muscle weakness, bone pain, and pathological fractures. Due to the non-specific nature of these symptoms, the lack of clinical suspicion, the failure to include serum phosphorus levels in routine blood chemistry tests and the difficulty in determining the responsible tumor, the diagnosis is usually delayed for several years. In addition, due to the rarity of these tumors and the morphological overlap with other mesenchymal tumors, they are often missed in histology.


Retroperitoneal liposarcomas (RPLS) are usually grow large with frequent recurrences. Complete surgical excision remains the gold standard treatment for primary and even recurrent tumours. Their prognosis depends on their histological type and grade. We report a recurrent giant de-differentiated RPLS weighing 18.55 kg which was completely excised. To the best of our knowledge, this is one of the largest liposarcoma reported in the literature.A 40 year old female presented with a gradually progressing large abdominal lump for 1year. She had had a similar large lump twice in the past and undergone excision of the tumour elsewhere. Firm non-tender mass felt all over abdomen with edema noted over abdominal wall and bilateral lower limbs. PET CT showed large heterogeneously enhancing mass occupying almost the entire abdominopelvic cavity. 50 × 40 × 40cm tumour was completely excised and biopsy showed grade 2 dedifferentiated liposarcoma (DDLS). She is under close follow up with no recurrence at 12months.DDLS have lower risk of distant metastases but have a high risk of local recurrence. The most important favourable prognostic factor in these tumours is complete resection with negative margins. Because of the ineffectiveness of current chemotherapy and the requirement of intolerably high radiation doses, surgical excision remains the most effective treatment even for the localized recurrences of RPLS.The dedifferentiated subtype should be suspected in locally aggressive RPLS. Close follow up with early detection of recurrences and prompt excision with negative margins lowers the risk of recurrences and improves survival. •Retroperitoneal liposarcomas are rare malignant tumours and are the most common sarcomas arising in this region.•Prognosis depends on their histological type and grade.•Surgical excision remains the most effective treatment even for localized recurrences.•Chemo/radio therapy have very limited role in their treatment. Retrope2A 40 year old female, suffering from hypothyroidism for 6 years, presented to our outpatient department with a gradually progressing large abdominal lump for 1year associated with bilateral pedal edema and difficulty in breathing for 1 month. She had had a similar large lump in 2013 and 2017, and had twice undergone excision of the tumour elsewhere. Biopsy revealed a well differentiated liposarcoma. She received 6 cycles of chemotherapy after the second surgery and her last cycle was in March 2018. She had not had radiotherapy. She was well till November 2018 when she again noticed a lump in the lower abdomen which gradually increased in size occupying her entire abdomen. There were no symptoms suggestive of bowel or urinary bladder involvement and no history of jaundice, back pain or headache.On examination, she was moderately built and nourished with weight of 83 kg, height of 161 cm and body mass index (BMI) of 32. She had a distended abdomen with a midline scar from a previous laparotomy. Firm non-tender mass felt all over abdomen with edema noted all over abdominal wall and bilateral lower limbs. Her bowel sounds were heard in the left upper quadrant of the abdomen. On digital rectal examination, a mass was felt anteriorly compressing the rectum. Her all lab parameters were within normal limits except for raised thyroid-stimulating hormone that was managed by increasing the dose of thyroxin from 25mcg to 50mcg once daily. She was evaluated with a PET CT  which shAs it was a second recurrence of the tumour and the patient refused neo-adjuvant therapy, it was decided to relieve her symptoms by surgical excision. On exploration by a senior consultant in surgical gastroenterology and liver transplantation department in this tertiary care center, a huge 50 × 40 × 40cm yellowish encapsulated multilobular retroperitoneal tumour mass was found extending from the diaphragm to the pelvis . The entHer post-operative course was uneventful. At the time of discharge, 1 week after surgery, her weight was reduced to 61 kg with BMI of 23.5. The final histopathology report was suggestive of large grade 2, dedifferentiated liposarcoma (DDL) with undifferentiated pleomorphic sarcoma (UPS) features , with le3Retroperitoneal liposarcomas (RPLS) are rare malignant tumours, representing between 0.07 and 0.2% of all neoplasms and are the most common sarcomas arising in this region . They arMost of the giant liposarcomas reported in the literature belongs to the dedifferentiated subtype ,10 as thA dedifferentiated liposarcoma (DDLS) is defined as a primary or recurrent well-differentiated liposarcoma (WDLS), with a region of abrupt transition to a non-lipogenic sarcoma . Both faDDLS have a lower risk of distant metastases than other high-grade liposarcomas but have a high risk of local recurrence. In a series of 65 primary retroperitoneal DDLS patients, the 3-year recurrence-free survivals observed were 17% for local and 70% for distal recurrences and the 5-year disease-specific survival was only 20% . The mosMortality from RPLS is usually due to local recurrence as a result of incomplete resection. This occurs mostly due to difficulty in differentiating the tumour from adjacent normal fat and due to an inability to obtain a safe margin in the absence of a definite vascular-lymphatic peduncle of the tumour. RecurrenBecause of the ineffectiveness of current chemotherapy and the requirement of intolerably high radiation doses, surgical excision remains the most effective treatment even for the localized recurrences of RPLS. The possibility of complete surgical resection in patients with a first recurrence is up to 80%, however it decreases to 60–70% for the subsequent recurrences [All symptomatic local recurrences and asymptomatic recurrences which are impinging on critical structures or suspicious of dedifferentiation on CT scan with a growth rate of less than 1cm per month should be offered surgery. The asymptomatic local recurrences with a growth rate of more than 1 cm per month should be offered systemic chemotherapy or new targeted therapy trials .4Recurrence after excision of retroperitoneal liposarcomas is common. The dedifferentiated subtype should be suspected in cases which are locally aggressive. Close follow up with CT scans detects early recurrences and prompt reoperation with complete excision with negative margins lowers the risk of recurrences and improves survival.None declared.None.Ethical approval was not required.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Lalith Kanthala – Data Collection and analysis, Drafting article.Samrat Ray, Sri Aurobindo Prasad Das – Study conceptualization and designing, Drafting.Samiran Nundy, Naimish Mehta – Final Drafting.N/a.Dr Lalith Kanthala.Not commissioned, externally peer-reviewed.None.


A 62‐year‐old woman with a severely distended abdomen and no palpable superficial lymph nodes visited the hospital. Computed tomography with contrast enhancement revealed multiple fused and homogeneously contrasting masses filling the abdominal cavity. She was diagnosed with diffuse large B‐cell lymphoma by ultrasound‐guided needle biopsy performed on admission. Malignant lymphoma can be a cause of peritoneal dissemination of unknown primary lesions. Because malignant lymphomas which present with peritoneal dissemination are usually highly malignant, they should be diagnosed immediately. On admission, physical examination revealed tachycardia, tachypnea, severe abdominal distension, and no palpable superficial lymph nodes. Laboratory examination showed a normal peripheral blood smear, lactate dehydrogenase concentration of 1,215 U/L, and soluble interleukin‐2 receptor concentration of 13,207 U/mL. Chest and abdominal contrast‐enhanced computed tomography revealed multiple fused masses without primary lesions. The masses were homogeneously contrasting and filling the abdominal cavity .Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Intestinal stenosis of Garré can occur as a result of prolonged ischemia after all types of hernia surgery. Intestinal stenosis of Garré can occur as a result of prolonged ischemia after all types of hernia surgery. Herein, we present the first reported case of symptomatic intestinal stenosis of Garré occurring after emergency primary ventral hernia repair.A 63‐year‐old Caucasian man was admitted with symptoms of chronic intestinal obstruction. He had previously undergone an emergency suture repair of a long‐standing umbilical hernia. Prior to that procedure, a computed tomography (CT) scan demonstrated the presence of a small bowel loop in the umbilical hernia defect Figure . IntraopUpon readmission, a repeat CT scan of his abdomen and pelvis showed features suggestive of gastrointestinal obstruction due to segmental small bowel stricture Figure . The patThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.BP and DG: contributed to the clinical data collection and prepared the case report. CS and LS: contributed to the design of the case report presentation and performed the final revision of the manuscript.Informed consent was obtained from the patient and is available upon request by the editorial office; no ethical committee approval was required for the publication of this case report.


Intracardiac blood cysts are very rare primary cardiac tumors. Blood cysts originated from the mitral valve represent a minority of cases, and previous cases have been mainly treated with conventional surgery through median sternotomy. When the tumor involves heart valves and histopathological diagnosis remains unknown preoperatively, minimally invasive surgical resection of an intracardiac tumor can be challenging, especially through an endoscopic approach. We herein present the first case of successful surgical resection for a rare mitral valve originated blood cyst in a minimally invasive, totally thoracoscopic approach.An apparently healthy 38-year-old male presented to his local hospital with six months history of palpitation and exertional dyspnea. Transthoracic echocardiography showed a mobile round cystic mass inside the left ventricle, attached to the anterolateral papillary muscle and chordae tendineae of the mitral valve. The local doctor diagnosed an intracardiac tumor and suggested a surgical resection through median sternotomy. However, the patient refused to have a sternotomy. He was then referred to us seeking minimally invasive surgery. We assessed the location, appearance and relationship to nearby structures of the tumor with echocardiography, and made a diagnosis of a suspected primary cystic intracardiac tumor. Since we had enough experience of totally endoscopic mitral surgery, our surgical plan was to resect the tumor in the aid of thoracoscopy, and manage the possible deformation and dysfunction of the cardiac structure if necessary. Using femoro-femoral cannulation and cardiopulmonary bypass, we successfully resected the tumor through a thoracoscopic approach in a closed chest, and well preserved the subvalvular structure and valvular function. Postoperative recovery was quick and uneventful. Pathologic diagnosis confirmed a simple blood cyst.Surgical resection is warranted for symptomatic cases of intracardiac blood cysts. With prudent preoperative diagnosis and comprehensive surgical plan, we believe the thoracoscopic approach is a safe, curative and viable alternative for complete resection of cardiac valvular tumors.The online version contains supplementary material available at 10.1186/s13019-021-01535-6. Intracardiac blood cysts are uncommon congenital pseudoneoplasms. Although small blood cysts can occasionally be found in postmortem examinations in infants, large cysts in adult patients are extremely rare, and very few cases have been reported to date , 2. Due A 38-year-old male complained of palpitation and exertional dyspnea on his first visit to a local hospital in February. He never had a fever, arthralgias, weight loss or fatigue, nor did he have a personal or relevant family history of cardiovascular disease or neoplasms. A grade II/6 pansystolic heart murmur was heard during physical examination. Transthoracic echocardiography (TTE) revealed a large mass in the left ventricle, attached to the anterolateral papillary muscle and chordae tendineae. The local doctor made a preliminary diagnosis of suspected intracardiac fibroelastoma or myxoma, and suggested surgical resection for this intracardiac neoplasm through conventional median sternotomy. However, the patient was deterred by the invasiveness of sternotomy, and refused to have surgery in his local hospital. In May, as he learned about our experience in minimally invasive cardiac surgery, he came to our center.We reexamined the patient. The TTE confirmed a mobile round cystic mass inside the left ventricle. The mass had a hyperechogenic wall and hypoechogenic content and was attached to the anterior mitral leaflet Fig. A. In sysNon-invasively distinguishing aggressive from non-aggressive intracardiac tumors is an important clinical challenge. Preoperative biopsy for histopathological diagnosis is inapplicable to intracardiac tumors. In this case, fortunately, the TTE provided significant information on morphology, localization, biological characteristics, as well as tumor vascularity-perfusion. The mass had a smooth surface, clear border, and low echodensity. No imaging evidence showed any features of malignancy like vascularity-perfusion, invasion or filtration into the cardiac structure, permeation to the great vessels, or pericardial effusion. So, there was a fairly high probability that this mass would be benign. We made a diagnosis of a primary intracardiac cystic tumor according to the obtained information, and decided to resect the tumor.Generally, a benign intracardiac tumor in this location and size can be accessed via trans-aortic or mitral orifice approach through mini-thoracotomy. Since we have enough experience of totally endoscopic mitral surgery, we decided to perform the operation in a totally thoracoscopic approach, and manage the possible deformation and dysfunction of the cardiac structure if necessary.Tumor resection was planned and performed through a totally endoscopic, video-assisted approach with thoracoscopy and femoral cannulation . The cardiopulmonary bypass and the surgical approach were established as the conventional endoscopic mitral surgery Fig. A. A 35-mAdditional file 1: Video S1. Totally thoracoscopic resection of a blood cyst originated from the mitral valve.The excised mass was 25 mm*20 mm*20 mm in size Fig. A. PatholThe intracardiac blood cyst was first reported by Elsässer in 1844. Blood cysts are typically lined by flattened endothelial cells and filled with nonorganized blood. These lesions can occasionally be found during autopsy in fetuses or infants, arise characteristically from the mitral and tricuspid valves . AlthougMinimally invasive cardiac surgery (MICS) is being applied with increasing frequency in all areas of cardiovascular surgery, and cardiac tumors are no exception. However, experience is generally confined to benign tumors. This is perhaps due to both the difficulty of preoperative pathologic diagnosis and the different adoption of MICS between cardiac centers. Since invasive heart biopsy procedure is usually inapplicable for intracardiac tumors, surgical management for cardiac tumors mainly relies on preoperative differential diagnosis with cardiovascular imaging. Although TTE has offered sufficient basis for us to diagnose and make a surgical plan in this individual case; for common cases, TEE, contrast-enhanced cardiac CT, cardiac magnetic resonance, or even 18F-fluorodeoxyglucose positron emission tomography should be considered with discretion in preoperative evaluation, to facilitate in planning the most appropriate therapeutic strategy for cardiac tumors. To our knowledge, this is the first reported case that had an intracardiac blood cyst surgically resected with a totally endoscopic, closed-chest approach. Previous cases involving mitral valve or causing LVOT obstruction were treated with conventional surgery through a sternotomy , 8. As wThis case additionally benefited from the totally thoracoscopic approach in the following aspects. Firstly, the endoscopic approach provides direct and targeted access to the mitral orifice and the tumor, allowing excellent visualization of the surgical target. The magnification of thoracoscopy enhances scrutiny into the subvalvular apparatus and facilitates a precise dissection at the appropriate layer. Meticulous removal of the mass can be achieved without fragmentation. Besides, since preoperative images well delineated the tumor anatomy and valve involvement, our policy is to perform a full-layers resection of the tumor whenever possible and manage the valvular derangement and dysfunction. This approach even allows a resection and reattachment of the anterior portion of the mitral valve through the access of mitral orifice for exposure, if indicated intraoperatively. Further mitral valve repair could also be performed easily as usual. Moreover, the thoracoscopic approach features a small skin incision Fig. B, sternuIn conclusion, a rare blood cyst originated from the mitral valve was successfully resected through a totally thoracoscopic approach. Surgical resection is warranted for symptomatic cases of intracardiac blood cysts. This case exemplifies the expanding potential of thoracoscopic cardiac surgery. If performed adequately, we believe the thoracoscopic approach is a viable and safe alternative for the complete removal of cardiac valvular tumors.


We report the modified surgical reconstruction technique for correction for a large isolated congenital sternal cleft in 6 years old girl using a methyl methacrylate marlex mesh sandwich plate (MMS). The patient was referred to our tertiary care institution with a sizeable anterior chest wall bony defect. There was a large bulging under the skin due to protrusion of mediastinal viscera and visible cardiac pulsations with breathing. A chest x-ray and computed tomographic scan (CT) of the thorax was done to evaluate the bony defect. We reconstructed the sternal bony defect by our innovative technique using methyl methacrylate. The patient was discharged after three days for further follow up in outpatient. One year follow up patient is doing well with excellent results. Our technique is simple, cost-effective, and provides a perfect cosmetic effect for children's sternal large defects.Sternal clefts are rare congenital malformations that result from the defective embryologic fusion of paired mesodermal bands in the midline. This rare anomaly incidence is 1:100,000 cases per live births, which constitute 1% of all congenital chest wall deformities. The first Case of the sternal cleft was reported in 1740. The hereditary sternal gap is rare, and hence sporadic cases have been reported in the medical literature. Ravitch described that the first surgical correction was reported by Lannelongue et al., in 1988., But Burton published the first successful repair in 19474. An isolated sternal cleft is a rare entity and is classified into two categories' complete and incomplete sternal gap. Early repair is recommended; otherwise, surgical correction is challenging in children as the hypo plastic sternal edges cannot be approximated primarily, and this requires prosthetic, autologous grafts or some kind of parasternal chondroplasties.Since birth, a six-year-old girl was referred to our tertiary care center with a large central chest wall defect. She was a full-term normal delivery with no other congenital malformations. The defect was noticed at birth and became more evident as she grew up. In addition to cosmetic concern on coughing, there was bulging under the skin and visible cardiac pulsation. On examination, there was a large gap (7cm) in the midline of the chest with sternal adages well apart, moving independently.The sternal cleft is a congenital anomaly with less than 0.15% and is more common in the female gender. Isolated sternal cleft without any other associated abnormalities is very rare. It has been reported as a part of defined syndromes like PENTALOGY OF CANTRELL, VACTREL, DANDY WALKER, and PHASE .6 Embryo logically sternum originate from the somatic layer of lateral mesodermal plates as bilateral bands. They fuse in the midline by the 10th week to constitute a cartilaginous framework of manubrium, sternum, and xiphoid process. Failure of this fusion can lead to a partial or complete sternal cleft.7 Etiology of this disease is unknown; however, it has been linked with riboflavin or methyl-cobalamin deficiency, high alcohol intake during pregnancy.in conclusion, our improvised reconstruction technique for large sternal cleft in children has several advantages. There is no need to do extensive chordotomies or using bone grafts. Less complicated procedure Provides more rigid frame for protection of thoracic structures and better chest wall stability. Hospital stay is minimal and is very cost-effective. The child's future growth is not affected as ribs and costal cartilages are left intact in this technique. There is no chance of displacement or excursion of the MMS plate. In female patients, this provides better cosmoses as there is no need to mobilize the pectoralis significant muscles flaps for coverage. The geometry of the rib cage is well preserved. •A six years old girl presented with wide sternal gap, sternal edges moving apart paradoxically.•Mediastinal viscera were bulging under the skin and visible cardia pulsations.•A computed tomographic scan (CT)of the chest 3 D reconstruction revealed a large sternal cleft.•The sternal cleft was surgical repaired with our Modifies reconstruction technique with excellent results.•Our technique provides excellent chest wall stability and very good cosmoses. This rare anomaly incidence is 1:100,000 cases per live births, which constitute 1% of all congenital chest wall deformities . The fir in 1947 .This cas in 1947 .2Since birth, a six-year-old girl was referred to our tertiary care center with a large central chest wall defect. She was a full-term normal delivery with no other congenital malformations. The defect was noticed at birth and became more evident as she grew up. In addition to cosmetic concern on coughing, there was bulging under the skin and visible cardiac pulsation. On examination, there was a large gap (7cm) in the midline of the chest with sternal adages well apart, moving independently. The patient was extubated on the table and transferred to a high dependency unit for overnight observation. The patient had an uneventful post-operative recovery and was discharged home for follow up in outpatient clinic. The wound was nicely healed without any residual defect. Operative steps are shown in illustrated drawings 3The sternal cleft is a congenital anomaly with less than 0.15% and is more common in the female gender. Isolated sternal cleft without any other associated abnormalities is very rare. It has been reported as apart of defined syndromes like PENTALOGY OF CANTRELL, VACTREL, DANDY WALKER, and PHASE : No conflict of interest and there was no source of funding or financial assistance in this Case.IRB Approval.Yes written consent obtained from the father of the child.IUC, Operating surgeon drafting the article, Critical revision and final approval of the article. (Corresponding author).AC, wrote structured abstract.CA wrote abstract.AAA highlights.FA searched references.ZA illustrative drawings.MT wrote the part of discussion and review.Ikram ul haq Chaudhry.Not commissioned, externally peer reviewed.


Localized or isolated neurofibromas are peripheral nerve sheath tumors. They are rare in the orbit and occur without a systemic neurofibromatosis. There are few cases of bilateral tumors reported but none affecting both supraorbital and infraorbital nerves. We report a 45-year-old female who presented an extraconal mass in the right orbit as an incidental finding in a head computer tomography, without ocular symptoms. Magnetic resonance image showed a well-defined oval mass in the right supraorbital and infraorbital nerves, of similar characteristics, as well as smaller masses in the left supraorbital and infraorbital nerves. A progressive increase in size of the left supraorbital and infraorbital tumor motivated their surgical excision. The histological result was compatible with a neurofibroma. These uncommon orbital tumors are slow growing and affect the sensory nerves of the trigeminal nerve. Neurofibromas usually present progressive symptoms due to the orbital mass, proptosis, or visual changes although not in this case. Surgical removal is the only definitive treatment. Neurofibromas are classified within the tumors that affect peripheral nerves. Localized or isolated neurofibromas are peripheral nerve sheath tumors and are rare in the orbit, representing less than 1% of orbital tumors . Unlike Three years ago, a 45-year-old female presented an extraconal mass in the right orbit as an incidental finding in a head computer tomography scan and magnetic resonance image (MRI) during investigations following two syncopal episodes.On examination, she had a best corrected visual acuity (BCVA) of 1.0  in both eyes with no exophthalmos nor diplopia and only a minimal asymmetry of the palpebral fold between both eyes. Extraocular muscle movement was normal. There were no alterations in fundoscopy, and the intraocular pressure was normal.The MRI showed a well-defined hypodense oval mass in T1 and hyperintense in T2 sequencing. There was also an ill-defined area, appearing hypodense on T2 but of intermediate density in T1, measuring 24 × 9 mm Figures . The masAs the masses were affecting several nerves and were asymptomatic, a watchful wait approach was adopted. During the 3 years of follow-up, MRI demonstrated the existence of similar lesions, located in the right supra- and infraorbital nerve as well as on the left side. However, there was a progressive increase in size and signal enhancement corresponding to the left supraorbital nerve during the last year, which also affected the left infraorbital nerve , leadingAn orbitotomy with access through the upper eyelid skin crease was performed, exposing a fusiform lesion, cystic in appearance, measuring approximately 3 cm in its major axis, protruding from the supraorbital nerve and extending deeply into the orbit . The lesThe microscopic analysis showed a lesion with a loose connective stroma, areas with spindle and oval cells with wavy nuclei, along with dense bundles of hyalinized collagen in the form of “shredded carrots” and others composed of concentric structures of Schwann cells around axons with an “onion bulb” appearance Figures . ImmunohFurther investigation showed an absence of axillary/inguinal freckling, cafe au lait spots, and Lisch nodules of the iris. No first- or second-degree relatives suffered from similar illness or had any such clinical stigmata. The patient had no other dysmorphic features or endocrine syndromes and no systemic stigmata indicative of familial NF, nor any compatible family history. Due to the benign appearances of the lesion, it was decided, together with the patient, to restart the watchful wait and to intervene only if there was a significant change in size or functional deficits. None have been noted after 20 months of follow-up.Isolated neurofibromas of the orbit  is the term used to refer to those neurofibromas of the orbit, which occur without a systemic diagnosis of NF1, previously known as von Recklinghausen disease . OverallEven though our patient was asymptomatic and the tumor was found as an incidental finding, patients with solitary neurofibromas usually present with a long history of progressive symptoms due to the orbital mass, a palpable mass, gradually progressing proptosis, visual changes, diplopia, hypoesthesia, or pain  , 11, 12.Six or more cafe au lait macules over 5 mm in their greatest diameter in prepubertal individuals and over 15 mm in postpubertal individualsTwo or more neurofibromas of any type or one plexiform neurofibromaFreckling in the axillary or inguinal regionOptic gliomaTwo or more Lisch nodules (iris hamartomas)A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudarthrosisA first-degree relative  with NF1 by the above criteriaWe were able to rule out familial NF. The diagnostic criteria require the presence of 2 or more of the following criteria :Six or Several imaging features, including multiplicity, multilobulation, ring-configured contrast enhancement, and MRI signal intensity heterogeneity, may point to the diagnosis of localized neurofibroma . MRI canThe orbital mass was biopsied via anterior orbitotomy by eyelid crease approach.Ultrastructural studies showed that this tumor was composed of a mixture of three cell types: Schwann cells, perineural cells, and fibroblasts , 16. ImmThe importance of the localized neurofibroma is that the tumor can be easily removed leading to a complete surgical cure. In cases where the tumor was not completely excised, no recurrences requiring further surgery were found after long follow-up periods , 11. PatNeurofibromas without associated NF rarely occur in the orbit. In addition, the peculiarity of our case lies in the bilateral involvement of the supra- and infraorbital nerves not previously described in medical literature.


Up to 30% of all scrotal masses are sarcomas. Leiomyosarcoma of the scrotal wall is rare, and its clinical significance and prognosis have not been well defined, since the most reported cases have little or no follow-up.We report a 45-year-old Caucasian man who was admitted with a firm, nontender, mobile scrotal wall mass from 15 months ago. Laboratory data including testicular tumor markers were within normal range, and transscrotal ultrasonography revealed an oval-shaped, hypoechogenic, solid mass with blood flow and well-defined border. Histopathologic examination and immunohistochemistry staining, following surgical excision, were in favor of malignant leiomyosarcoma.Here we describe the morphological features and immunohistochemical presentations of the tumor and the patient’s relatively long-term follow-up. Up to 30% of all scrotal masses are sarcomas. Soft-tissue sarcomas of the genitourinary tract account for 2.1% of soft-tissue sarcomas in general and only 1–2% of urological malignancies [These tumors can be seen in any age group but mostly in the sixth decade, and 80% of patients are above 40 years . The cliScrotal wall leiomyosarcoma not developing from the spermatic cord, epididymis, or testes is exceptional, and its clinical significance and prognosis have not been well defined. Here we describe the morphological features and immunohistochemical presentations of the tumor and its relatively long-term follow-up.A 45-year-old Caucasian man, a welder, was admitted to our hospital with the chief complaint of a painless right scrotal wall mass from 15 months ago, which had been, recently, increased in size. He denied any coexisting symptoms such as fever, chills, cough, dyspnea, nausea, vomiting, and diarrhea. He also denied any previous history of trauma, surgery, radiation exposure, and medications including anabolic steroids. Social history was positive for smoking tobacco use at 10 pack-years. His family history was negative for a similar condition. Initial physical examination on admission revealed body temperature 36.8 °C, heart rate 70 beats per minute, and, blood pressure 135/86 mmHg. Head and neck examination showed no evidence of lymphadenopathy. Heart and lung sounds were normal. Thorough abdominal examination findings were unremarkable, and the inguinal lymph nodes were not enlarged on palpation. Neurologically, the patient was completely normal. Genital examination showed a firm, nontender, mobile mass in the posterior wall of the right hemiscrotum, while penis, bilateral testes, epididymis, and the spermatic cords were clinically normal.Initial laboratory work-up included complete blood count with leukocyte count of 7200/μL, hemoglobin of 14.5 g/dL, and platelet count of 186,000/μL, renal function tests with blood urea nitrogen of 12.6 mg/dL and serum creatinine of 1.1 mg/dL; blood glucose of 99 mg/dL, erythrocyte sedimentation rate (ESR) of 12 mm/hour, and C-reactive protein (CRP) of 8 mg/L; biochemistry of Na 135 mEq/L, K 4.3 mEq/L, Ca 8.7 mg/dL, serum glutamic oxaloacetic transaminase (SGOT) 32 IU/L, serum glutamic pyruvic transaminase (SGPT) 36 IU/L, and alkaline phosphatase 214 IU/L. Urinalysis revealed no pathologic findings. The testicular tumor markers were within normal range: lactate dehydrogenase (LDH) 150 units/L, alpha-fetoprotein (AFP) 12 ng/mL, and beta-human chorionic gonadotrophin (β-HCG) less than 2 mIU/mL. Transscrotal ultrasonography revealed a 35 Subsequently, the patient underwent an excisional biopsy, during which the mass was felt to be a 30 entclass1pt{minimaPreoperatively, we prescribed intravenous cefazolin (2 g) as the prophylactic antibiotic that was converted to oral cephalexin (500 mg per day) after discharge. The patient did not receive any neoadjuvant chemotherapy or radiation. Postoperative close follow-up was planned, and during the 20-month period, there was no evidence of recurrence or distant metastasis.The specimen was an oval, encapsulated, solid, vaguely lobulated, creamy mass with a smooth surface measuring 28 × 25 × 10 mm. The cut surface was nodular and heterogeneous, consisting of regions with tan-yellow, gelatinous appearance and necrotic areas. Focally, the capsule was breached, and the tumor was touching the inked surgical margin. The subsequent margins showed no tumoral involvement (Fig. Histological study revealed an encapsulated nodular mass, composed of densely cellular atypical spindle cells with a fascicular arrangement. High power demonstrated spindle cells with cigar-shaped, prominently atypical nuclei. Multifocal necrosis with peripheral tumor cell palisading and occasional atypical mitotic figures Fig.  was apprWe described a rare case of malignant leiomyosarcoma arising from the scrotal wall in a 45-year-old man who was referred with a firm, nontender, mobile scrotal wall mass from 15 months before admission. Leiomyosarcoma of the scrotal wall is rare, and its clinical significance and prognosis have not been well defined. We reported the morphological features and immunohistochemical presentations of the tumor and its relatively long-term follow-up during which no evidence of recurrence or distant metastasis was discovered. Leiomyosarcomas have three typical histological features: perpendicularly arranged fascicles of spindle cells with eosinophilic cytoplasm, hyperchromatic blunt-ended nuclei, and scattered paranuclear vacuoles. Immunohistochemical staining shows an expression of SMA, muscle-specific actin, and desmin in most leiomyosarcomas, and expression of S-100 protein, CD34, Ki-67, myogenin, and cytokeratin has also been reported in some cases [We investigated Google Scholar for the peer-reviewed case reports of scrotal leiomyosarcomas from 1965 to 2021, and in Table The primary imaging method for any scrotal abnormality is ultrasonography with a sensitivity of 95–100% for differentiating intratesticular from extratesticular lesions. A solid, heterogeneous, irregular mass with increased vascularity on color Doppler will usually be detected. It can also show variable echogenicity, with or without central necrosis or a whirling pattern; however, histological examination of tissue is required for diagnosis , 5. OtheDistinguishing malignant and benign sarcomas is challenging, and simple excision of tumors is inadequate, as previous studies have indicated that up to one-third of patients who underwent simple excision had the residual microscopic disease . The risEarlier reports showed with surgery alone high rates of local failure will be seen; therefore, adjuvant radiotherapy is suggested for potential benefit in local control improvement. However, our patient did not agree with further treatment, so we placed him on closed clinical follow-up. The prognosis of leiomyosarcoma is related to its site, size, histological grade, and nodal or distant metastases . The proIn summary, this case report outlines the morphological and immunohistochemical presentations of leiomyosarcoma of the scrotal wall and its long-term follow-up in a patient.


Acute appendicitis in children is known to present in two broad forms: (1) uncomplicated and (2) complicated. Apart from this, a variety of atypical presentations can occur that may pose difficulty in diagnosis or treatment approach. We hereby present a series of such rare experiences namely appendiceal oxyuriasis, sub-hepatic appendicitis and appendiceal mucocele that were encountered and managed accordingly. The life time risk of developing acute appendicitis (AA) throughout the age groups is 7% . The inaAlso the modality of treatment is equally crucial for the best outcome. For instance, sudden right upper abdominal pain would normally be perceived as an upper abdominal pathology in most situations, until guided by sonological findings diagnosing sub-hepatic appendicitis (SHA), which dictates a modification in the surgical approach. Likewise, an appendiceal mucocele (AM) on preoperative sonology would be dealt with open approach to avoid peritoneal contamination when chances of malignancy are predictablyhigh.A 10-year-old boy presented to the emergency room with 2 days of abdominal pain initially over the peri-umbilical region and later localizing to right iliac fossa (RIF) with an episode of non-bilious vomiting. Physical examination revealed low-grade temperature (100°F) and tenderness with guarding overRIF.Hematological tests showed polymorph nuclear leukocytosis with left shift without eosinophilia. Biochemical tests and urinalyses were normal. Abdominal radiographs were unremarkable. Ultrasonogram (USG) abdomen could not visualize the appendix, but reported significant probe tenderness inRIF.With clinical impression of AA, he underwent diagnostic laparoscopy under general anesthesia.Intraoperatively, a retro-cecally located appendix was found that was mildly inflamed with surface congestion more towards the tip (with visible leash of prominent vessels) and a healthy base as shown in There was no perforation, peritoneal reactive fluid or pus and no omental reaction. Aware of his clinical presentation, a possibility of other pathologies like Meckel diverticulum, mesenteric lymphadenitis and any other small bowel lesions were thought of. On walking the bowel beyond 2 feet proximal to Ileo-Caecal Junction (ICJ), no other obvious lesions were found. Laparoscopic appendectomy was performed. Specimen was retrieved in a plastic bag in an attempt to avoid contamination.Enterobius vermicularis as shown in Histopathologically, gross examination confirmed the operative findings showing a 5.5 × 0.7 cm appendix with venous congestion over the serosal surface. Microscopically, the section showed mild congestion and a luminal parasite with features compatible with The histopathological finding came as a diagnostic surprise, since historically he never complained of appendiceal colic (AC), anal pruritus or worm defecation in the past. Moreover, eosinophilia was also not observed in the peripheral smear. Attributing his symptom complex to manifestation of AO, he was treated with a single dose of albendazole to be repeated after 2 weeks. His family members were also advised a similar treatment course. At 1 year follow up, he remained symptomfree.A 10-year-old boy presented with history of peri-umbilical pain later migrating to right upper abdomen for 3 days and associated three episodes of non-bilious vomiting. He did not have fever, nausea or anorexia. He was moving bowel and bladder normally. Physical examination revealed tachycardia (110 beats per minute) and tenderness over entire right upper quadrant associated with rebound tenderness. Hematological tests were unremarkable. Biochemical tests were normal. Abdominal radiographs were unremarkable. USG abdomen showed a blind ending tubular, non-compressible, non-peristaltic structure measuring 9.5 mm, suggesting an enlarged appendix with its tip located in the sub-hepatic region as shown in With clinical impression of SHA, he underwent an emergency diagnostic laparoscopy under general anesthesia. Intraoperatively, findings were confirmed, an inflamed turgid appendix with its tip just beside the gall bladder in the sub-hepatic region was noted with a healthy base as shown in Laparoscopic appendectomy was performed as shown in Histopathologically, gross findings included an 8 cm long appendix with cut section showing lumen filled with fecal material. Microscopically, the section showed suppuration, edema and congestion along with peri-appendiceal inflammation and focal areas of destruction of the muscular layer suggestive of gangrenousAA.He had an uneventful postoperative period and was discharged the next day. At follow up a week later and 1 year later, he was doingwell.A 13-year-old boy presented with sudden onset RIF pain for a day associated with vomiting, nausea and anorexia without fever. He was moving bowel and bladder normally. Physical examination revealed guarding and rebound tenderness over RIF. Hematological tests showed polymorph nuclear leukocytosis. Biochemical tests and urinalyses were normal. Abdominal radiographs were unremarkable. USG abdomen showed a blind ending tubular, fluid-filled, non- compressible, non-peristaltic structure in RIF measuring 13 mm, suggesting an enlarged appendix with mucocoele formation as shown in In view of known associations of mucocoele with malignancy, he underwent open appendectomy as shown in He had an uneventful postoperative period and was discharged the next day. At follow up a week later and 1 year later, he was doingwell.Ever since the theory of luminal obstruction and consequent infection was suggested by Zwalenberg in1905, numerous etiologies have been implicated in the causation and clinico-pathological manifestation of AA . AO, a lAlthough known to cause a wide variety of gut problems like ileocolitis, perianal abscesses, enterocutaneous fistulae and mesenteric abscesses, AO is still not a common cause of AA . It is nHowever, the diagnosis cannot possibly be confirmed until the histopathological analysis. Therefore, in patients with intraoperative findings that are incongruent with the clinical picture, the suspicion of this lesser known pathology should be borne in mind. This group of children could possibly benefit with observations and serial assessments to avoid operation. Meanwhile, fecal sampling and night time cellophane tape application over the perineum to detect the parasite as well as empirical antihelminthic therapy could be instituted . A similLikewise, the appendicular location could impose a diagnostic challenge when presenting with acute symptoms of inflammation . The appOwing to its location, AA in sub-hepatic position mimics hepatobiliary or gastro duodenal pathologies, clinically leading to a delayed diagnosis and complications like suppuration, perforation, intra-abdominal abscess and sepsis . With a With symptom complex of AA and all the findings located over the right upper abdomen, it could have been easily mistaken for an upper abdominal pathology. Even though a cross-sectional abdominal imaging like computed tomography scan has been favored by a few studies, in our patient, an abdominal ultrasound was adequate for diagnosis . LaparosLastly, the surgical approach to AA also depends on preoperative predictability of sinister findings as with an appendicular mucocele, which was diagnosed on ultrasound in Case 3.Mucocele of the appendix is an exceedingly rare presentation of AA in children with scarce descriptions and sporadic reports . It implWith a clinical presentation often mimicking AA, mucinous neoplasms of appendix are difficult to distinguish clinically. Since, tactile examination to confirm tumor in the adjacent large bowel is desirable, an open approach was favored in Case 3 to deal with this potential pathology. However, with normal findings, the procedure could be concluded with a simple appendectomy.When on table findings are incongruent with the clinical picture, rarer cause of AA like AO needs to be considered.When symptom complex of AA does not follow a clinico-anatomical correlation, a developmental malformation like abnormal appendico-cecal location must be suspected.When symptom complex of AA is accompanied by an uncommon radiological finding, the surgical approach should be guided by the foreseeable intraoperative findings.


Other Presentations. This case report has no prior publications apart from the abstract being accepted to the 2020 SIOP  meeting and 2020 ASPHO conference (canceled due to the COVID-19 pandemic) and subsequently published as an abstract only in Pediatric Blood and Cancer. We have also presented the abstract as a poster presentation at our institution's  annual research day conference in 2020.Acute pancreatitis in children is usually due to infection, trauma, or anatomical abnormalities and is rarely due to obstruction from malignancy. Sporadic Burkitt lymphoma (BL) is an aggressive non-Hodgkin B-cell lymphoma that usually involves the bowel or pelvis, with isolated cases presenting as acute pancreatitis. We report a case of BL in a 12-year-old male presenting as acute pancreatitis with obstructive jaundice and a right middle cranial fossa mass invading the sphenoid bone. The common bile duct in this case was dilated to 21 mm in diameter on abdominal ultrasound and to 26 mm on magnetic resonance cholangiopancreatography (MRCP), significantly greater than any value reported in the literature for BL. Given the rapidly progressing nature of BL, we emphasize the importance of recognizing heterogeneous presentations of this disease to improve patient survival. We also conclude that it is important to consider malignancy in a child with acute pancreatitis, particularly in the presence of obstructive jaundice or multisystem involvement.  Acute pancreatitis in children is mostly due to infection, trauma, anatomical abnormalities, or medications and is rarely due to obstruction from malignancy . Few casBurkitt's lymphoma (BL) is an aggressive rapidly dividing non-Hodgkin B-cell lymphoma that often presents with extranodal masses. It comes in three variants—endemic, sporadic, and immunodeficiency-associated subtypes. The sporadic variant is mostly seen in the United States and Western Europe. This form of BL accounts for 30% of pediatric lymphomas and usually involves the abdomen , unlike the endemic subtype seen in Equatorial Africa and New Guinea, which presents with a facial mass [We describe a case of a twelve-year-old boy who presented with severe pancreatitis associated with obstructive jaundice and a middle cranial fossa mass invading the sphenoid bone, who was diagnosed with Burkitt's lymphoma. The common bile duct (CBD) was dilated up to 2.6 cm on magnetic resonance cholangiopancreatography (MRCP), significantly higher than any value reported in the literature for Burkitt's lymphoma. This case highlights the importance of considering malignancy in a child with acute pancreatitis, especially in the presence of multisystem involvement.A previously healthy twelve-year-old male presented to the emergency department (ED) at NYU Langone Hospital - Long Island with abdominal pain, jaundice, and a right-sided facial mass. Prior to arrival, the patient had two weeks of bilateral knee pain, followed by right upper quadrant abdominal pain, multiple episodes of nonbloody nonbilious emesis, and weigh loss. There were no fevers, night sweats, sore throat, or travel abroad. During this time, he also developed right-sided facial swelling in the preauricular area that was initially tender and then numb with time. The patient was taken to an outside hospital where he was admitted for three days for transaminitis and acute pancreatitis. Amylase and lipase levels were 305 U/L and >1000 U/L, respectively. The abdominal ultrasound conducted there was normal. Labs improved with supportive care and the patient was discharged home.The following day, the emesis resumed. Abdominal X-ray performed by the pediatric gastroenterologist showed moderate to severe constipation and polyethylene glycol was started. Three days later, the patient developed jaundice and was taken to the NYU Langone Hospital—Long Island ED for further evaluation.In the ED, liver enzymes were elevated with an alanine aminotransferase (ALT) of 249 U/L, aspartate aminotransferase (AST) of 142 U/L, and alkaline phosphatase (ALP) of 361 U/L. Signs of biliary obstruction were evident with a gamma-glutamyl transferase (GGT) of 335 U/L, total bilirubin of 6.8 mg/dL, and direct bilirubin of 4.6 mg/dL. Lactate dehydrogenase (LDH) was 402 U/L. Inflammatory markers were also increased with a C-reactive protein (CRP) of 132 and an erythrocyte sedimentation rate (ESR) of 50. The respiratory viral panel was negative. Epstein-Barr virus titers were indicative of past infection. Chest X-ray was normal. Abdominal ultrasound showed a distended gallbladder with sludge and stones and a dilated common bile duct measuring 21 mm . ComputeMagnetic resonance cholangiopancreatography (MRCP) done on hospital day one revealed marked dilation of the common bile duct (CBD) to 26 mm, without associated cholelithiasis or cholecystitis. There was mild splenomegaly measuring 13.3 cm and signs of pancreatitis at the pancreatic head. Abdominal CT showed a dilated common bile duct with dilation extending up to the intrahepatic biliary ducts. Chest CT revealed regions of right basilar subpleural thickening versus nodules, representing an infectious, inflammatory, or metastatic process.In parallel to the abdominal work up, brain magnetic resonance imaging (MRI) was done on hospital day one. A 6.2 × 2.9 × 5.2 cm right temporal region mass was visualized, adjacent to the temporalis muscle. There was irregularity of the right sphenoid wing with an adjacent 4.5 × 3.1 × 2.5 cm intracranial mass Figures . The mast were detected in 75% of 200 interphase nuclei, suggestive of Burkitt's lymphoma. Pancreatitis and transaminitis improved following stent placement.Endoscopic ultrasound (EUS) followed, showing biliary sludge and a 3 mm biliary stricture and a hypoechoic mass at the head of the pancreas. Fine-needle aspiration of the pancreatic mass revealed CD20(+) and CD3(−) cells, suggestive of B-cell lymphoma Figures . BiliaryLytic lesions were assessed via X-rays of the lower extremities. Lytic lesions were present in the right proximal tibial metaphysis and left distal femoral metaphysis, and a sclerotic lesion was identified in the right proximal tibial diaphysis; however, bilateral bone marrow aspirates were negative for IGH-MYC gene rearrangements or evidence of disease. Bone marrow biopsy and peripheral blood were also negative for disease. Intrathecal methotrexate and hydrocortisone were administered and cerebral spinal fluid drawn at the time was negative for malignant cells. Allopurinol was initiated for tumor lysis prophylaxis, labs were monitored regularly, and the patient did not develop tumor lysis syndrome.The patient's clinical presentation was consistent with stage IV high-risk BL, given biopsy findings and intracranial involvement. He was therefore treated with chemotherapy as per the Children's Oncology Group protocol—COG ANHL1131, to which he rapidly responded.Burkitt's lymphoma is the fastest growing tumor, doubling every 24–48 hours, making early diagnosis and treatment critical for survival  and up tSporadic BL most commonly presents in the abdomen in 60–80% of cases , 8. ThesIn a recent case report and literature review by Lee et al. on BL presenting as acute pancreatitis, a total of 15 cases were identified , 10–21. Similarly, middle cranial fossa masses, like in our patient, are also rare in children. These masses can arise intracranially or through extracranial invasion from nasopharyngeal carcinoma, neuroblastoma, or lymphoma . The vasDespite its aggressive nature, BL is highly responsive to chemotherapy with an overall cure rate of 90 percent for the sporadic type in high-income countries . Given t


Spirometra mansoni. The patient visited us after a failure of four cycles of praziquantel treatment, recurrent seizures and hemiplegia with basal ganglia foci. Craniotomy was not carried out until the larva moved to the superficial lobe on follow-up MRIs, and pathology revealed sparganosis granuloma. The patient became seizure-free and recovered myodynamia but had long-lasting cognitive dysfunction due to severe brain damage. This case indicated the importance of tunnel signs and moving tumor-like foci on MRI as diagnostic clues of cerebral sparganosis. An early diagnosis is vitally important to avoid severe neural dysfunction by the long-living and moving larvae. Surgical removal of the larva is a critical remedy for cases failed by praziquantel treatment.Cerebral sparganosis is clinically non-specific and easily misdiagnosed, exposing patients to the risk of severe brain damage and neurological dysfunction caused by actively migrating larvae. Diagnostic biomarkers from typical cases can help to establish an early diagnosis and proper treatment. We present a 25-year-old woman who suffered from 9 years of refractory epilepsy and was misdiagnosed with glioma and subjected to surgery. The postoperative pathology confirmed granuloma, and the tumor-like foci reappeared 3 months later. Along with the “tunnel sign” on MRI, cerebral sparganosis was suspected and confirmed by positive serum and cerebrospinal fluid antibodies against  Spirometra mansoni, which has a strong contraction ability, moves into the brain tissue and lives in necrotic tunnels, causing formation of a parasite granuloma, typically with eosinophil infiltration. The ovum of S. mansoni develops into the coracidium in the contaminated water after excreted by the definitive host (often dogs and cats) and is then absorbeds by the cyclops, its first intermediate host, in which the coracidium develops into the procercoid. The procercoid infects its second intermediate host, tadpoles, which catches the infected cyclops and develops into the sparganum in the muscle as tadpoles grow into frogs. Contact to either infected first or second intermediate hosts can cause cerebral sparganosis. The clinical manifestation is usually non-specific and depends on the lesion location, including headache, epileptic seizure, mild hemiparalysis and blurred vision. Blood and cerebral spinal fluid (CSF) antibodies against Spirometra mansoni have high sensitivity and specificity for diagnosis. Neuroimaging can provide diagnostic clues, such as moving lesions and typical tunnel signs, which mainly located at the border between the white and gray matter of the frontal and parietal lobes and the centrum semiovale but rarely appears in the cerebellum and the basal ganglia  , 6. In HHere we presented a case of cerebral sparganosis with tortuous diagnosis and treatment process because of misdiagnosis as brain tumor and subjected to surgery. Four circles of praziquantel treatment was unsuccessful though diagnosis was corrected, and the larva moved to basal ganglia with surgical contraindication. Finally, the larva was finally removed by craniotomy when it moved to the superficial part of the lobe by repeated follow-up MRI scanning. Related literature was also reviewed in this paper.Our patient was a 25-year-old woman without a past medical history who complained of recurrent convulsive seizures for 9 years and a massive cerebral lesion observed 5 years prior. Her first unprovoked episode was considered an epileptic seizure at a local primary care clinic with a reported “abnormal EEG”, but no neuroimaging evaluation was performed due to her father's refusal (details unavailable), and no medication was given considering it was just one isolated episode when she was 16. A second similar episode recurred 2 years later, and she was discharged with oral valproic acid, without any other examinations due to her poor economic condition. The patient experienced tonic clonic seizures without specific aura every 3–4 months thereafter.At the age of 21, she presented the same symptoms of poorly controlled seizures and was admitted to the local hospital, where routine magnetic resonance imaging (MRI) revealed an intracranial space-occupying lesion suspected to be a glioma. She was discharged with carbamazepine (CBZ) after her father's refusal to allow surgery. One month later, she withdrew from the CBZ due to a skin rash and was seizure free for 1 year.When she was 22, she presented to the hospital again because of recurrent seizures and had a routine and enhanced MRI scan that revealed space-occupying foci with hypointensity on T1 and hyperintensity on T2 and fluid attenuated inversion recovery (FLAIR) sequences in the right frontal and temporal lobes with striped and patchy enhancement along with malacia foci without enhancement in the right frontal and parietal lobes . Based oThree months after the operation, her follow-up MRI revealed postoperative foci with hypointensity on T1 and hyperintensity on T2 and FLAIR sequences in the right frontal lobe and encephalomalacia foci in the parietal and temporal lobes with additional tunnel-like enhancement in the left frontal lobe . A detaiTherefore, antibody tests against various parasites in her blood and CSF samples were performed, and positive results confirmed the diagnosis of cerebral sparganosis. She was prescribed anthelmintic drugs  for four cycles and levetiracetam (LEV) for seizure control. The treatment effect seemed to be satisfactory. Repeated MRI after anthelmintic treatment suggested improvement , and her+ and left-sided increased tendon reflexes. Further examination confirmed decreased blood hemoglobin  and slightly increased cerebrospinal fluid (CSF) total protein of 45.2 mg/dL . Her routine blood tests, serum electrolytes and glucose levels, liver and kidney function, and nuclear cell count and electrolytes and glucose levels in CSF were all normal. Whether eosinophils presented in CSF or not were not performed because total white blood cell count in CSF was zero at that time and cell category was disabled in our instrument as the total number of nuclear cell was <50 × 106/L. Her third MRI since the onset was performed and it revealed restricted enhancement focus in the right centrum semiovale, corona radiate, insula and basal ganglia with punched-out and tunnel-like presentation, and a resective operation was contraindicated due to the high risk of hemiparalysis  displayed intermittent generalized 4–5 Hz theta waves and 2–3 Hz delta waves in the bilateral hemispheres. Sleep EEG displayed high-extremely high amplitude 11–12.5 Hz scattered sharp wave discharges and asynchronization in bilateral hemispheres. Her father refused praziquantel treatment again, and her AEDs were further adjusted to four AEDs combination at full dosage but with poor seizure control (secondary tonic-clonic seizures once per 1–2 months and clonic seizures in her left upper limb 2–3 times per month).She was admitted again to search for a better treatment strategy for her refractory epilepsy and active cerebral sparganosis. At the age of 26, her follow-up MRI revealed a new enhanced focus in her right frontal lobes, indicating that the larva had moved to the surface . Her repHer postoperative recovery was uneventful without neurological dysfunction except an increased tendon reflex of the left limbs at discharge and she was prescribed two AEDs at middle dosage. She achieved a seizure-free status in postoperative follow-up for 16 months. However, during the follow-up, the patient had impaired short-term memory and executive function, depression and daytime sleepiness and was unable to work. Her Mini-Mental State Examination (MMSE) score was 27 (losing three scores for orientation to space and time), and her Montreal Cognitive Assessment (MoCA) score was 24 . Her follow-up MRI scanning indicated only slight dural enhancement in the bilateral frontal lobe and anterior cingulate , and EEGOur patient was eventually diagnosed with cerebral sparganosis at the sixth year after her first seizure onset and even underwent craniotomy based on a misdiagnosis of glioma. Unfortunately, her cerebral structure and function were irreversible due to the damage caused by migration of the worm and repeated cerebral surgery. Our case demonstrates how easily cerebral sparganosis can be misdiagnosed and how important an early diagnosis and treatment is to avoid permanent and severe brain damage and to achieve a good prognosis.Taenia solium and typical cyst images in the brain  and an irregular hyperintense region on T2-weighted imaging (T2WI). Typical tunnel signs can be revealed as tubular or distorted bead-like structures with T1WI hypointensity, T2WI hyperintensity and evident enhancement . The pos surgery . ELISA a surgery , 14. A c surgery . In the Treatment modalities of cerebral sparganosis include the anthelmintic praziquantel and surgery removal. Although praziquantel is regarded as the standard medical treatment for human infection with trematodes and cestodes , conventSurgery for cerebral sparganosis is considered the optimal and radical treatment , 25, whiThis report presents a case of cerebral sparganosis with long-lasting refractory epilepsy, which was first misdiagnosed as glioma and underwent craniotomy. The larva failed to be removed by four circles of praziquantel treatment but was finally removed by opportune surgery. The current case indicated the typical diagnostic biomarkers of cerebral sparganosis and confirmed that early diagnosis and complete surgical removal of sparganosis granuloma is critical to the successful treatment, control of refractory epilepsy and the avoidance of severe tissue damage by the larva.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee on Human Research of Tongji Hospital. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.YC wrote the draft of the manuscript. XC collected all the clinical data. HK gave the main idea and edited the whole manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the National Natural Science Foundation of China (81974279), China Association Against Epilepsy Fund for Epilepsy Research-UCB Fund (2020020A), and Grants for Returned Overseas Doctors of Tongji Hospital and Health Commission of Hubei Province (WJ2021M131).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objective: To determine the cause and high-risk factors for the development of intestinal fistulas (IFs) after ultrasound-guided microwave ablation (MA) of abdominopelvic lesions, and to identify effective prophylactic and therapeutic actions.Methods: Clinical data were collected from patients with an IF after ultrasound-guided MA of abdominopelvic lesions in our hospital from January 1, 2010 to December 31, 2018. The cause, diagnosis, and treatment of IFs in these patients were analyzed.Results: Among 8,969 patients who underwent ultrasound-guided MA of abdominopelvic lesions, eight patients developed IF after MA, Seven patients were discharged after being cured and one died.Conclusion: Abdominopelvic lesions are close to the intestines, so histories of surgery, radiotherapy, and abdominopelvic infection are high-risk factors for IF development after MA of these lesions. Surgical treatment should be provided as soon as an IF is identified. Ultrasound-guided microwave ablation (MA) is a minimally invasive method that can result in rapid recovery, short hospital stay, and good tolerance to treatment . MA is uCommon complications of ultrasound-guided MA of abdominopelvic lesions include hemorrhage, secondary infection at the MA site, diaphragmatic injury, biliary fistulas, pneumothorax, hemopleura, and gastrointestinal injury . IntestiWe reviewed cases of IFs after MA of abdominopelvic lesions in our hospital and analyzed the primary disease, history and site of IFs, as well as the diagnosis and treatment after IF development in these patients. In this way, we identified the high-risk factors as well as prophylactic and therapeutic measures for IFs.This was a retrospective study approved by the Ethics Committee of our hospital. All treatments were provided after patients had provided written informed consent.There were 8,969 patients who underwent ultrasound-guided MA of abdominopelvic lesions in our department from 1 January 2010 to 31 December 2018: 7,240 cases of liver tumor, 464 cases of renal tumor, 60 cases of adrenal-gland tumor, and 1,205 cases of uterine myoma and adenomyosis. Eight patients  developed an IF. One patient (number 1) had primary liver cancer, 17 years of hepatitis-B infection, 11 years of cirrhosis, and a history of cirrhotic ascites, upper gastrointestinal bleeding (two episodes), and cholecystectomy (due to stones). Also, three patients (numbers 2–4) had renal tumors. Three patients (numbers 5–7) had uterine lesions. One patient (number 8) had metastasis to the right adrenal gland 5 years after resection of a right renal tumor and had received exploratory laparotomy and radiotherapy 1 year before hospital admission. The clinical diagnosis, history, and lesion status (location and dimension) of these eight patients are shown in MA was undertaken using a KY-2000 system . This system has a transmission frequency of 2,450 MHz and is equipped with a 15-G water-cooled MA electrode. Different levels of power and MA duration were used based on the diameter and location of the lesion . Real-tiAuxiliary measurements were applied to five of the eight patients during MA . TemperaOne day after MA, this liver-cancer patient experienced chills and fever. On day-2, MRI of the abdomen showed complete MA of the lesions without signs of intestinal perforation. On day-3, the patient developed a fever with a maximum temperature of 39.4°C, accompanied by abdominal distension and reduced air release. On day-4, the patient experienced persistent fever and abdominal distension, and ultrasound examination showed a peritoneal effusion . The patAll three patients with a renal tumor experienced abdominal distension 2 days after MA without abdominal pain or peritoneal irritation. Patient number 2 had intermittent, low-grade fever, whereas patient number 4 did not have fever within 1 week after MA. Patient number 2 and 4 had normal white blood cell (WBC) counts. Patient number 3 experienced intermittent post-meridian fever that reached ≤38.6°C. This patient had a WBC count of 13.17 × 100/L and a NE level of 0.865 1 day after MA, but these indices returned to normal after anti-inflammatory treatment. Imaging re-examinations (ultrasound and MRI/CT) of these three patients within 5 days after MA showed complete ablation of lesions without signs of an IF. Patients number 2 and 4 experienced intermittent fever 2 weeks after MA. On day-26 after MA, patient number 2 had a subcutaneous mass of dimension 12 × 8 cm at the needle-insertion site on the left abdominal wall, along with redness, swelling, fever, and pain. Abdominal CT showed an IF with local infection. The diagnosis was a post-MA IF. Patient number 4 experienced fevers on 14 days after MA, but abdominal CT showed no signs of an IF. This patient subsequently had intermittent watery stools (stool mixed with urine) 20 days after MA, as well as intermittent urination and air release 30 days post-MA. Nuclear MRI 52 day's post-MA suggested a left renocolic fistula . Patient9/L. Ultrasound examination of these three patients revealed pelvic effusion and poor sound transmission  complication of MA.Liang et al. reported that the prevalence of an IF after MA of a liver tumor is <0.2% . ReportsIt has been reported that a distance <1 cm between the intestines and MA site for a liver tumor or a distance <5 mm between the intestines and MA for a renal tumor are high-risk factors for intestinal injury , 16, 17.Misplacement of the microwave electrode into the intestines during MA can cause intestinal injury due to poor visibility of the electrode tip. This is a result of shielding by the strong echoes generated by air at the MA site.Adhesion resulting from a history of surgery, radiotherapy, abdominal infection, or endometrial displacement is a risk factor for an IF , 18. ArtPrevious radiotherapy of the proposed MA site and adjacent area results in radiation enteritis and increased intestinal permeability. Post-MA intestinal bacterial translocation causes infection at the MA site and leads to development of a secondary IF.Tumor invasion of the adjacent intestinal tract results in communication between the intestinal lumen and lesions, which results in an IF after MA.The small intestine has low air content and the intestinal tract shrinks if compressed. Hence, the small intestine is difficult to visualize by ultrasound , so the microwave electrode can penetrate through the intestinal tract directly and cause injury.Early diagnosis of IF after MA is important. Early diagnosis and treatment often affect the prognosis of patients. IF is diagnosed primarily based on symptoms, physical signs, imaging, and laboratory tests. The common symptoms and signs of IF are fever, abdominal distension, abdominal pain, peritoneal irritation, peritoneal effusion, and free intraperitoneal air. Patients may exhibit different initial symptoms and signs depending on the location of IF. If a fistula develops in the large intestine, leaking is slow and the leaked contents contain bacteria and air. The initial symptoms of patients are often fever and abdominal distension without obvious peritoneal irritation. Early MRI and ultrasound often reveal no positive results (which was the case for patient number 1). In contrast, if a fistula develops in the small intestine, the intestinal contents contain much fluid and leak fast, and the alkalinity of the leaking intestinal fluid  can cause chemical peritonitis. As a result, abdominal pain is often the initial symptom of patients with a fistula in the small intestine, and often the visual analog scale score is >5. Analgesic drugs are unsatisfactory for relieving the pain. Patients with fistulas in the small intestine often experience peritoneal irritation, manifesting as abdominal muscle tension, obvious abdominal tenderness and rebound pain, and weakened/disappearance of bowel sounds, as revealed by physical examination. Increased leakage and secondary infection may result in bacterial peritonitis (patients numbers 5–7). However, the symptoms of peritonitis may be mild or absent in such cases because the intestinal contents do not pass directly through the abdominal cavity as a result of the adhesion.Further examinations  should be done if intestinal injury is suspected. An IF often manifests as free air in abdominal and pelvic cavities on abdominal and pelvic CT and abdominal radiography, and the site of intestinal injury may be visible on abdominal and pelvic CT in some cases. Conversely, an IF manifests primarily as free fluid in the abdominopelvic cavity by ultrasound, and the effusion has relatively poor sound transmission. However, further diagnoses may be made after a diagnostic puncture. If leakage of intestinal contents is localized and they do not enter the abdominopelvic cavity directly after IF development, peritoneal irritation is often absent and this condition is more common in an injury to the descending colon. The initial symptom is often non-specific abdominal distension, which occurs <3 days after MA but disappears after 3 days. The symptom of fever is often delayed, which occurs if there is leakage of a relatively large amount of intestinal contents after MA and is mostly evident 10 days after MA. The symptom of fever gradually exacerbates over time but is often not accompanied by chills. Due to the application of antibiotics, the WBC count and neutrophil count are often normal or slightly higher than normal. Blood-culture results can be positive with increasing leakage and development of bacteremia due to local secondary infection. There are no important specific manifestations by imaging <1 week after MA. Infectious changes in the MA site and surrounding area (mainly caused by leakage and secondary infection) can be revealed by imaging if local leakage is increased and the patient displays obvious systemic symptoms. These changes manifest as signs of air in cystic and solid lesions as well as intestinal contents and pus in the puncture fluid or drainage fluid. Such patients have a lower chance of developing bacteremia and sepsis compared with those with direct leakage into the abdominal cavity (patient numbers 2 and 8). A fistula between the intestine and urinary system is considered to be an internal IF. Due to mild symptom of fever and absence of abdominal signs and peritoneal irritation, identification of an IF by imaging is often delayed, which makes an early diagnosis quite difficult. This situation is more common following MA of a left-kidney tumor. The initial symptom is mostly mild abdominal distension, and the specific symptom is intermittent air release during urination. A diagnosis can be made if a stool is visible in urine (patient numbers 3 and 4).General management includes abstinence from food and water, gastrointestinal decompression, fluid replacement and nutritional support, anti-inflammatory therapy, and surgical consultation , 19. SurFirst, relevant imaging (CT/MRI) before MA must be done and the imaging results interpreted carefully. Full evaluation of the relationship between the lesion and intestines on transverse, coronal, and sagittal planes must be carried out. Full evaluation of the relationship and distance between the lesion and the intestines using image fusion and three-dimensional reconstruction techniques may be necessary.Second, a detailed medical history and treatment history must be obtained. Adhesions and relative spatial changes in abdominal and pelvic organs can be caused by surgery in abdominal and pelvic areas, radiotherapy of the lesion and surrounding areas, peritonitis, abdominal infection, and endometrial displacement. If the lesion is in close proximity to the gastrointestinal tract and the patient has one of the medical histories mentioned above, a post-MA IF may occur due to the inability of artificial ascites to separate the adhesion in some locations.If the lesion is close to the intestines and the distance between the MA site and intestines is <5 mm, auxiliary measurements should be taken to reduce the risk of intestinal injury before and during MA. Eight parameters should be considered.An appropriate amount of oral laxatives  should be taken after the evening mean 1 day before MA and fasting should be maintained from the morning of MA. The purposes of intestinal cleansing are to: change the relative distance between the intestines and lesion; reduce the leakage of intestinal contents after development of IF; reduce the severity of post-IF infection. The cleanliness of the intestines is beneficial for surgery.Artificial ascites can change the relative distance between the lesion and intestines, create a safe path for needle insertion, and reduce the temperature of the intestine near the MA site , 20–22. The relationship between the needle-insertion path and intestines should be evaluated fully before MA, especially if the small intestine lies on the needle-insertion path. Hence, the probe should be pressurized and relaxed repeatedly several times, a high-frequency probe should be adopted, or fusion images of CT/MRI and ultrasound should be used to ensure that the intestine is not on the needle-insertion path.The microwave electrode should not be placed with its tip pointing directly in the direction of the intestines. This strategy is used to prevent the intestinal injury caused by forward displacement of the microwave electrode due to poor visibility of the needle tip as a result of shielding by strong echoes during MA.The distance between the MA site and intestines should be >5 mm. If the distance is <5 mm, temperature measurement should be undertaken concurrently during MA to ensure a temperature of <54°C near the intestines .125I particles, radiotherapy, and laparoscopic ablation can be undertaken.If use of artificial ascites results in poor separation or failure to separate adhesions, other treatments should be carried out instead of MA. Alternative treatments include alcohol-injection coagulation, implantation of After MA of lesions close to the intestines, the duration of food/water abstinence should be extended appropriately (≥24 h) . MultiplIntestinal injury due to MA of renal and adrenal-gland lesions often lacks early specific symptoms and peritoneal irritation, and the initial symptom is often non-specific abdominal distension. Therefore, such patients should be monitored closely more than 1 month.IF often occurs following MA of lesions close to the intestines. IF is a rare complication of MA. Although the prevalence of IF is low, its consequences are often serious. A distance <5 mm between the margin of the target lesion and intestines and a history of surgery, radiotherapy of the proposed MA site and surrounding area, cirrhosis, ascites, abdominal infection, and dysmenorrhea are high-risk factors for post-MA IF.125I particles, radiotherapy or by laparoscopic ablation. Surgical treatment is often required after IF development. Care should be taken if MA is to be done in patients intolerant to surgery and have a high-risk of intestinal injury following MA.The prevalence of IF can be reduced by undertaking three actions: (i) full evaluation of the relationship between the lesion and intestines by imaging, planning the needle-insertion path, and cleansing the intestines before MA; (ii) applying artificial ascites and measuring the real-time temperature during MA; (iii) treating tumors near the intestines with alcohol-injection coagulation, implantation of The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by this was a retrospective study approved by the Ethics Committee of our hospital. The patients/participants provided their written informed consent to participate in this study.ST, ZC, and XY made substantial contributions to the research design, analysis and interpretation of data. PL, ZH, YG, JZ, FL, and ZC contributed lot of the data analysis and appropriate method to the research. YG and RL took part in the building of the clinical database. ST drafted the manuscript. All the authors read and approved the final manuscript.Our study was supported by Grants  from the National Scientific Foundation Committee of China, and the National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital [NCRCG-PLAGH-2019011].The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.