We describe the case of an 82-year-old female referred to the vascular clinic for further evaluation and management of suspected inferior vena cava (IVC) thrombosis. She had previously presented to the general practitioner with a one-week history of vague abdominal pain in the right and left loins. Contrast-enhanced magnetic resonance imaging (MRI) of the abdomen and magnetic resonance angiography/magnetic resonance venography (MRA/MRV) revealed a 10 cm filling defect in the IVC, with the inferior margin of ≈5.8 cm proximal to the aortic bifurcation and its superior margin in the intrahepatic portion of the IVC. The filling defect had a transverse diameter of 2.6 cm and displayed heterogenous enhancement with contrast.We performed an endovascular biopsy with fluoroscopy  being utilized throughout the procedure to locate the mass and position the forceps in the tumor bed. The IVC was accessed via the right common femoral vein with a 10F catheter sheath. The sheath was advanced using the Seldinger technique to within ≈1 cm of the mass; then, a biopsy forceps  was inserted, and six tissue samples were obtained.We report this case to add to the growing evidence that endovascular biopsy of IVC tumors can be performed safely and effectively. Malignancy of the inferior vena cava (IVC) is rare, with most cases being secondary to renal, liver, testicular, and adrenal tumors . PrimaryAn 82-year-old female was referred to the vascular clinic for further evaluation and management of a suspected IVC iliofemoral thrombosis. She had previously presented to the general practitioner with a one-week history of vague abdominal pain in the right and left loins. Initial computed tomography (CT) scan revealed features suggestive of an IVC thrombus with extensive left iliofemoral thrombosis. Upon presentation at the vascular clinic, there were no clinical findings suggestive of IVC or iliofemoral thrombosis.A contrast-enhanced magnetic resonance imaging (MRI) of the abdomen and magnetic resonance angiography/magnetic resonance venography (MRA/MRV) were performed, and a 10 cm filling defect was noted in the IVC, with the inferior margin of ≈5.8 cm proximal to the aortic bifurcation and its superior margin in the intrahepatic portion of the IVC , possibly signifying a metastatic lesion. A low T1/ high T2 signal paracaval mass lesion of ≈2.6 cm × 5 cm was noted, suggestive of infiltrative lymphadenopathy; there appeared to be infiltration of the IVC. It was thus determined that a biopsy of the IVC mass was required.The IVC was accessed through the right common femoral vein with a 10F catheter sheath. The sheath was advanced using the Seldinger technique to within ≈1 cm of the mass. The biopsy forceps  was then inserted, and six tissue samples were taken Figure . ThroughMicroscopy revealed a neoplastic lesion composed of sheets of cells with indistinct borders and round nuclei, many of which contained clear cytoplasm. There was significant tumor cell necrosis. The tumor was strongly positive for cathepsin K and melan-A and positive for smooth muscle actin (SMA) and transcription factor E3 (TFE3) and further displayed focal staining for cytokeratin AE1/AE3 and very weak focal staining for carbonic anhydrase IX (CAIX). The Ki-67 proliferative index was ≈60%. The tumor was negative for desmin, renal cell cancer antigen, human melanoma black 45 (HMB45), cytokeratin CAM5.2, calretinin, sex-determining region Y protein (SRY)-related high mobility group (HMG)-box 10 (SOX10), steroidogenic factor 1 (SF-1), chromogranin, synaptophysin, and inhibin. The overall impression was that of a malignant tumor of predominantly epithelioid morphology, although a definitive sub-classification proved difficult; epithelioid angiomyolipoma and microphthalmia transcription factor (MiT) family translocation-associated renal cell carcinoma were considered the most probable diagnoses. The patient opted against surgical intervention and was thus referred to the oncologic clinic for further management.The European Society for Medical Oncology (ESMO) recommends that the initial assessment of soft tissue sarcomas comprise radiologic imaging, i.e., either ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT), to determine the extent of tumor involvement, followed by histopathologic diagnosis . Major hThe definitive sub-classification of the reported patient’s tumor proved difficult. The absence of renal mass lesion on radiologic imaging suggested that renal cell carcinoma was unlikely, although there exist reports of metastatic renal cell carcinoma without a primary lesion ,8.Endovascular biopsy has emerged as an alternative to percutaneous biopsy  and is aThe efficacy and safety of endovascular biopsy for IVC tumors have thus far been demonstrated primarily in case reports and small case series Table .Although there is little homogeneity in these cases regarding the exact method of endovascular biopsy, it is significant that there were no procedure-associated complications recorded in any instances. Indeed, even if there is bleeding of the vessel wall due to trauma from the various instruments, it would simply traverse the circulation. While further data and larger studies are needed to consolidate the advantages offered by endovascular biopsy compared to percutaneous biopsy and to evaluate if any one endovascular biopsy technique is superior to another, we believe that there is yet sufficient evidence to recommend endovascular biopsy be considered in future patients.Malignancy of the inferior vena cava is rare, and a specimen sample is required to establish the diagnosis as either primary or secondary. Endovascular biopsy is an alternative to percutaneous biopsy for the diagnosis of vascular malignancy and is associated with a lower risk of massive hemorrhage. This case adds to the growing evidence that endovascular biopsy of IVC tumors can be performed safely and effectively.


Rectus sheath hematoma is a rare cause of acute abdomen, and its clinical diagnosis is challenging without any imaging methods. We describe a case of a 50-year-old woman with no significant medical history who developed a sudden abdominal pain following a cough paroxysm. On physical examination, there was intense pain after light percussion and tenderness on palpation. Laboratory findings were within normal range. The imaging findings allowed us to diagnose a spontaneous rectus sheath hematoma. A conservative approach was opted. The patient had a favorable course. Accurate diagnosis is of the utmost importance as it may avoid unnecessary interventions, and in some cases, especially for elderly people, it can be fatal. This case alerts us to a rare cause of acute abdomen. Rectus sheath hematoma is an uncommon condition that can present in a similar fashion to other life-threatening causes of acute abdomen. Awareness of such a condition is vital, as its diagnosis is challenging, in order to reduce iatrogenic procedures. Trauma and antithrombotic medication are the most common risk factors . A thoroA woman in her 50s presented to the emergency department (ED) due to a viral respiratory infection, being discharged with acetaminophen. A week later, during a cough burst, she developed a sudden, sharp and limitative pain in the left iliac fossa, being admitted to the ED again the following day. The pain was refractory to analgesics, and the patient had no bowel movements since the beginning of the episode. She had no significant medical history except for hypertension and hypothyroidism and her medications did not include antithrombotic drugs.9/L, respectively, normal platelet counts, normal coagulation tests, reactive C protein of 0.54 mg/dL and the remaining lab values were unremarkable. Initially, an abdominopelvic ultrasound was performed and a 4x7cm heterogenic lesion, mainly liquid, in the abdominis rectus muscle topography was seen, with no other abnormalities . Spontaneous nontraumatic rectus sheath hematoma may present following strenuous exercise, cough paroxysms, vomiting, or defecation, and requires a high index of suspicion. This case highlights the potential of sustained cough to cause abdominal hematomas even in the absence of anticoagulants and its correct diagnosis is crucial to administer the proper treatment, usually conservative, but in complicated cases, invasive treatment may be considered.


Acute appendicitis is one of the most common causes of right iliac fossa (RIF) pain in the younger population. However, multiple other pathologies presenting with RIF pain can mimic acute appendicitis. In the female gender, the differentials for RIF pain are broader. Multiple pathologies can present with similar symptomatology that can mimic acute appendicitis, leading to an incorrect diagnosis, unnecessary surgical interventions, and complications. In females of reproductive age, gynaecological causes can present similarly. Here, we present a case of an ovarian teratoma mimicking acute complicated appendicitis.A female of reproductive age presented to our hospital with RIF pain of six days, associated with fever, nausea, vomiting, and anorexia. A clinical diagnosis of acute complicated appendicitis was suspected, and further imaging was arranged to confirm the diagnosis. Imaging showed a normal appendix with a right adnexal mass separated from the ovary, representing a teratoma. She underwent elective surgery for the excision of teratoma after further investigations. Ovarian teratomas are not a common mimicker of appendicitis. One should consider possible gynaecological causes as a differential for RIF pain. Due to the wide variety of differentials, when in doubt, especially in the female gender, further imaging should be considered for confirmation of diagnosis. Acute appendicitis is one of the most common causes of right iliac fossa (RIF) pain in the younger population. Typical presentation includes periumbilical colicky abdominal pain migrating to RIF, associated with constitutional symptoms such as vomiting, nausea and anorexia. Acute appendicitis is primarily a clinical diagnosis . HoweverIn this report, we discuss a case of torsion of a large ovarian teratoma presenting as acute complicated appendicitis. Ovarian teratoma is not a common cause of RIF pain. Here, we will discuss the importance of thorough history taking, examination and appropriate investigations, including imaging, to make an accurate diagnosis and prevent unnecessary surgical Interventions. Our primary focus in this case report and literature review is on differentiating acute appendicitis from its mimickers.This case report has been reported in line with the SCARE  criteria .A 29-year-old nulliparous female presented to our emergency department with six days of non-migratory RIF pain associated with nausea, vomiting, fever and anorexia. She denied any vaginal bleeding or vaginal discharge. Her last menstrual period was one week ago. She was an otherwise healthy lady and was not on regular medications. On examination, she was febrile at 38.2° C and tender in the RIF with fullness. Her white cell count (WCC) (15.82 x 109/L) and neutrophil count (12.1 x 109/L) were high, with a markedly elevated C- reactive protein (CRP) (231 mg/L). Beta human chorionic gonadotropin (HCG) was negative. Due to ongoing fevers, a palpable mass in the RIF and markedly elevated CRP, the possibility of complicated appendicitis with an abscess or a phlegmon formation was suspected.She underwent a computed tomography (CT) scan to confirm the diagnosis. The CT scan showed a normal appendix and a 128 mm X 109 mm X 88 mm heterogeneous, mixed solid and cystic lesion within the pelvis  to characterise the cyst further Figure .The cyst volume was 537 ml with no internal vascularity. The right ovary was identified separately and adhered to the cyst. She had further blood tests, including tumour markers: alpha-fetoprotein, cancer antigen (CA) 19-9, carcinoembryonic antigen and CA 125. All the markers were within the normal range other than the mildly elevated CA 125.She underwent an uncomplicated elective laparoscopic surgery on day 6 from the presentation. The cyst (diameter of 15 cm) had adhered to the omentum, small bowel, pelvic sidewalls and anterior abdominal wall. The right ovary and tube were torted around the teratoma and necrosed. A right salpingo-oophorectomy was performed along with the excision of the cyst. The specimen was retrieved via an extended suprapubic incision. Histopathology showed haemorrhagic and largely infarcted fatty tissue with scattered hair shaft fragments, neuroglial tissue, cartilage and calcification Figures , 5.No immature or malignant elements were identified. She was sent home on the same day postoperative.Acute appendicitis is one of the most common general surgical pathologies encountered in the emergency department. It is common in the age group 10 to 20 years  and is sThe typical presentation of acute appendicitis is colicky periumbilical pain, then migrating to RIF . Pain isPeriumbilical pain can be caused by many midgut origin viscera, leaving a wide variety of differentials in a patient presenting at the initial stage of the disease, for example, Meckel’s diverticulitis. Subsequent RIF pain can be caused by diseases in the terminal ileum  and cecum . Inflammation of the mesenteric lymph nodes resulting in mesenteric adenitis and fat necrosis of the epiploic appendages causing appendagitis epiploica are a few other causes of RIF pain. They can present with RIF pain with or without preceding periumbilical pain and constitutional symptoms, mimicking acute appendicitis. Gynaecological causes, especially in reproductive-age females, broaden the long differentials list for RIF pain. This is likely the reason for high negative appendicectomy rates in females aged 15 to 24, which is 2.5 times higher than the males of the same age [There are scoring systems to guide the diagnosis of appendicitis, and the Alvarado score is one of the commonly used scores. One systematic review revealed that the Alvarado score overpredicts the probability in women; however, is a valuable tool to rule out the diagnosis of acute appendicitis at or below a score of five .Teratoma is not a common mimicker of acute appendicitis. In our case, the patient presented with non-migratory RIF pain associated with nausea, vomiting and anorexia. She was not mid-cycle and denied any vaginal bleeding, vaginal discharge, or previous gynaecological history. Her serum beta-human chorionic gonadotropin (HCG) was negative. Considering this history, we ruled out many of the gynaecological causes. Our initial diagnosis was acute complicated appendicitis due to fever, six days of pain and the markedly elevated CRP level; hence, a CT scan was arranged to confirm the diagnosis and further characterise the appendicular complication. In this scenario, fever is likely caused by the necrosed ovary. The RIF pain is possibly explained by the increasing size of the teratoma exerting pressure symptoms, capsular distention of the teratoma, haemorrhage and infarction, and the torsion of the ovarian teratoma complex. Ovarian torsion is a gynaecological emergency that needs urgent attendance to restore the blood supply to salvage the ovary. In her case, the presentation was late with an already compromised blood supply, resulting in ovarian ischaemia and necrosis.Teratomas can occur in other parts of the body; however, they are common in gonads. Ovarian teratomas are the most common germ cell tumour  and theyFemales of reproductive age can experience physiological pain secondary to ovulation, which could mimic appendicitis. Endometriosis, adenomyosis, pelvic inflammatory disease and retrograde spillage of menstrual blood are a few more causes that could mimic acute appendicitis. Other significant gynaecological causes are ectopic pregnancy and ovarian torsion, presenting as acute abdomen and will need emergency interventions. A thorough gynaecological history and examination, including a speculum examination in a reproductive-age female, is of value in differentiating such a pathology from acute appendicitis.Jerusalem guidelines (2020) from the World Society of Emergency Surgery, recommend a customized approach to the diagnosis of acute appendicitis by constructing a diagnostic pathway based on age, gender and clinical symptomatology . UpToDatAcute appendicitis is a clinical diagnosis. Multiple other pathologies can present similarly, mimicking acute appendicitis or acute complicated appendicitis and can cause diagnostic challenges as in this scenario. When assessing a patient, one must consider the many possible causes of RIF pain. For a female of reproductive age, gynaecological causes need to be considered as a differential diagnosis. Further investigations, including imaging, should be arranged in doubt. A thorough history, examination and appropriate investigations will help to prevent unnecessary surgical interventions.


Renal cell carcinoma (RCC) is an aggressive tumour, with 25% of the cases presenting with distant metastases at the time of diagnosis. Approximately 33% of the patients with RCC eventually develop metastatic spread. RCC can metastasize to various sites including the lung, liver, bone, brain, adrenal gland, and more. Cardiac metastasis is rare in RCC, but even rarer in the absence of inferior vena cava (IVC) involvement. This case report presents a 60-year-old male patient who was referred by his general practitioner due to breathing difficulties. An initial echocardiogram revealed a right ventricular outflow tract obstruction caused by a mass. A subsequent cardiac MRI showed a right ventricular mass with features suggestive of a metastatic spread. A CT scan of the thorax, abdomen and pelvis was done to ascertain the primary tumour which revealed RCC, without involving the IVC. Due to the presence of metastases, advanced disease, and heavy tumour burden, the multidisciplinary team concluded that there were almost negligible treatment options available at that stage and recommended the best supportive care and community hospice support. The patient was discharged once his symptoms improved, as per his request, and he passed away peacefully at home within a month. This case highlights the very rare occurrence of cardiac metastasis of RCC without IVC involvement. It also illustrates the approach and investigations involved in the evaluation of complex cardiac masses. Renal cancer is among the most common cancers in the United Kingdom (UK) and generally occurs in adults in their 60s or 70s, though rarely seen under 50s as well. Every year over 12,500 people in the UK are diagnosed with this condition [We describe the case of a 60-year-old male who was referred to our cardiology outpatient clinic by his GP for evaluation of his recent onset SOB. The GP had ruled out respiratory causes of said SOB and had referred the patient for an echocardiography scan. Except for bilateral pedal oedema and a tricuspid regurgitation murmur, the rest of his examination was reassuring. A routine ECG done before the echocardiography showed an S1Q3T3 pattern, which is sometimes suggestive of a pulmonary embolism (PE). Echocardiography was done immediately, which showed a dilated right ventricle (RV) with impaired systolic function, especially mid to apical radial function. RV hypertrophy was also seen with a free wall measured up to approximately 8 mm. A large echo-dense mass of irregular shape and minimal mobility was seen adjacent to the anterior free wall with right ventricular outflow tract (RVOT) obstruction. Small localised pericardial effusion was also seen adjacent to the RV free wall  was scheduled immediately, which showed sufficient small filling defects in the sub-segmental branches of the pulmonary artery in the right lower lobe, suggesting PE. The radiologist also made note of a large obstructing thrombus in the RV, which was not extending into the pulmonary trunk. No evidence of acute heart strain was found; however, mild pericardial effusion was seen. Thus, all the findings of our echocardiography report were corroborated. A special feature of this CT scan was that the radiologist added a note at the end about a large lytic lesion present in the posterior part of the T7 vertebral body with extension into the vertebral arch, which he thought was probably metastatic Figure .In light of these findings, a CT scan of the abdomen and pelvis (CTAP) with contrast was done to try to locate the malignancy. CT showed a large 12.5 x 12.4 x 8.3 cm enhancing mass with central hypoattenuation centred on the upper pole of the left kidney (Figure Based on all these findings, a diagnosis of mRCC was made. The case was then discussed with our hospital’s parent tertiary cardiology department after starting therapeutic anticoagulation and diuretics, who advised the transfer of the patient. Given that it is unheard of for an intracardiac tumour thrombus extension from RCC without involving IVC, it was decided to perform a cardiac MRI scan to determine the morphology of the lesion inside the heart. Cardiac MRI showed bulky RV mass associated with RVOT, RV dilatation, severe RV impairment, severe tricuspid regurgitation and cardiac decompensation Figure . A speciBecause of the severe disease burden and its widespread nature, it was decided in the multidisciplinary team meeting that the patient was not a surgical candidate nor would he benefit from complex systemic therapy. Detailed conversations were held with the family and patient, who wished for palliative care only and did not wish for any resuscitation. The palliative care team was taken on board for “end-of-life” care and the bereavement office was contacted for psychosocial support due to the suddenness of the disease. The patient was managed symptomatically, and after some improvement, he wished to go home. Given that he had capacity, he was discharged home with hospice community care support. He remained at home and peacefully passed away after one month.RCC has various subtypes, with the most prevalent one being clear-cell renal cancer. Less frequently encountered variants include papillary RCC and chromophobe RCC. When detected in its early stages, RCC is often curable, but the likelihood of a cure diminishes significantly once metastasis occurs. RCC is characterized by a considerable propensity for metastasis, with approximately 20-30% of patients presenting with metastatic or locally advanced disease at the time of diagnosis . ApproxiRCC has a high inclination towards venous invasion. RCC can invade through the renal vein into the IVC, and can then extend into the lumen, with tumour-thrombus complex formation occurring in about 5% to 15% of all cases. The tumour can sometimes extend right up to the right cardiac chambers as well from there in about 1% of the cases . In almoWhile primary cardiac tumours are rare, cardiac metastases are common and represent up to 9% of the intracardiac masses. These are a result of either direct extension or haematogenous or lymphatic spread . Here, wOn a literature review, although there are some cases of intracardiac tumour metastases without IVC or renal vein involvement such as those reported by Raiker et al. , Ansari Every RCC patient should ideally begin treatment with an anti-programmed death-1-based therapy, according to the Society for Cancer Immunotherapy. However, there is not enough data to determine the effectiveness and safety of checkpoint inhibitors for patients with uncommon metastatic sites, such as intracardiac metastases like in our case. Cardiac involvement without IVC tumour is not that common and presents a unique treatment challenge, even with the new anti-programmed cell death receptor-1 monoclonal antibody . AdditioPatients with mRCC and intracardiac metastases, in the absence of IVC involvement, are exceptionally rare. Generally, this subpopulation experiences unfavourable outcomes as they are often diagnosed at an advanced clinical stage. The optimal treatment approach for RCC patients with cardiac metastases remains uncertain. Intracardiac metastases can manifest with various clinical consequences, including haemodynamic disturbances from ventricular outflow obstruction, embolism, and cardiac dysfunction, or sometimes with seemingly minor symptoms such as increased breathlessness. Given the non-specific nature of these symptoms, it is imperative to maintain a high clinical suspicion to guide appropriate investigations. Echocardiography, though valuable, may have limitations in distinguishing cardiac metastases from thrombi, endocarditis, or primary tumours. Therefore, additional cardiac MRI or PET/CT imaging is often necessary for precise differentiation and to inform treatment decisions.


Endometriosis is one of the most frequent gynecologic disorders, clinically confirmed or suspected in one of nine women by the age of 44 years. Its location of occurrence can be classified into intra and extra pelvic. Abdominal wall endometriosis (AWE) is one of its rare location, with frequency of 0.04 to 5.5 %. Furthermore there are only a few cases of AWE in Indonesia that have been reported.Here we present two Indonesian patients at a General Hospital in Tangerang, Indonesia. The first patient, 26 years old, complained of an umbilical mass 2 years after caesarean section. The second patient, 36 years old, complained of an umbilical mass since 8 months, with no history of prior surgery. Both patients had pre-operative ultrasonography (US) and underwent wide local excision. Histopathology examination with presence of endometrial glandular components and endometrial-like stroma confirmed the diagnosis of AWE.AWE is defined as any endometrial tissue found superficial to the peritoneum, locating most commonly at umbilical, inguinal area, and anterior abdominal wall. Pre-operative diagnostic tools include abdominal ultrasonography (US) or abdominopelvic computed tomography (CT) scan. Since treatment with medications is usually not effective, surgical treatment is recommended, along with confirmation by histopathological examination.Diagnosis of AWE should be suspected in all women with symptoms of an abdominal mass and cyclic pain, especially if the patient had history of surgery at the abdominal region. AWE is quite rare, but its symptoms can affect quality of life. Hence, a multi-disciplinary approach is necessary, with the strongly recommended treatment of wide local excision to prevent recurrence and malignant transformation. •Endometriosis is one of the most frequent gynecologic disorders, located at intra or extra-pelvic.•Abdominal wall endometriosis (AWE) is one of its rare location, which comprises only 0.03 to 0.40% of reported incidence.•AWE should be suspected in all women with an abdominal mass and cyclic pain, especially with a history of abdominal surgery.•AWE can affect quality of life and should be treated surgically to prevent recurrence and malignant transformation. It is cAWE is defined as any endometrial tissue found superficial to the peritoneum with estimated frequency of 0.04 %–5.5 %. AWE can be classified into primary (spontaneous) and secondary  . Maligna2A 26-year-old Indonesian woman came to the surgery outpatient department with chief complaint of a painful, palpable, mass of the abdomen since 6 months ago. The patient described that the mass started out as barely noticeable, then enlarging to a diameter of 0.5 cm, and keep enlarging to a diameter of 5 cm on examination. The mass was accompanied by pain that had a cyclic characteristic. During her menstrual period, the pain restricted her daily activities and rated 7 out of 10 on the pain scale. She reported no other abnormalities relating to her menstruation, no fever nor weight loss. The patient had a history of one pregnancy with an uncomplicated caesarean section 2 years prior. The patient denied any hormonal or birth control use. The patient reported no significant personal and family history of any disease, medication and/or genetic condition.Cutaneous examination of the abdominal region reveals a painful, hard, partially mobile mass about 5 × 5 cm located in the hypogastric region, at the caesarean section scar. A diagnosis abdominal wall endometriosis (AWE) was suspected given the patient's history of caesarean section and flares of pain with menstrual periods. Transabdominal ultrasonography (US) revealed heterogenous hypoechoic lesion in the subcutaneous region of the lower abdomen suggestive of endometriosis .Fig. 1UlSurgery of wide local excision with 1 cm free margin was done , and the3The second case report is of a 36-year-old Indonesian woman with chief complaint of painful and palpable nodular mass, located in the umbilical region of the abdomen since 8 months ago. The patient also experienced cyclic pain and bleeding related to the onset of her menstrual period. She has no history of menstrual abnormalities or any abdominal or pelvic surgeries. The patient denied any hormonal or birth control use. The patient reported no significant personal and family history of any disease, medication and/or genetic condition.Cutaneous examination reveals a painful, well-defined, nodular tender mass, 2 × 2 cm in size in the umbilical region of the abdomen. Upon the abdominal ultrasonography (US) examination, we found an inhomogen hypoechoic lesion, hypovascular, 2,12 × 1,46 × 1,96 cm in size with posterior shadowing in the umbilical region of the abdomen suggestive of umbilical endometriosis .Fig. 6UlTreatment of choice in the second patient was also wide local excision with 1 cm free margins  and histAfter the surgery, both of the patients stayed in hospital for 1 day and complained of mild pain at excision area. Both patients were discharged with medication of Mefenamic acid 500-mg TID. Follow-up was done 3 and 7 days after surgery at outpatient department with adequate wound healing without any complications.4Endometriosis is one of the most frequent gynecologic disorders that is defined as the presence of functioning endometrial glandular epithelium and stroma implants outside of the uterine . AccordiWhile often located at organs inside the pelvic cavity, endometriosis can also occur outside the pelvic cavity: lung, abdominal wall, or inguinal area . AbdominA systematic review comprising of 455 AWE patients found that approximately 80 % of the patients had history of prior surgery, with caesarean section being the most common. The mean time interval between surgery and presentation of AWE was 2 to 5 years [The first patient of this case series had secondary AWE at caesarian section incision scar, while the second one had primary AWE as she had no history of prior surgery. Secondary AWE experienced by the first patient had onset of symptoms 2 years after caesarean section.Presenting symptoms of AWE can include a palpable mass at the abdominal region, characteristic of cyclic pain, general endometriosis symptoms such as dysmenorrhea, dyschezia, or dyspareunia, and/or bleeding from superficial lesion and lower abdominal pain . HoweverPathogenesis of AWE had been a long topic of discussion, among many, there are three that are most influential. Sampson first described theory of implantation, where the endometrial cells reflux and implant on the surrounding pelvic structures during menstruation. This theory was supported with study findings of higher refluxed menstrual blood in women with endometriosis and higher incidence of the disease in females with outflow obstruction. However, it was also found that incidence of retrograde menstruation is similar in women with and without endometriosis leading to the conclusion of a multi-factorial mechanism. Furthermore, this theory does not explain endometriosis occurring outside the pelvic cavity ,5,13.The second theory: vascular dissemination is described by Halban where endometrial cells escape from the uterus through lymphovascular channels to the peripheral circulation, then to various sites. The third theory involves metaplasia of the undifferentiated cells in the abdominal wall into endometrial tissue, induced by imitative metaplasia or hormonal manipulation. Other than the tree main theories, immunity is hypothesized to have a bigger role in endometriosis, which might affect the clearance ability of the refluxed endometrial cells. Altered or deficient immunity, more specifically reduced Natural Killer (NK) cells ability and cell-mediated immunity may contribute to the development of endometriosis. Once endometriosis has occurred, a chronic inflammatory process can be observed, evident with the increased number of leukocytes and macrophages. These cells secrete pro-inflammatory cytokines such as IL-6, TNF-α, IL-1 and IL-8 along with vascular endothelial growth factor (VEGF) to increase neoangiogenesis which further contribute to the progression of endometriosis ,13.A study by Marras et al. suggested that post-surgical AWE is likely caused by iatrogenic implantation of endometrial cells during surgery, while AWE without prior surgery is more likely caused by lymphatic or hematogenous dissemination or metaplasia . DespiteThe site of AWE can produce differential diagnosis of hernia, abscess, lipoma, desmoid tumor, hematoma, lymphadenopathy, or malignancy ,15. DiffAbdominal ultrasonography (US) or abdominopelvic computed tomography (CT) scan are the most commonly used pre-operative diagnostic tools for suspected AWE . AdditioAbdominal ultrasonography (US) is the first line and cost efficient diagnostic tool that was used in both of these patients. On ultrasonography, AWE lesion will appear as a heterogenous isoechoic or hypoechoic area surrounded by peripheral vascularization ,15. WhilOn CT scan, the lesion will appear as a solid heterogeneous mass with mild-to-moderate enhancement with administration of intravenous contrast. While on MRI, it will appear as a hyperintense or isointense heterogenous on T1- and T2-weighted images ,15.The significant negative impacts of AWE on psychosocial, sexual, and professional aspects demands a multi-disciplinary approach to treat AWE and its possible complications. Effects on quality of life varies from mild to significant restriction of activities depending on severity of pain and/or discomfort. Patient experiencing pain which does not respond to first-line treatment may benefit from a consult with a pain specialist. Gynecologists also have a significant role as hormonal and fertility might also affect sexual aspects of the patient. Infertility might be the result of pelvic adhesions, impairment of oocyte release or pick-up, disorder of myometrial contractions, and impairment of fertilization and embryo transport ,13.There have been multiple studies concerning the efficacy of pharmalogical treatments with ambiguous results. Pharmacological treatment can be initiated on the basis of clinical suspicion and has the benefits of symptoms relief and inhibition of further development of endometriosis. However, pharmacological treatments have shown no improvement in endometriosis-associated infertility and generally should be discouraged in patients who desire a live birth, except those undergoing in-vitro fertilization (IVF) .Administration of drugs such as non-steroidal anti-inflammatory drugs (NSAIDs), contraceptives, gonadotropin-releasing hormone (GnRH) agonists and aromatase inhibitors showed improvement of symptoms, but no change in lesion size. Discontinuation of treatment is also likely to cause recurrence of symptoms ,13,16,17Pharmalogical treatment might serve to eliminate symptoms prior to surgery or as a treatment of choice in patients who refused to undergo surgery . Wide exThere is currently no recommendation or mutual agreement on how wide the negative margins should be, but there had been suggestion of 1 cm minimal margins to prevent recurrence and/or malignant transformation (occurring in 1 % of endometriosis) ,16. In bTwo histological features out of three diagnostic triads are required to diagnose endometriosis: endometrial glands, endometrial stroma or hemosiderin pigments . HistopaRecurrence rate after wide local excision is much lower (1.5 %–7.5 %) when compared to medical treatment ,19. As pAWE case reports in the Indonesian population are still limited, but it might be under-reported. Diagnostic and treatment guidelines of AWE would be beneficial as this disease implicate several important aspects  which can significantly decrease quality of life.5Diagnosis of AWE should be suspected in all women with symptoms of an abdominal mass and cyclic pain, especially if the patient had history of surgery at the abdominal region. AWE is quite rare, but its symptoms can affect quality of life. Hence, a multi-disciplinary approach is necessary, with the strongly recommended treatment of wide local excision to prevent recurrence and malignant transformation.At 1-day post-op follow up, both patients felt relieved and content that the tumor had been excised. At 3-days post-op follow up, the first patient still complained of mild pain, but at 7-days post-op follow up, she was content that the pain had decreased and the scar resulted was healing well. The second patient experienced minimal pain and expressed satisfaction at the scar result at 3-days and 7-days post-op follow up.Written informed consent was obtained from patients about these case reports writing and publishing. Both patients understood well and gave consent. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.As it is a case report, ethical approval is exempted by our institution.This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.NMC, VS, HL, KIG: the conception and design of the study, or acquisition of data, or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, final approval of the version to be submitted.Natalia Maria Christina acts as the guarantor of this study.The authors declare that there is no conflict of interest.


Intracranial mass lesions occur within the cranial cavity, and their etiology is diverse. Although tumors and hemorrhagic diseases are the common causes, some rarer etiologies, such as vascular malformations, might also present with intracranial mass lesion manifestations. Such lesions are easily misdiagnosed due to the lack of manifestations of the primary disease. The treatment involves a detailed examination and differential diagnosis of the etiology and clinical manifestations. On 26 October 2022, a patient with craniocervical junction arteriovenous fistulas (CCJAVFs) was admitted to Nanjing Drum Tower Hospital. Imaging examinations showed a brainstem mass lesion, and the patient was initially diagnosed with a brainstem tumor. After a thorough preoperative discussion and a digital subtraction angiography (DSA) examination, the patient was diagnosed with CCJAVF. The patient was cured using interventional treatment, and an invasive craniotomy was not required. During diagnosis and treatment, the cause of the disease might not be apparent. Thus, a comprehensive preoperative examination is very important, and physicians need to conduct the diagnosis and differential diagnosis of the etiology based on the examination to administer precise treatment and reduce unnecessary operations. Since the cranium is a relatively closed space, intracranial mass lesions often displace normal tissues, damage focal nerves, and increase intracranial pressure ,2. TheseThe patient  was admitted to the hospital with “intermittent headache with hoarseness for 10 days”. The patient experienced intermittent headache 10 days prior, which was intense during the attack but subsided after taking rest, accompanied by hoarseness. The patient did not experience dizziness, nausea, vomiting, weakness of the limbs, twitching of the limbs, difficulty in swallowing, or choking while drinking. A physical examination showed that his consciousness was clear, and his speech was fluent but slightly hoarse. Both pupils (2.5 mm in diameter) were equal in size and round and responsive to light, the muscle strength of the limbs was grade V, and the muscle tone was normal. The patient was admitted to the hospital and underwent routine imaging tests. Computed tomography (CT) examinations suggested an abnormal brainstem density A, and CTWe ruled out the possibility of an intracranial hemorrhagic lesion, which is often associated with increased intracranial pressure, severe headache, or loss of consciousness ,7,8. To Tumors are the most common cause of intracranial mass lesions, such as gliomas, auditory neuromas, and intracranial metastases ,10. WhenCCJAVFs are relatively rare in clinical practice and are caused by the formation of fistulas in the arteriovenous region of the craniocervical junction, which can occur when inflammation, trauma, or other factors lead to disturbances in the arteriovenous pressure gradient and the obstruction of venous return. The etiology is not clear and might be related to congenital anatomical abnormalities, trauma, thrombosis, or medically induced injuries ,15. Due In the clinical setting, common etiologies of intracranial mass lesions and the underlying etiology need to be investigated. Only by improving the efficacy of preoperative examinations can the rate of misdiagnosis be reduced. CCJAVF has a complex vascular configuration, lacks typical symptoms, and is easily misdiagnosed on imaging. CTA was performed during admission and did not suggest vascular abnormalities. Although CTA is less accurate than DSA for vascular diseases, it is widely used as a preliminary screening tool for vascular diseases. As CTA cannot detect vascular abnormalities, vascular diseases cannot be ruled out following a CTA examination. Additionally, CTA does not have a high detection rate for arteriovenous fistulas (AVFs). The diagnosis of AVF is not complicated, and DSA is the gold standard for diagnosis . StudiesTo effectively treat AVF, the venous drainage of the fistula needs to be occluded, and a normal venous flow needs to be restored. The main treatment modalities for AVF include microsurgery, which allows for direct treatment of the fistula , and intMulti-disciplinary treatment (MDT) is very important. In modern medicine, medical disciplines are more finely classified to provide targeted treatment for diseases, and specialists might only be familiar with a small field. Our patient was initially treated by an oncology specialist who was not aware of the vascular abnormality and thought it might be a manifestation of a tumor. During a comprehensive neurosurgery consultation, the vascular specialist identified the case and recommended a DSA examination to clarify the relationship between the vessel and the mass lesion, which was eventually diagnosed as an AVF. This suggested that during diagnosis and treatment, if certain symptoms do not match the field of expertise of a specialist, multi-disciplinary discussions involving other specialists need to be conducted at the earliest possible moment.To summarize, a cranial mass lesion is a very common clinical syndrome that mostly starts with impaired neurological functions, and identifying the etiology of a cranial mass lesion is important. We should pay attention to the clues that would lead to considering AVF. Although most intracranial mass lesions are caused by tumors or hemorrhage, we reported the case of a brainstem mass lesion caused by CCJAVF. Our findings suggested that intracranial mass lesions might also be caused by arteriovenous malformations. Cranial mass lesions caused by arteriovenous malformations might be misdiagnosed as tumors, especially when the patient mostly has neurological involvement and lacks the typical symptoms of vascular malformations. Thus, to avoid misdiagnosis, clinicians need to differentiate arteriovenous malformations or other types of vascular diseases when the clinical manifestations of intracranial mass lesions are unclear or when certain clinical manifestations do not match the typical symptoms of common causes. DSA examinations need to be performed during clinical treatment to reduce the rate of misdiagnosis.


Teaching Point: Cystic brain necrosis is a rare but severe post-radiation complication; the late post-radiation context, the temporal location, and the MRI features can suggest the diagnosis. A 55-year-old patient, with a history of an undifferentiated nasopharyngeal carcinoma, eight years ago, benefited from 3D conformal radiation therapy (70 Gray at 2 Gray per fraction) and concomitant Cisplatin-based chemotherapy. The patient remained under control for years before being lost to follow-up.The patient then presented for headaches. dizziness, and behavioral changes. The physical examination showed no notable anomaly, and blood investigations were unremarkable.A brain magnetic resonance imaging (MRI) was performed, showing bitemporal lobe cyst-like lesions , T2 FLAICystic brain radionecrosis is a rare and grave late complication of radiotherapy for cervical and intracranial neoplasms .In the case of nasopharyngeal carcinoma, a cancer for which radiotherapy is the main treatment, the temporal lobes are inevitably included in the irradiation field, given their proximity to the base of the skull, which explains the high incidence of temporal localization of radionecrosis .The mean latency between radiotherapy and brain cystic radionecrosis is 9.2 years. It is often asymptomatic; however, when it becomes voluminous, it may lead to mass effect and occurrence of non-specific symptoms. The most frequent symptoms are dizziness, headaches, memory impairment, and secondary seizures .On MRI, cystic radionecrosis presents as cyst-like lesions, hypointense on T1, hyperintense on T2 and T2 FLAIR, without diffusion restriction, and presenting sometimes a discrete peripheral enhancement. They can be single or multiple, surrounded by perilesional edema which is hyperintense on T2 and T2 FLAIR. These lesions have the tendency to progressively increase in size, leading consecutively to mass effect [The differentiation between tumoral recurrence and radionecrosis is fundamental. The late post-radiation context, the temporal location and the MRI aspect are clues to the diagnosis; nevertheless, histology remains the best diagnostic tool .The therapeutic arsenal in case of symptomatic cystic necrosis includes, mainly, drainage of the cysts, and surgical resection. Conservative treatment relying on steroids can be prescribed temporarily for minimally symptomatic patients to reduce their symptoms .


Enterobius vermicularis (E. vermicularis) and acute appendicitis has not been settled, a few case reports of this very rare encounter are beginning to come to light. E. vermicularis is one of the most common parasitic infections around the world, and acute appendicitis, on the other hand, is also a commonly encountered condition in general surgery. However, the association between these two conditions remains controversial. Here we present a case report of a young woman with appendicitis associated with E. vermicularis.While the debate on the association between  One of the most common emergency abdominal operations worldwide is for suspected acute appendicitis . AppendiEnterobius vermicularis (E. vermicularis) has a worldwide prevalence, though crowded conditions are a risk factor for infection, and they are somewhat more common in developing countries [E. vermicularis, also known as pinworms, is the most common human parasite, being the most common helminth infection reported in the United States and are an infection transferable only by humans [Escherichia coli can adhere [ountries ,5. E. vey humans . Among tn adhere . PinwormE. vermicularis in relation to the pathogenesis of a few cases of acute appendicitis has been the subject of controversy for many years, as pinworms have been discovered in the appendix as far back as 1634 by Fabrius [E. vermicularis eggs were found within the lumen of the appendix.The role of  Fabrius ,8, despi9, and a C-reactive protein level of <4.0 mg/L. The coagulation profile and renal function tests were normal.A 21-year-old female with no significant past medical or surgical history presented to the emergency department at the Royal Hospital in Muscat, Oman, complaining of right iliac fossa abdominal pain of a one-week duration. The pain was progressive with associated anorexia. She denied any history of fever or change in her bowel habits but reported having regular clear vaginal discharge before menstruation. Her last menstrual period was a month ago. On examination, her vital signs were within normal limits. Her abdominal examination revealed tenderness in the right iliac fossa with a positive rebound sign. Urine analysis showed that no infection was present and the pregnancy test was negative. Laboratory investigations showed a hemoglobin level of 13.3 g/dL, a white cell count of 4.1 × 10The patient’s pelvic ultrasonography showed normal ovaries with no free fluid. A computed tomography (CT) scan was performed given the low probability of acute appendicitis (Alvarado score of 4), which showed a retrocecal appendix with a short segment wall thickening of 7 mm and no significant fat stranding suggestive of borderline tip appendicitis. When a reevaluation was performed, abdominal tenderness was persistent despite adequate analgesia and hydration; therefore, a diagnostic laparoscopy and laparoscopic appendectomy under general anesthesia was performed. Intraoperative findings revealed a mild hyperemic appendicular tip, which was adherent to the lateral abdominal wall and cecum with minimal hemorrhagic fluid in the pelvis. Her postoperative period was unremarkable, and she was discharged home after 24 h.E. vermicularis eggs were found within the lumen of the appendix. The patient and her family members received 400 mg of albendazole once weekly for three weeks. On her follow-up appointment, she was feeling well with no complaints . They can, however, be swabbed and identified under a microscope without much difficulty. A so-called Scotch tape test, also termed an adhesive cellophane swab, can be performed, even by the infected individual themselves. The test, a sample collection, must be performed first thing in the morning before any washing of the genital area or defecation. Using readily available adhesive tape, with the buttocks spread apart, one can press a small strip several times to the anal and perianal region. The worm eggs are then able to be identified microscopically by affixing the tape, adhesive side down, to a slide .Appendicitis is caused by obstruction of the appendiceal lumen, which leads to the increase in the intraluminal pressure, followed by inflammation caused by bacterial overgrowth, and probably ischemia and rupture without surgical intervention. Fecal stasis, fecaliths, lymphoid hyperplasia, vegetable residues, fruit seeds, and tumors are considered as the most common etiologies of appendiceal lumen obstruction ,20.Ascaris lumbricoides, Trichuris trichura, and Taenia species, have been reported as possible causes of acute appendicitis. The most common helminth reported among them is E. vermicularis [E. vermicularis was detected histopathologically in 0.3–4% of surgically removed appendixes [E. vermicularis, which is a low rate, but one that proves the occurrence [E. vermicularis and appendicitis is controversial. Despite years of study into the relationship between E. vermicularis and the pathogenesis of appendicitis, how influential this parasite is to induce inflammation is still unclear. Although it may have a role in causing appendiceal discomfort or appendiceal chronic inflammation following obstruction, the majority of cases have not shown acute inflammation. Enterobius infection can cause diseases like acute appendicitis, chronic appendicitis, ruptured appendicitis, gangrenous appendicitis, and perforation, resulting in peritonitis [E. vermicularis was lymphoid hyperplasia [Different intestinal helminths, namely icularis . Studiespendixes . In a recurrence . The assitonitis . Nevertherplasia .E. vermicularis eggs within the lumen of the appendix was the only pointer towards the cause. Therefore, even though it is rare, E. vermicularis should be noted as one of the differential diagnoses for the commonly presented condition of acute appendicitis, as parasitic appendicitis requires a high index of suspicion and can easily be overlooked in low-prevalence regions [E. vermicularis and acute appendicitis. These case reports from across the globe reported the incidences of acute appendicitis, the causes of which were attributed to Enterobius vermicularis upon the detection of either the parasite at the time of the operation or on the histopathological examination. The age ranged from 5 to 31 years of age, and the modality of treatment was appendicectomy and the use of anthelminthics.It has been well established that acute appendicitis is more prevalent in children and adolescents , like in regions . Table 1E. vermicularis, the need to treat close household contacts to prevent the transmission and possible complications as stated above, is however, an unexplored field.Laparoscopic appendectomy remains the treatment of choice for acute appendicitis. However, evidence has been mounting towards the use of broad-spectrum antibiotics, such as piperacillin–tazobactam monotherapy or combination therapy with either cephalosporins or fluoroquinolones with metronidazole, which has successfully treated uncomplicated acute appendicitis in approximately 70% of patients. The imaging findings have been sorted to categorize these patients, with CT showing an appendiceal dilatation , or the presence of appendicoliths, which has been defined as the conglomeration of feces in the appendiceal lumen and was identified patients for whom an antibiotics-first management strategy was more likely to result in failure. Therefore, for these group of patients who are fit for surgery, defined as having a relatively low risk of adverse outcomes or postoperative mortality and morbidity, appendicectomy was recommended. But in patients without the above-mentioned high-risk CT findings, either appendectomy or antibiotics were considered as the first-line therapy. Even in those patients with high-risk CT findings, who were rendered as being unfit for surgery, the antibiotics-first approach was recommended, and surgery was considered if the antibiotic treatment were to fail . SimilarE. vermicularis infection in the right circumstances where the patient has a high worm burden that can cause appendiceal lumen obstruction and eventually acute appendicitis, the mere presence of E. vermicularis alone in the appendix may otherwise only cause a local irritation, which leads to lymphoid hyperplasia but not diagnosable appendicitis. Enterobiasis can mimic the clinical picture of acute appendicitis without the inflammation of the appendix. As observed in this case, most patients who presented with a clinical picture of acute appendicitis where E. vermicularis was found in their appendix had normal inflammatory markers, and their appendix showed lymphoid hyperplasia. This could imply that the presence of E. vermicularis might actually only mimic acute appendicitis. There is perhaps a need to assess for the presence of E. vermicularis prior to appendectomy, especially if the patient has normal inflammatory markers and is clinically stable. This could lead to the avoidance of unnecessary surgeries and their possible associated complications by simply treating their E. vermicularis infection. However, this is just a possibility, and this theory requires further discussions in the future to come to a unified protocol on how to treat cases of suspected appendicitis.Hence, to conclude, though real, genuine appendicitis can still potentially be caused by


Sarcoidosis is a benign systemic disease; its diagnosis is based on a suggestive radiological presentation, and the isolation of an epithelioid and gigantocellular granuloma (EGGC) without caseous necrosis with the elimination of other causes of granuloma. However, sometimes the radiological presentation is atypical and misleading, posing problems in terms of differential diagnosis. In this report, we present a case of pseudotumor sarcoidosis, in which MRI played an essential role in characterizing the lesion and suggesting its benignity. We also discuss the role of MRI in evaluating atypical forms of sarcoidosis. Sarcoidosis is a benign, systemic disease of unknown cause characterized by epithelioid and gigantocellular granuloma (EGGC) infiltrates without caseous necrosis . While iThe patient was Mrs. F, a 56-year-old female who consulted for a chronic dry cough complicated by exertional dyspnea evolving for one year without extra-respiratory signs; she had no comorbidities or any risk factors, being neither a smoker nor professionally exposed. Her general condition was found to be well. The thoracic CT scan Figure  revealed2/s, reflecting its hypocellular character and thereby indicating a benign lesion. A scan-guided biopsy was performed, which confirmed the benign nature of the process; it was ultimately found to be a non-necrotizing granulomatous lesion mimicking sarcoidosis in its tumoral form. The patient underwent a sarcoidosis workup to look for other localizations, as well as a functional impact assessment.The MRI showed a right upper lobar tissue mass with multiple nodules without diffusion restriction Figures , 3; thisSarcoidosis is a systemic disease of unknown cause, characterized by infiltration of affected organs by epithelioid and gigantocellular immune granulomas  without caseous necrosis. It is epidemiologically heterogeneous and its clinical presentation is variable. It can affect the whole body, but mediastino-pulmonary involvement is by far the most frequent, present in about 90% of patients, and isolated in half of the cases . It affeRadiological abnormalities are most often suggestive, and sometimes the only manifestations of the disease discovered by chance on a chest X-ray. This allows the disease to be classified into four stages. CT is more sensitive than the standard X-ray in terms of characterizing the observed abnormalities. It can better describe the elementary lesions as well as their anatomical distribution. Contrast injection is useful to analyze adenopathies. The CT findings can be extremely variable, ranging from typical aspects because of their frequency and the lymphatic distribution of the lesions to atypical aspects that are less frequent and pose problems of differential diagnosis.The most frequently found lesions are diffuse micronodules of lymphatic distribution predominantly in the middle and upper parts of the lungs, as well as adenopathies that are bilaterally symmetrical and non-compressive . In someDiffusion MRI is a technique that can measure molecular diffusion in vivo. It allows calculating at each point of the image the distribution of the diffusion directions of water molecules. The movement of these water molecules depends on both the integrity of the cell and the cell density. ADC is a parameter that refers to the specific diffusion capacity of a biological tissue, which has been shown to be useful in differentiating a benign mass from a malignant one. ADC is inversely proportional to cellularity; tumors generally have a higher cell density. However, no consensus has been reached regarding the optimal threshold value of ADC between benign and malignant lesions. In a recent meta-analysis, Shen et al.  reportedThe place of MRI in the diagnosis of pulmonary sarcoidosis is not clear at the moment and remains to be defined. According to the case illustrated above, diffusion MRI can be of great help with misleading forms of pulmonary sarcoidosis, especially in pseudotumor forms, by showing the benign character of its lesions, which allows us to rule out the main differential diagnosis in this case, which is related to the tumor origin. The evolution of these lesions is most often towards resolution either spontaneously or with treatment.The spontaneous evolution of pseudotumor forms of sarcoidosis is unpredictable. In some series, the evolution was spontaneously favorable with a radiological clearance time ranging from one to two years . In BattThe diagnosis of pseudotumor pulmonary sarcoidosis is often difficult. Discordance between the discreteness of the clinical presentation and the extent of the radiological lesions should, however, help with the diagnosis. Histological evidence is necessary to rule out other etiologies, especially tumors. Thoracic MRI with diffusion is a non-invasive and non-irradiating diagnostic tool that can predict the benignity of these tumor lesions. However, the definitive role of this examination remains to be defined in this context.


Primary hyperparathyroidism (PHPT) in pregnancy is a rare condition. Because of gestational physiologic changes, it is easily under-recognized; in some cases, patients may remain symptomless while maintaining high serum calcium levels, posing a risk to the health of both mother and fetus.Our patient is a pregnant woman in her 30th week of gestation admitted to the hospital with typical features of acute pancreatitis. All possible causes of acute pancreatitis were ruled out. Further investigation, including neck ultrasound, revealed a hypoechoic, well-defined, heterogeneous, and vascularized lesion measuring 1.9×1.7 cm, seen posterior to the left thyroid lobe and mostly representing a parathyroid adenoma. The patient was diagnosed to have a PHPT as the etiologic factor and underwent a successful parathyroidectomy after the failure of medical treatment.Pregnancy-related parathyroid disease is uncommon. Several changes in calcium-regulating hormones occur during pregnancy, making the diagnosis of PHPT noticeably challenging. Therefore, serum calcium levels must be closely monitored during pregnancy for optimization of maternal and fetal outcomes. For the same reason, the appropriate management of gestational PHPT is mandatory, either medically or surgically. HighlightsHypercalcemia-induced acute pancreatitis due to primary hyperparathyroidism is a rare but serious and life-threatening medical condition during pregnancy.Gestational primary hyperparathyroidism is a rare condition that can be misdiagnosed; it poses a risk to the mother’s and fetus’s health.To optimize maternal and fetal outcomes, early diagnosis and medical and/or surgical management are mandatory.Primary hyperparathyroidism (PHPT) is caused by an excessive abnormal production of parathyroid hormone (PTH) by one or more parathyroid glandsA 31-year-old female patient, gravida 4, para 3, presented at her 30th week of gestation for epigastric pain. The pain was gradual in onset, epigastric, progressive, and constant, radiating to the back with no relieving factors, of 2 days’ duration, and associated with nausea and vomiting once of normal gastric content. She denies any fever, previous similar attacks, or any other complaint. The patient reported no personal and/or family history of cancer; any acute, repeat, or discontinued medications; any allergies; or any genetic or psychosocial issues. Past medical and surgical histories were free. On physical examination, the patient was fully conscious, alert, and oriented, with stable vital signs, a gravid abdomen, soft laxity with severe epigastric tenderness, and voluntary guarding. Laboratory tests showed leukocytosis with a left shift (12 800/μl with 88% neutrophils), alanine aminotransferase of 13 U/l, aspartate aminotransferase of 27 U/l, alkaline phosphatase of 313 IU/l, direct bilirubin of 0.3 mg/dl, total bilirubin of 0.9 mg/dl, and 10 times elevated amylase of 1383 IU/l. Pancreatitis was diagnosed based on the clinical presentation and laboratory findings. The patient was kept NPO  with pain control medications and intravenous (i.v.) fluids. While investigating the etiology of pancreatitis, an ultrasound of her abdomen showed an enlarged liver with a 19 cm span at mid-clavicular, regular contour, normal echotexture, and no dilatation of intrahepatic biliary ducts. Gallbladder is normally distended, with no stones or thickening of the walls. Common bile duct is not dilated. The visualized proximal parts of the pancreas appear edematous and echogenic and measure 3.5 cm. However, her calcium level was found to be significantly elevated, with a value of 11.7 mg/dl with low serum phosphorus and magnesium levels of 1.2 and 1.16 mg/dl, respectively, and a serum albumin level of 2.5 g/dl. PTH levels were elevated at 701 pg/ml and 25-hydroxyvitamin D levels were 21 ng/ml. Based on the above-mentioned results, PHPT was identified, and the resulting hypercalcemia was thought to be the underlying pathologic agent of her acute pancreatitis. A neck ultrasound revealed a well-defined heterogeneous, mostly hypoechoic, solidly vascularized lesion measuring 1.9×1.7 cm, seen posterior to the left thyroid lobe and mostly representing a parathyroid adenoma. The right thyroid lobe shows a well-defined spongiform nodule measuring 1×0.6 cm and a tiny pure cyst; otherwise, the left thyroid lobe is normal in size and echotexture, with no enlarged cervical lymph nodes  had parathyroidectomy while pregnant, while 274 cases (71.7%) were treated nonsurgically. The majority of surgeries (67.6%) were performed during the second trimester. Complications and/or deaths were less likely to occur after second-trimester surgery (4.48%) compared to third-trimester surgery (21.1%). Despite the fact that nine surgically treated cases resulted in infant complications and/or death, none of these nine cases had any surgical complications. Despite these complications, the overall infant complication rate for surgical patients remained lower than that of conservative therapy patients (9.1% versus 38.9%)The diagnosis of PHPT in pregnancy is rare and challenging since most cases are mild and asymptomatic (80% of cases). With the exception of normal physiological changes in pregnancy , the diagnosis is similar to nonpregnant patients. Alternatively, ionized calcium does not change significantly with pregnancy and may represent a better assay to assess serum calcium levels during pregnancyThe biochemical diagnosis of PHPT is based on elevated serum albumin-adjusted calcium concentrations or elevated serum ionized calcium concentrations with an inappropriately normal or elevated PTH concentrationInternational guidelines recommend parathyroidectomy in patients below the age of 50 years; usually conservative treatment options including oral and i.v. rehydration and cinacalcet should be temporary until surgery. Cinacalcet has been used in several pregnant women without significant safety concerns, but safety evidence are still considered insufficient for official approval. Safety concerns argue against the use of bisphosphonates regarding its effects on fetal bone development. Subcutaneous calcitonin does not cross the placenta and can help reduce maternal calcium levels, but its benefits are often short-lived because tachyphylaxis soon developsIn summary, hypercalcemia due to PHPT is a rare but serious and life-threatening medical condition that is likely underdiagnosed in pregnancy, in which prompt diagnosis and aggressive treatment are important to prevent maternal, fetal, and neonatal consequences. Surgical treatment is associated with better outcomes compared to conservative management. In this case study, we affirm the significance of early detection and management of PHPT during pregnancy.Our institution has exempted this study from ethical review.Written informed consent was obtained from the patient for the publication of this case report. A copy of the informed consent is available for review by the Editor-in-Chief of this journal on request.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.A.M., M.A., K.A., and O.N.S.: writing the manuscript; A.K.: imaging description and reviewing and editing the manuscript.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.None.Oadi N. Shrateh.Not commissioned, externally peer-reviewed.All authors attest that they meet the current ICMJE criteria for authorship.


Small bowel bleeds, while uncommon, are often challenging with regard to diagnosis and therapeutic intervention. This is primarily due to their occult nature, the location offending lesions and limitations of current technology used to assess them. This review highlights two patients who presented with signs and symptoms of a small bowel bleed, where initial diagnostic workups were inconclusive, and intraoperative enteroscopy served a diagnostic and therapeutic role. We discuss the current literature on intraoperative endoscopy and propose an algorithm that introduces intraoperative enteroscopy earlier as a viable curative option, particularly in a rural setting. This case series proposes considerations for earlier introduction of intraoperative enteroscopy for diagnosis and treatment of small bowel bleeds. Small intestinal bleeds are relatively uncommon, only accounting for 5–10% of gastrointestinal (GI) bleeding [et al. and Pat et al. Such studies have identified IOE as an important technique for the diagnosis and guidance of management in small bowel bleeding for patients where previous workup was inconclusive or could not be performed [IOE is considered an invasive procedure used to evaluate the small bowel during surgery, requiring an endoscopist and surgeon. Although it has a high diagnostic yield, IOE is associated with a morbidity and mortality  . These rerformed . It is terformed . As suchPatient 1 was a 70-year-old female with breast cancer  diagnosed in 2019, currently undergoing chemotherapy via a left chest port. She presented to the ER for a syncopal episode. She recently underwent port placement 2 weeks prior to presentation and received her first cycle of chemotherapy 5 days prior, which she did not tolerate well. She reported severe generalized weakness, joint pains and nausea since treatment, and one episode of emesis just before admission. Her hospital stay was complicated by declining renal function, melena and down trending hemoglobin, necessitating multiple transfusions of platelets and packed red blood cells (PRBCs). Esophagogastroduodenoscopy (EGD) showed an esophageal ulcer and gastroduodenitis, and colonoscopy revealed old blood in the terminal ileum without evidence of active bleeding or mucosal lesions. Despite a negative Meckel’s scan and mesenteric CT angiogram showing no evidence of mesenteric bleeding, her hemoglobin continued to decline to 5.3 on hospital day 20, at which time the patient received two units of PRBCs. Abdominal CT with oral contrast showed mild extravasation in the jejunal loop  and b. ADue to persistent melena and down trending hemoglobin despite multiple transfusions, general surgery was consulted. Upon exam, the patient just had a large bowel movement with melena and multiple blood clots and was complaining of moderate abdominal cramping and diffuse abdominal tenderness to palpation without guarding or peritoneal signs. She was hemodynamically stable after receiving blood products, and the decision was made to perform a diagnostic laparoscopy/laparotomy, hand-assisted PE and possible small bowel resection. Intraoperatively, two bleeding nodules in the jejunum were identified and resected. No intraoperative or postoperative complications were noted, estimated blood loss was 10 ml and the patient was discharged on postoperative day 2. Final pathology identified normal small bowel mucosa with multiple foci of arteriovenous malformations (AVMs) without any evidence of malignancy. On 2-week postoperative follow-up, the patient presented with no signs of infection or postoperative complications and return of normal bowel function. She reported complete resolution of melena and no further syncopal episodes.Patient 2 was a 57-year-old male with no pertinent medical history who presented with persistent iron deficiency anemia despite prior negative findings on upper endoscopy and colonoscopy. At this time, the patient was hemodynamically stable and without any acute symptoms of anemia, melena or hematochezia. A CE was then performed and identified a distal jejunal mass. An attempt to reach the mass via spiral enteroscopy was unsuccessful, and an India ink tattoo was placed at the most distal location possible. The patient was then taken for a diagnostic laparoscopy/laparotomy, push small bowel enteroscopy and small bowel resection. During the procedure, the jejunal tattoo was identified ~60 cm distal to the ligament of Treitz. Manual advancement of the small bowel directly over the enteroscope identified a pedunculated lesion in the small bowel lumen 40 cm distal to the tattoo. The lesion was then resected and taken for pathology. No intraoperative complications were noted and estimated blood loss was ~10 ml. No postoperative complications were noted, and the patient was discharged on postoperative day 2. The final pathology showed a hamartomatous polyp with smooth muscle core and lobular architecture, which was diagnostic of Peutz-Jeghers syndrome. At the 2-week postoperative follow-up, the patient showed no signs of infection or postoperative complications and had returned to normal bowel function. Final pathology report noted findings consistent with a hamartomatous polyp with no concerns for malignancy.The same surgical approach was used for each patient. After laparoscopic exploration of the abdomen and lysis of adhesions where necessary, a PE and subsequent small bowel resections were performed. An upper midline incision was made, and the bowel was eviscerated. Simultaneously, the gastroenterologist began by advancing the upper endoscope orally to the max distance of scope, ~50–60 cm within the small bowel. The remainder of the small bowel was advanced manually to the ileocecal valve using the scope to visualize the lumen and external mucosa of the bowel in both anterograde and retrograde fashion  and b.During antegrade push and retrograde pullback, dual visualization of the small bowel by the endoscopist intraluminally and by the surgeon externally with the transilluminated bowel was performed . Once thet al. refer to malignancies initially missed on CE, which were later identified on further imaging studies such as CT or MR enterography (CTE or MRE) [Evaluation for deep small bowel bleeding requires both a trained endoscopist and the technology available to rapidly identify the ongoing bleed. This can prove difficult for patients who present to rural hospitals, where resources such as CE or spiral enteroscopy might not be readily available. In addition to these barriers, the use of a spiral and PE carries a greater risk of perforation compared with normal endoscopy and is often unable to reach the source of bleeding past the proximal jejunum . On the  or MRE) , 7. Withet al. published data in support of the IOE in the diagnostic workup of small bowel bleeds. The study identified that IOE helped establish a diagnosis in an additional 31% cases with a negative preoperative workup and changed the management in 37.1% patients by locating new or additional lesions. This study identified improved statistics regarding the use of IOE compared with previous studies of its kind, presenting a diagnostic yield of 91.3% in small bowel bleeding [The diagnostic yield of IOE in small bowel bleeding is reported to be between 56 to 88%, compared with that of VCE and simple PE, 56–66.6% and 25–56%, respectively [Four main factors should be evaluated when considering the use of IOE in the management of suspected small bowel bleed: (i) stability of the patient, (ii) occult versus overt bleeding, (iii) resources available, (iv) how will diagnostic test results impact further management . Figure As an invasive procedure requiring general anesthesia, IOE carries greater risks than the previously mentioned diagnostic methods, but, overall, is a safe procedure that can be performed by a general surgeon and endoscopist. Despite their varying level of acuity and comorbid conditions at presentation, both patients received the same treatment, because they reached a point in the algorithm in which the benefits outweighed the risks of IOE. Understanding the place of intraoperative PE is especially important in the treatment of unstable patients and those presenting in a rural setting where access to deep enteroscopy technology and trained specialists is limited.


Appendiceal tumors are incidentally detected in 0.5% cases of appendectomy for acute appendicitis and occur in approximately 1% of all appendectomies. Here, we report two cases of appendiceal collision tumors in two asymptomatic women. In both cases, imaging revealed right-lower-quadrant abdominal masses, which were laparoscopically resected. In both cases, histological examinations revealed an appendiceal collision tumor comprising a low-grade appendiceal mucinous neoplasm and well-differentiated neuroendocrine neoplasm (NEN). For complete oncological control, right hemicolectomy was performed in one patient for the aggressive behavior of NEN; however, histology revealed no metastasis. The other patient only underwent appendectomy. No further treatment was recommended. According to the latest guidelines, exact pathology needs to be defined. Proper management indicated by a multidisciplinary team is fundamental. Primary appendiceal tumors are rare entities in heterogeneous group of tumors, with an incidence of approximately 1.2 case per 100,000 people annually in the United States .When tumor components are composed by two adjacent, different but separate neoplasms from 2 different cellular lines, they are called collision tumor , 4. AppeA 49-year-old Caucasian woman with no significant medical history visited an ambulatory gynecology clinic for a routine check-up. Transvaginal ultrasonography revealed an oval mass with a mixed content measuring 74 mm × 44 mm in diameter, suggesting a dermoid cyst or an ovarian fibroma. Abdominal magnetic resonance imaging (MRI) also described a tumor close to the right ovarian gland (69 mm × 40 mm × 46 mm), with contrast enhancement in the arterial phase and clear margins afterward and a small nodulation inside . MetastaA 59-year-old Caucasian asymptomatic woman underwent an abdominal ultrasound which revealed a right pelvic mass. Her Ca-125 value was 3.2 U/ml . Abdominal MRI revealed a cystic oval mass [diameters 3.7 cm × 4.5 cm × 6.4 cm; hyperintense in T2-weighted images  and hypoGross morphology of the resected specimen showed a 9 cm-long cyst-like dilated appendix measuring 6 cm in diameter. The appendix was filled with thick mucus. Histologically , the speAppendiceal tumors are extremely rare entities, usually detected incidentally following an emergent appendectomy for acute appendicitis in approximately 1% .Incidental diagnosis of asymptomatic patients in the course of another examination is relatively common, as noted in the two cases described.According to the 5th edition of the WHO classification , appendiThe mucinous tumors of the appendix are categorized into serrated polyps, hyperplastic polyps, LAMNs, high-grade appendiceal mucinous neoplasms (HAMNs), and mucinous adenocarcinomas , 6. MuciMoreover, among the most common types of primary malignant lesion of the appendix are appendiceal NENs, with an incidence of approximately 0.15 per 100,000 people annually . The Ki-Collision tumors results from the proliferation cellular lines. They are two distinct but adiacent neoplasms, retaining a transition between the two. Otherwise, a multidirectional differentiation of cells from a single tumor results in a combined neoplasm , 4.age at diagnosis of patients with appendiceal collision tumors is 43 ± 12 years (23–60 years), with prevalence in women (8/5).The association between mucinous and neuroendocrine appendiceal tumors is an uncommon event with only few cases described . We founClinical presentation is not specific and is characterized by a wide spectrum of findings and symptoms. Patients may have specific symptoms of clinical acute appendicitis or colorectal carcinoma syndrome or even nonspecific symptoms. The diagnosis is usually made incidentally in the course of another examination. Our patients did not report any symptoms, including NEN-related symptoms .The role of tumor markers is still insufficiently defined. An elevated serum carcinoembryonic antigen (CEA) level was reported in 3 cases of the literature , 16, 34.Preoperative diagnosis of appendiceal collision tumor is often incidental because this entity has no special radiological or clinical features . An evenGold standard treatment is surgery for selected case. Laparoscopic approach appears to be a safe and feasible option for not advanced cases . AppendeInitially, we performed a laparoscopic appendectomy with peritoneum biopsy in one case. Through the laparoscopic exploration, a pseudomyxoma peritonei was excluded. Postoperative morbidity was not observed. The effect of two different histological components increases the complexity of therapeutic approach because it is not yet clear whether biological behavior depends on a larger or more aggressive component .Histologic findings are relevant to the prognosis and treatment of patients, and the management of collision tumors is guided by component neoplasms . GeneralThe most important factor for improving the outcome is early and accurate diagnosis with adequate histopathological examination to confirm the presence of two components within the same neoplasm . ImmunohMoreover, adjuvant chemotherapy for collision tumor has not been evaluated in prospective randomized trials. Adjuvant chemotherapy is not recommended for low-grade, well-differentiated mucinous tumors and should only be considered in cancers with invasive features such as lymphovascular or lymph node involvement . PreventIn previous studies, recurrent disease was only found in 3 patients with metastasis at the first operation , 32, 33.Long-term surveillance and follow-up are necessary for both tumor types according to final pathological reports. However, there are no suggested guidelines for an optimal postoperative follow-up .Appendiceal collision tumors are rare diseases; therefore, they continue to be challenging for physicians. Unfortunately, the small sample size of this study does not allow for definitive conclusions to be made. Considering the controversy relating to its deﬁnition, the limited diagnostic ability of biopsies, and the lack of awareness of this diagnosis within the scientiﬁc community, the disease remains underestimated. Currently, no shared guidelines are available. Moreover, the definitive diagnosis can be achieved only after surgery because NEN could be overlooked during diagnosis because of its small dimension. Therefore, each patient must be managed case by case, and a multidisciplinary team, including gynecologists, surgeons, radiologist, oncologist and pathologists with expertise in NENs, is important for appropriate management of patients. This approach involves various health professionals from different organizations to provide utmost care and advanced treatment to patients based on latest available insights into the disease.


A 14-year-old previously healthy male presented with acute onset of esophageal food impaction. Patient endorsed progressively worsening dysphagia for 4 weeks, initially with solids but now with liquids. He denied any other symptoms including fevers or weight loss and had no previous history of allergies, eczema, or asthma. An esophagram at an outside hospital revealed a 7-cm narrowing Fig. A that coPrimary involvement of the esophagus is a rare manifestation of lymphoma, with few published cases in adults and even fewer in children . Less th


Intradural extramedullary tuberculomas are a rare manifestation of tuberculosis that can lead to neurological deficits. We present a case of a 26-year-old male from Myanmar with lower limb weakness and gait disturbance, who was diagnosed with tuberculosis and found to have an intradural extramedullary lesion in the thoracic spine. Prompt surgical intervention was performed to address the lesion located at the T2-4 level. Although complete resection was hindered by strong adhesion, significant improvement in lower limb paralysis was achieved. The elasticity loss of the dura mater posed a challenge in suturing, necessitating duraplasty with a synthetic graft material. This case report emphasizes the potential significance of surgical intervention, including partial excision, in the management of intradural extramedullary tuberculomas. Surgical treatment can play a crucial role in improving neurological outcomes in patients with intradural extramedullary tuberculomas, even in challenging scenarios. Tuberculosis (TB) has been prevalent for a long time and is still an epidemic and problem in both developing and developed countries . TB is aAnother feature of IETSC is that it is known to occur after the administration of anti-tuberculosis drugs. A widely accepted explanation for the progression of TB despite adequate treatment is a paradoxical response to chemotherapy ,10. ThisSurgical intervention is a recognized treatment approach for IETSC, but the existing literature lacks information on the quantity of tuberculoma that is typically removed during surgery, and the extent of resection that is necessary for optimal symptom resolution is still a matter of debate. Here, we present a case of IETSC who developed rapid paralysis after administration of anti-tuberculosis drugs but improved paralysis after partial excision of IETSC. This case adds information to the currently limited literature on the management of IETSC and highlights the potential importance of surgical intervention, even partial resection, in the treatment of this rare disease.A 26-year-old male patient was admitted to our hospital due to the acute onset of weakness in both lower extremities, concurrent gait disturbance, and urinary bladder dysfunction over the preceding three days. He had a history of TB of a one-month duration and underwent anti-tuberculous treatment with rifampicin, isoniazid, ethambutol, and pyrazinamide. On admission, motor power of both lower limbs was 1/5 on manual muscle test (MMT), and both patellar and Achilles tendon reflexes showed clonus.Magnetic resonance imaging (MRI) of the thoracic spine was performed and revealed an intradural extramedullary lesion posterior to the spinal cord at the T2-4 level. The lesion showed hypointense on T1-weighted imaging (T1WI) and hyperintense on T2-weighted imaging (T2WI). Intramedullary signal intensity changes suggestive of edema were seen in the spinal cord at the level of the lesion Figures -1C.A diagnosis of lower limb weakness and bladder dysfunction secondary to the tuberculoma was made, and surgery was promptly performed. Total laminectomy from T1 to T5 was performed to expose the dura mater. An incision was made through the dura mater, revealing a white-yellow hematomatous lesion under the arachnoid membrane. The arachnoid adhered to the lesion, and cerebrospinal fluid did not drain even when the arachnoid was incised. The solid lesion was attached to the spinal cord on the dorsal side Figure . The lesHistological analysis showed that the granulomatous structures were formed and proliferated by epithelial-like histiocytes. Infiltration of lymphocytes and plasma cells was observed and Langhans giant cells were also observed Figure .During the surgical procedure, a specimen from the tuberculoma was acquired and subjected to analysis via an acid-fast smear in order to ascertain the presence of Mycobacterium tuberculosis. Based on the positive result of this analysis, a diagnosis of an IETSC was made. Subsequent to the surgical intervention, the patient was administered a postoperative antituberculosis regimen encompassing rifampicin, isoniazid, ethambutol, and pyrazinamide. Additionally, dexamethasone, a corticosteroid agent, was initiated.Following the surgical procedure, the patient exhibited prompt amelioration in both lower extremity muscle strength and bladder function. After five months, the patient was able to ambulate independently. Informed consent was obtained from the patient for publication.We presented a case of paralysis of the lower limbs due to IETSC during treatment for TB, which required surgery. The excision of the tuberculoma was hindered by the strong adhesion to the spinal cord, resulting in the necessity for a partial resection. However, the postoperative administration of anti-tuberculosis medication and corticosteroids led to a significant improvement in the paralysis of the lower limbs. The dura mater had lost its elasticity, making suture repair difficult. Hence, we employed duraplasty by utilizing a synthetic dural graft material. These findings add to the limited literature on the management of IETSC and highlight the potential importance of surgical intervention, even partial resection, in the treatment of this rare disease. These findings contribute to the existing body of literature concerning the management of IETSC and underscore the potential significance of surgical intervention, encompassing partial resection, as a therapeutic approach for this uncommon ailment.In this case, neurological deficit and spinal cord compression due to a tuberculoma lesion on an MRI scan were found, and the patient underwent urgent surgery. Although medical therapy is the mainstay of treatment, prompt surgical intervention may be warranted for those with significant neurological deficits attributed to cord compression . In pastIn this case, the strong adhesion between the tuberculoma and the spinal cord made it challenging to completely remove the IETSC. However, we were able to improve the patient’s neurological deficits by resecting as much of the tuberculoma as possible and suturing the dura mater with an artificial dural substitute. In the review article of the IETSC, the tuberculoma compressed the cord in all cases and was closely adhered to the cord, leaving no clear plane of cleavage with it, in at least five patients . To the We presented a case of lower limb paralysis caused by IETSC during tuberculosis treatment, necessitating surgical intervention. Despite challenging adhesions limiting complete tuberculoma removal, partial resection resulted in significant improvement in lower limb paralysis. In cases characterized by formidable adhesions, achieving complete IETSC removal can be challenging. Nonetheless, our case demonstrates that even partial resection and the use of an artificial dura mater can lead to substantial neurological improvement, shedding light on the management of IETSC where total removal may not always be feasible.


We report a case of a relatively large desmoid fibromatosis that responded completely to tamoxifen as a single drug therapy. A 47-year-old Japanese man underwent laparoscopy-assisted endoscopic submucosal dissection for a duodenal polyp. He developed postoperative generalized peritonitis and underwent an emergency laparotomy. Sixteen months after the surgery, a subcutaneous mass was found on the abdominal wall. Biopsy of the mass revealed estrogen receptor alpha-negative desmoid fibromatosis. The patient underwent total tumor resection. Two years after the initial surgery, he was found to have multiple intra-abdominal masses, with the largest mass measuring 8 cm in diameter. Biopsy revealed fibromatosis, as in the case of the subcutaneous mass. Complete resection was impossible due to the proximity of the duodenum and superior mesenteric artery. Tamoxifen was administered for three years, resulting in complete regression of the masses. No recurrence was observed for the following three years. This case indicates that relatively large desmoid fibromatosis can be successfully treated with a selective estrogen receptor modulator alone and that its effect is not dependent on the estrogen receptor alpha status of the tumor. Desmoid fibromatosis (DF) is a mesenchymal tumor that exhibits aggressive local growth but lacks metastatic potential. Local growth of DF causes pain, limitations in mobility, impairment of organ function, and bowel obstruction . The degA 47-year-old Japanese man was referred to our hospital for a duodenal polyp detected on esophagogastroduodenoscopy. His medical history included hyperlipidemia and colorectal polyps. The patient had no family history of familial adenomatous polyposis. A biopsy of the polyp revealed an adenoma. Laparoscopy-assisted endoscopic submucosal dissection (ESD) was performed. Histological examination of the resected specimen revealed tubular adenocarcinoma in the duodenum. He developed ESD-related duodenal perforation and generalized peritonitis on the ninth postoperative day. We performed an emergency laparotomy, closed the perforated duodenum, and placed drains. He was treated percutaneously for a residual abscess and discharged 42 days after the initial surgery.The patient underwent outpatient follow-up, including periodic computed tomography (CT) examinations. Sixteen months after the surgery, a subcutaneous mass was noticed on the abdominal wall of the left hypochondrium, which was at the site of the surgical wound Figure .A needle biopsy of the mass revealed DF. The patient underwent complete tumor resection. Immunohistochemical analysis indicated that the tumor was negative for ERα and progesterone receptor (PR) but positive for β-catenin Figure .Two years after the initial surgery, multiple intra-abdominal nodules were detected on a CT scan Figure , the larThe uptake of 18F-fluorodeoxyglucose in these masses during positron emission tomography imaging was low, with a maximum standardized uptake value of 4.1 . This case report highlights two important clinical issues. First, relatively large abdominal DF can be treated with an SERM alone. Second, the expression of ERα in the tumor may not be related to the effectiveness of SERMs.SERMs have been used as systemic therapy for DF. In a review of 168 patients with DF, the overall response rate (ORR) to SERMs was 51%. However, this review did not report the CR rate . In a laThe literature on the association between hormone receptor expression and clinical outcomes is limited. Most studies have shown that DF is ERα negative -10. ThesAlthough the surgery was the primary treatment modality for DF before 2000 , non-opeWe encountered a case of ERα-negative DF, measuring 8 cm in diameter, treated with an SERM alone. This case study indicates that DF with one poor prognostic factor (tumor size >7 cm) can be effectively treated with non-surgical interventions and that the absence of ERα in the tumor does not predict the efficacy of SERMs. Even in relatively large DF, SERMs are one of the most effective therapeutic options with few side effects.