A 73-year-old female patient presented with small bowel obstruction and underwent an emergency right hemicolectomy for a caecal mass.
The patient had multiple comorbidities: chronic obstructive pulmonary disease, hypertension, deep vein thrombosis, non-ST-elevation myocardial infection, coronary artery bypass graft, osteoarthritis and a hiatus hernia. The patient was a current smoker with a 13-pack year history and minimal alcohol consumption.
Post-operative histology described a poorly differentiated caecal adenocarcinoma with clear resection margins and 4/20 regional nodes involved (TNM staging, T4N2M0). The colorectal multidisciplinary team (MDT) meeting recommended adjuvant chemotherapy to reduce the risk of cancer recurrence and treat any micro-metastatic disease. The recommendation was to complete eight cycles of capecitabine (130mg/m
2) and oxaliplatin (1000 mg/m
2 twice daily) chemotherapy over six months. Unfortunately, the patient only completed one cycle, declining further treatment due to the severity of side effects.
At one-year follow up, colonoscopy and a computerised tomography (CT) abdomen demonstrated no evidence of recurrent disease. Three years later, on surveillance imaging, para-aortic lymph node metastases were detected on positron emission tomography (PET) scanning. The patient underwent external beam para-aortic radiotherapy 50.4 Gy in 28 fractions, which was well tolerated, and was discharged to regular surveillance.
Three years later, a rapidly enlarging painless left-sided neck lump was detected. There was no dysphagia, odynophagia, dysphonia, loss of appetite or weight loss. On examination, there was a palpable small level IV neck lump which was smooth, non-fluctuant and non-tethered to underlying structures.
Routine blood tests, including full blood count, liver function and renal function, were unremarkable. Carcinoembryonic antigen, a tumour marker for colorectal carcinoma, was elevated at 24.0 mg/L (normal range <2.5 mg/L).
Ultrasound of the lump showed a 6-mm level IV cervical lymph node with intranodal calcifications, loss of hilar architecture and increased vascularity suspicious for malignancy.
Cytology from fine-needle aspiration of the node under ultrasound guidance showed clusters of atypical cells with pleomorphic nuclei and a moderate amount of cytoplasm. Immunohistochemical analysis of the cell block preparation showed cells which were positive for cytokeratin AE1/AE3 and CDX2. AE1/AE3 is an antibody-based assay which reacts with epithelial based tissues, and CDX2 is an intestine-specific transcription factor that is highly sensitive and specific for adenocarcinomas of intestinal origin
.
Whole-body PET-CT showed elevated tracer uptake in an 8.4mm left level IV LN, and in a second 7-mm left supraclavicular lymph node with no further evidence of thoracic or abdominal recurrent disease (See
).
In the post-cancer-treatment surveillance context of this patient, any new, persistent lymphadenopathy should stimulate a high degree of diagnostic suspicion and investigations should be suitably intensive.
In the general population, the considered differential is broader. A ‘Surgical Sieve’ approach is useful in diagnosing a neck lump. The authors find the mnemonic VITAMIN-C particularly helpful (see
).
Following a thorough history and examination, the principal method of investigating a neck lump is through ultrasound imaging and if suspicious, a fine-needle aspiration or core biopsy.
Reactive lymph nodes have a different ultrasound appearance to malignant ones which are typically larger and more spherical in shape. An irregular border indicating extracapsular spread, hypo-echogenicity, macrocalcifications, intranodal necrosis and peripheral vascularity are all pathological features concerning for malignant disease
. Further imaging with CT, PET-CT, or MRI is useful in defining the lesion, staging disease and in radiotherapy planning.
On day 35 following re-presentation, the patient was discussed at the Head and Neck Cancer MDT in conjunction with the Colorectal Cancer MDT, the recommendation was made for a selective neck dissection of levels 2, 3, 4, and 5. The surgery went without complication, and the patient was discharged the following day.
Histology from the dissection showed 6/20 lymph nodes with metastatic deposits of poorly differentiated adenocarcinoma. There was with evidence of intracellular mucous and positive staining for CK20 and CDX-2. Immunohistochemical analysis confirmed an intestinal origin (
).
The patient recovered well from the neck dissection, and at two-month review, the patient was disease-free and asymptomatic.
At two-year review, the patient had developed some intermittent abdominal discomfort. CT imaging revealed small volume retroperitoneal and pelvic lymphadenopathy. Since she had previously received radiotherapy to the area, the oncology team felt that the only treatment they would recommend would be chemotherapy; however, the patient declined because of side-effects and her comorbidities. She remains under three-monthly surveillance in the outpatient department.


We present a case of a 36-year-old Asian female who initially noticed a right breast lump. She was reviewed by the breast surgeons and biopsy confirmed triple negative (estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2) breast cancer. Ultrasound-guided biopsy of the right axillary node was negative. Neoadjuvant FEC-D chemotherapy was commenced together with monthly goserelin as ovarian protection with eight cycles given in total. She also received granulocyte colony-stimulating factor (G-CSF) to prevent neutropenia.
She tolerated the FEC-D chemotherapy well apart from an episode of grade 1 thrush and migraine. This was treated with nystatin, fluconazole, and co-codamol. She also attended the accident and emergency department for urinary tract infection and was prescribed trimethoprim. She was not on other medications at that time. She received adjuvant two-field radiotherapy and a boost to increase the amount of radiation delivered to the area at highest risk of breast cancer recurrence. She underwent wide local excision and sentinel lymph node biopsy 5 months after initiation of chemotherapy.
The patient noticed dark pigmentation of her left thumb nail a few days after the second cycle of chemotherapy. Over the next few months, the linear pigmentation on her thumb nail became darker. She denied pain, bleeding, or preceding history of trauma. There was no toenail involvement. She did not have any previous skin disease including psoriasis or lichen planus.
On presentation to the dermatology department, the left thumb nail pigmentation was linear, uniform, and well demarcated extending from proximal nail fold to free margin (Fig. a, b). Hutchinson’s sign was negative. No other nails were involved, and no rash noted elsewhere. There was no pigmentation of the oral mucosa. Patient was otherwise clinically well. Blood tests including full blood count, renal profile, liver function test, HbA1c, thyroid function test, erythrocyte sedimentation rate, lipid profile, coagulation profile, B12, folate, iron studies, phosphate, and magnesium were all in the normal range.
At 12-month follow-up after initial review, the appearance was stable and was suggestive of striate melanonychia. At 24 months follow-up, the changes remained stable. Despite the reassuring clinical features, the patient was understandably anxious whether this might be a presentation of acral melanoma given her history and was referred to the plastic surgeons for a nail matrix biopsy. Biopsy reassuringly was reported as melanosis (Figs. , , ). Figures and show evidence of central pigmentation which was confirmed as melanin with positive staining with Masson Fontana (Fig. ). There is no evidence of significant atypia noted.
Striate melanonychia in this lady was felt most likely due to the synergistic effect of chemotherapy drugs compounded with racial predisposition. Chemotherapy agents most likely to have contributed include cyclophosphamide, docetaxel, epirubicin and 5-fluorouracil (Tables and ) [, ].


A 47-year-old female, presented to the emergency department with right upper quadrant pain, vomiting and fever for two days. She was previously known to have gallstones and was awaiting cholecystectomy for recurrent biliary colic. On examination, she was found to be tender in right upper quadrant with minimal rebound tenderness. Her liver function tests on admission showed total bilirubin 12.4 umol/L (2.0-21 umol/L), alanine aminotransferase (ALT) 25 IU/L (5-33 IU/L), gamma-glutamyl transpeptidase (GGT) 44 IU/L (3-40 IU/L), alkaline phosphatase 78 IU/L (30-130 IU/L), WBC 7.7 x 109 (4-10 x 109) and C-reactive protein (CRP) 32 mg/L (0-5 mg/L). All other laboratory parameters were within normal limits. Clinical impression of acute cholecystitis was made and ultrasound was done.
Ultrasound revealed a thick-walled gallbladder, gallstones, dilated common bile duct (CBD) with intra and extrahepatic duct dilation; no stone was identified in the CBD (Figure , ).
Following this report a magnetic resonance imaging (MRI) was performed which confirmed a dilated common bile duct but no stones were identified in the common bile duct (Figure ). The patient underwent a cholecystectomy.
Laparoscopic approach was undertaken and the omentum was found to be wrapped around the gallbladder, on mobilization of the omentum, a contained perforation of the gallbladder fundus was identified. Severe fibrosis was noted at the Hartmann’s pouch making it difficult to identify the cystic duct and artery, a dilated CBD was also noted intraoperatively. Due to difficult dissection, gallbladder was opened at the level of the Hartmann’s pouch, stones were removed and a subtotal cholecystectomy was done. A drain was placed in the gallbladder fossa. Apart from the histopathology of the gallbladder the peritoneal fluid (collected prior to gallbladder mobilisation) and bile aspirate were sent for gram stain and culture.
The patient had an uneventful postoperative course and the drain was removed on third postoperative day. However, the bile culture grew Actinomyces naeslundii and as per microbiologist’s suggestion the patient was started on Benzylpenicillin 2.4 gm IV four times a day for two weeks followed by three months of amoxicillin. The peritoneal fluid culture and the tissue culture from the abscess cavity showed no growth and the histopathology reported active chronic cholecystitis.


The patient is a 55-year-old male without any history of smoking or drinking or any special family history. On December 11, 2015, the patient came to our hospital for “eating difficulty without obvious inducement and progressive aggravation for 3 months”. Prior to this, the patient underwent a computed tomography (CT) scan and the esophageal tissue 17 to 31 cm below the upper incisor was removed for biopsy in a local hospital. Subsequently, submucosal lymphoid follicles of the same size were observed. Combined with the results of immunohistochemistry, the diagnosis of non-Hodgkin's lymphoma was not excluded. Therefore, the patient came to our hospital for treatment.
After consultation with the external hospital pathology, we believed that the patient met the diagnosis of T-cell non-Hodgkin's lymphoma, and the original tissue sample immunohistochemistry findings were: CD3 (+), CD7 (+), CD8 (+), CD5 (−), CD20 (−), bcl-6 (−), mum-1 (−), CD10 (−), bcl-2 (−), Kappa (−), Lambda (−), CyclinD (−), CD56 (−), CD138 (−) (Fig. . tif). In addition, CT scan of the local hospital showed that the upper and middle thoracic esophageal walls and mediastinal lymph nodes were thickened and moderately uniformly enhanced (Fig. A-D. tif). Combined with the pathological types, clinical manifestations and imaging data, the patient was finally diagnosed as stage IV esophageal PTCL-NOS with expression of CD3, CD7 and CD8. No obvious abnormal bone marrow image was found in bone marrow puncture.
On admission, the patient had already developed dysphagia without heartburn, epigastric pain, cough, expectoration, dyspnea, chest pain, fever and night sweats. The Eastern American Cancer Cooperation Group (ECOG) performance status of the patient scored 2 points. Laboratory hematology and blood biochemical tests revealed that leucocyte 13.37/L (3.5–9.5/L), neutrophils 11.46/L (1.8–6.8/L), neutrophils percent 85.7% (40%–75%), and albumin / globulin 1.01 (1.2–2.4). No abnormality was found in lymphocyte count, platelet count, serum biochemical test, anti-HIV antibody and hepatitis virus detection, Furthermore, there was no palpable obvious lymphadenopathy, ascites or organomegaly. According to Ann Arbor staging, the disease was grade IIE, the age-adjusted international prognostic index (aa-IPI) was high-intermediate and the prognostic index for PTCL- NOS (PIT) belongs to Group 2.
After 2 cycles of first-line chemotherapy with CHOP regimen (Epirubicin 80 mg d1 + cyclophosphamide 0.6 g d1,8 + vincristine 2 mg d8 + prednisone 100 mg po d1–5), dysphagia worsened and dyspnea occurred. Enhanced CT showed enlarged lesions protruding from the esophagus to the anterior mediastinum, resulting in uniform tracheal compression (Fig. E–H. tif). In order to reduce the life-threatening compression of local tumors, the patients received radiotherapy with a total dose of 48Gy/24f. Upon admission to the hospital after radiotherapy, the patient reported a significant remission of dyspnea, which was later confirmed by enhanced CT scans: the tumor disappeared (the efficacy was evaluated as CR according to RECIST criteria) (Fig. I–L. tif). Subsequently, the patient received gemcitabine 1.6 g d1,8 + oxaliplatin 200 mg d2 for 6 cycles, during which CT showed no signs of recurrence. However, according to the patient's report, mild intermittent dysphagia still existed. Positron emission tomography (PET) revealed hypermetabolic lesions in the esophagus at the thoracic inlet, which were considered a residual tumor (Fig. A. tif). Therefore, we removed part of the tissue through upper gastrointestinal endoscopy for biopsy. Subsequently, the hypermetabolic lesions were pathologically confirmed as necrotic material and superficial squamous epithelial mucosa. This suggests that esophageal stenosis due to tissue edema caused by inflammation after radiotherapy is difficult to distinguish from symptoms of tumor recurrence. After 4 months of anti-inflammatory treatment, the symptoms of dysphagia disappeared and PET showed that the hypermetabolic foci disappeared completely (Fig. B. tif). This further confirms that the hypermetabolic lesions shown by imaging after radiotherapy are not necessarily caused by tumor remnants.
As of October 01, 2020, the patient has been diagnosed with PTCL-NOS for more than 57 months, the progression-free survival (PFS) has reached 27 months and the OS has not reached. Now, the patient is undergoing continuous follow-up. According to the regularity of follow-up, it is concluded that there was better intervention adherence of this patient. In addition, the patient did not have any treatment-related adverse events (TRAE) during radiotherapy.


A 55-year-old male presented in the outpatient clinic with a large and foul-smelling tumor growing out of his left eye since a year ago. The mass was initially a small black nodule on the temporal side of the limbus. Other than complete blindness of the left eye, there were no symptoms related to central nervous, cardiorespiratory, or gastrointestinal system. History ocular trauma, excessive sun exposure, and family with malignancy was denied. Physical examination revealed a baseball-sized irregular mass with dark brown to greyish discoloration protruding out of the left eye socket. The fungating tumor surface was partially covered with necrotic tissue, slough, and blood clot. Computed tomography (CT) scan with contrast demonstrated a mixed density mass with antero-posterior diameter of 7.7 cm and latero-lateral diameter of 7.8 cm, phthisic left globe, extra cavitary stretching of optic nerve, ophthalmic vein, and extraocular muscles (). There was no evidence of distant metastasis from head neck CT-scan, and pulmonary plain radiography.
The patient was reported to display an increasingly abnormal behavior within the last two years with reports of disorganized speech, self-talk, and difficulty in communication. The patient mostly lived alone or by the care of his siblings after his spouse and children left him. There was no history of medical treatment for the tumor or mental illness. The dominant symptoms at the time of admission and during hospital stay were auditory hallucinations, suspicious behavior, and delusion of persecution. The psychiatric assessment confirmed the diagnosis of paranoid schizophrenia (International Classification of Mental and Behavioral Disorders [ICD]-10 Code F20.0). He was prescribed Olanzapine 10 mg daily, Amitriptyline 100 mg daily, Trihexyphenidyl 1 mg daily, and Diazepam 15 mg daily along with routine psychotherapy throughout the hospital stay.
The patient underwent left exenteration and wide excision that include the eye globe, eyelids, retrobulbar soft tissues, and periosteum with tumor-free margin confirmed by intraoperative frozen sections (). The left orbital defect was reconstructed using forehead flap and split-thickness skin graft (STSG) harvested from the left lateral thigh to cover the forehead wound (A). The surgery was performed board-certified specialists: one ophthalmologist, one oncologic surgeon, and two plastic surgeons. Pathologic analysis confirmed the diagnosis of invasive conjunctival melanoma (ICD-Oncology code 8720/3) with evidence of tumor invasion to the retrobulbar vasculature and fat tissue. Frozen sections revealed clear resection margins thus, no nonexcisional adjuvant therapy was applied. To facilitate postoperative drainage, a single 16 French tube was inserted at the posterolateral side of the left orbit.
However, 2 days later it was forcefully pulled out by the patient caused by his paranoid nature. Bilateral arm restraints were applied and additional intravenous Diazepam 10 mg was administered as necessary. Serohemorrhagic fluid was observed to be oozing from the previous drain tract saturating the gauze, requiring daily change. Bulging of the distal flap covering the orbit was noted one-week post-operation necessitating seroma drainage. The drainage was performed twice at day 10 and day 15 before the patient was finally discharged 16 days post-operation under stable psychiatric condition. Post-operation at day 21 showed vital forehead flap and STSG with satisfactory cosmetic results (B). Regrettably, this is the latest information we had regarding his postoperative condition since the patient only managed to came once for postoperative control 7 days after discharge (21 days post-operation).


A 20-year-old teenage boy with abrupt fever, confusion, and epileptic seizures was referred to the Department of Neurology of the Guangzhou General Military Hospital. The patient was otherwise a healthy boy until he had an unusual health status prior to 5 days. Cerebral spinal fluid (CSF) analysis was performed on admission, and the result showed negative Pandy test with a predominance of lymphocytes. Besides, CSF test for Mycobacterium tuberculosis, herpes simplex virus (HSV), cytomegalovirus (CMV), and rubella virus revealed negative results. Two days later, antibody analysis of autoimmune encephalitis was also shown to be normal. Brain magnetic resonance imaging (MRI) showed hypersignal intensity in bilateral frontal as well as temporal lobe.
Next, the patient was diagnosed with encephalitis due to unidentified etiology, and then systemic administration of steroids was given without antiviral treatment. He was prescribed with intravenous methylprednisolone, 1 g/d for 3 consecutive days, followed by 0.5 g/d for 3 days, and then was maintained on 80 mg/d for 2 weeks. Two weeks after admission, the boy showed no sign of improvement. A second brain MRI showed much worsened manifestation of hypersignal in both bilateral frontal and temporal lobe, and a second CSF analysis showed negative results of the pathogen as shown in the first CSF analysis. He was therefore presumed to have “autoimmune encephalitis” by primary neurologists and was prescribed with gamma globulin 25 g/d for 5 days. Later, he had less fever and seizures, and improvements were observed in his oral expression. So, intravenous methylprednisolone administration was gradually reduced and replaced it by oral prednisone of 60 mg/d and then was discharged. One day after being discharged, he had sudden vision loss in his right eye, and then the boy was urgently referred to our hospital.
After admitting in our hospital, the patient’s physical and neurological exams were found to be unremarkable. His best corrected visual acuity (BCVA) showed light perception with correct light location in the temporal region of the right eye (OD), and 20/20 with that of the left eye (OS). Ophthalmological examination of his right eye revealed positive Tyndall (+) and cell (++) in the anterior chamber, with obvious opacity (+++) in the vitreous chamber. The fundus of his right eye showed yellow-white lesions, with narrowing retinal vessels and white-sheath and peripheral hemorrhage. Also several tiny retinal holes that lead to retinal detachment (RD) were observed in the peripheral retina (Fig. a). No remarkable changes were observed in his left eye.
New brain MRI performed in our hospital suggested multiple abnormal signals in the brain parenchyma, which were in accordance with the manifestations of viral encephalitis (Fig. ). So, viral-related retinal disorders were highly suspected in our case. Vitreous humor was obtained through vitreous chamber tapping to perform polymerase chain reaction (PCR) analysis. DNA of HSV-1 virus (9.0 × 106/ml) was identified 5 days after intravitreal antiviral treatment, and the positive results of IgG and IgM antibodies in the blood serology also supported HSV-1 infection, thus confirming the diagnosis of ARN by HSV-1.
Intravitreal administration of ganciclovir (0.4 mg/ 0.1 ml) was immediately performed following vitreous chamber tapping at the time of admission to our hospital. Two days later, the boy was relieved from vitreous opacities (+). Antiviral treatment was therefore considered to be effective, and broad-spectrum antiviral medicine (ganciclovir 250 mg every 12-h) was started intravenously, and then replaced with intravenous acyclovir (500 mg every 8-h) after confirmation of HSV pathogen. As the patient also suffered from RD, his right eye was treated by pars plana vitrectomy (PPV), endolaser and silicone oil tamponade 3 days after admission. During the surgery, a second time intravitreal ganciclovir (0.4 mg/0.1 mg) was given.
The patient received intravenous antiviral treatment for 2 weeks and was discharged with oral antiviral medicine (famciclovir 375 mg twice a day) as planned for 3 to 4 months. On the day of discharge, BCVA was 20/80 OD and retinal edema in his right eye has been greatly relieved (Fig. b). At 5 weeks of follow-up, recurrent vision declination occurred with 20/500 OD due to recurrent RD (Fig. ). Therefore, silicon oil displacement and endolaser were performed to repair the retina, as well as intravitreal ganciclovir (0.4 mg/0.1 mg) was given for third time. The BCVA of his right eye was increased to 20/80 within 3 days after the surgery. Six months later, after removing the silicone oil, the BCVA was shown to be 20/200 OD with complicated cataract.


A 26-year-old Pakistani man presented with fever and vomiting (non-bilious and non-bloody). He had been under treatment in another hospital for the past 2 months. Due to progressive worsening of symptoms, he was kept as an inpatient with a working diagnosis of acute hepatitis A and jaundice and was managed accordingly. A mediastinal mass was incidentally found during a routine chest X-ray (Fig. a, b). A computed tomography (CT) scan was then ordered to characterize the lesion. The CT scan showed a large circumscribed soft tissue density lesion in the anterior mediastinum, extending laterally in the right hemithorax abutting the anterior and right lateral chest wall without evidence of infiltration (Fig. a, b). Superiorly, it was extending into the root of the neck, abutting the posterior cortex of the medial end and compressing the superior vena cava, displacing the ascending and arch of the aorta as well as its major branches, trachea, and esophagus toward the left side. Multiple foci of coarse calcifications were also noted within the lesion. The lesion measured 16.9 × 12.8 × 11.0 cm. The described imaging features suggested the possibilities of a germ cell tumor or hydatid cyst. For surgical resection of the mass, the patient was referred to our hospital. The patient was briefed about the procedure and was taken to the operating theatre for right thoracotomy and tumor resection with an American Society of Anesthesiologists (ASA) score of II. Intraoperatively, a 20.3 × 12.7 cm solid mass filled with green cystic fluid was visualized extending to the right hemothorax. It was not adherent to the lung but had definite adhesions with the hilar structures.
Grossly, the resected mass was encapsulated and measured 17.0 × 12.0 × 11.0 cm. The cut surface was gray white with a whorled-like appearance and foci of calcification and cystic areas (Fig. ). Histologically, a spindle cell lesion is seen with alternating myxoid and hyalinized areas. The shaped cells were arranged in bundles. In areas, myxoid hypocellular areas were identified with few intervening dilated blood vessels and dense collagen bundles (Fig. a, b). Multiple foci of calcifications were visualized at the periphery with collagen rosettes. A few areas also showed a sprinkling of inflammatory cells, predominantly plasma cells. IHC staining was performed, which showed positive reactivity patterns with MUC4 and focally for epithelial membrane antigen (EMA) (Fig. c, d). CD34, anti-smooth muscle actin (ASMA), desmin, and S100 protein stains were negative. The diagnosis was confirmed as LGFMS.
Postoperatively, the patient was kept nil per oral for 6 hours and started on intravenous analgesics and antibiotics. His chest x-ray showed no residual mass, consolidation, pneumothorax, or pleural effusion. He was sent home in a stable condition on the 4th day of surgery and followed in the clinic for 2 months. The patient is free of symptoms and recurrence 22 months after surgery.


A normally fit and well 15-year-old male presents after being pinned between a tree and a car at low speed. He has no loss of consciousness and self-extricates on scene. On arrival, he is alert and haemodynamically stable. He has minor bruising to his upper abdomen and no other external injuries. His abdominal examination is reassuring with no peritonism. His biochemistry is normal with a haemoglobin of 143 g/L and a lactate of 1.2 mmol/L. An abdominal focussed assessment with sonography in trauma (FAST) scan is positive for free fluid. The patient remains stable and proceeds to contrast-enhanced abdominal computed tomography (CT), which reveals small volume haemoperitoneum and a hyperdense focus 45 × 31 × 30 mm between bowel loops left mid-abdomen in keeping with interloop mesenteric haematoma, abutting the base of a 5 cm length of entero-enteric intussusception (). Adjacent small bowel loops are thick walled, with no evidence of obstruction or perforation.
Given his reassuring biochemistry and clinical examination, and with a known benign lead point, the patient is managed conservatively with bowel rest and serial abdominal examinations. He remains pain free for the duration of his hospital stay, and his follow-up haemoglobin and venous gas are unchanged. Tertiary survey reveals no new injuries. He is subsequently discharged from hospital after 48 h of observation, having tolerated a slow diet upgrade and passed a normal bowel motion. He has no abdominal complaints at follow-up 5 months post-injury.


A healthy 37 year old IV gravida II para came to our hospital in 22 + 6 weeks of pregnancy for a second opinion with suspected placenta percreta. She has had two prior caesarean sections (the first one due to breech presentation, the second one planned repeated) and one early abortion followed by curettage. In ultrasound, the placenta praevia totalis of the anterior uterine wall showed distinct signs of placenta percreta with suspected bladder invasion. No myometrium between placenta and bladder and very irregular patterns of perfusion were observed, such as large lacunas and bridging vessels in the interface (Figs. and ). The MRI confirmed the suspected placenta percreta with no valid signs of invading other organs. She was counseled in detail about the serious risks of this diagnosis. Termination of the pregnancy was not an option for our patient. She had the urgent wish to preserve fertility due to unfinished family planning with a new partner. Segmental excision (if possible) or leaving the placenta in situ was planned. For the case of emergency, we also had her consent for hysterectomy, though. At 34 + 5 weeks of gestation, she presented with preterm contractions, secondary caesarean section through a fundal uterine incision after amniotic drainage and exteriorization of the gravid uterus [] was performed in combined neuraxial anesthesia and general anesthesia after birth without complications. Due to high risk of intraoperative bleeding, an arterial line and two 16 G peripheral vein cannulas were placed. Additionally, red blood cell concentrates as well as fresh frozen plasma were provided in theatre and cell savage, and norepinephrine was prepared in case of massive bleeding. Prophylactic tranexamic acid was applied continuously in a dosage of 15 mg/kg/bw during surgery without complications. A healthy boy of 2800 g, Apgar 8/8/8, NapH 7.31 was delivered, estimated blood loss was 500 ml. Due to extensive size of at least 10 × 8 cm of the percrete area, the placenta was left in situ. No transfusions of blood or hemostatic products were necessary and no further postpartum hemorrhage occurred.
The postoperative course remained without complications. She received an antibiotic prophylaxis with metronidazole and cefuroxime, regular blood tests for inflammation parameters and cervical swabs for bacteria were taken and showed no signs of infection, no vaginal hemorrhage occurred. She was discharged into ambulant care on day seven; weekly check-ups for infection and the antibiotic prophylaxis (400 mg of metronidazole two times a day, 500 mg of cefuroxime three times a day, oral application) were continued. Matching the antibiogram of bacteria from cervical swabs, the antibiotic therapy was changed to amoxicillin in the further course.
On day 54, she presented with vaginal bleeding. Blood tests still showed no signs of infection, in ultrasound, the placenta was in situ with reduced perfusion.
The different treatment options were discussed; embolism of the uterine arteries, hysterectomy vs. segmental uterine resection (if possible) or expectant management. On ultrasound examination, the uterus and also the percrete area presented significantly smaller, a surgical approach with uterine preservation (if possible) was planned. The preoperative blood work-up showed a reduced Quick value of 41%, increased d-dimere levels > 20 mg/l (normal range < 0.5 mg/l) and reduced fibrinogen levels of 0.59 g/l (normal range 1.6–4 g/l), so that 1 g of tranexamic acid was administered preoperatively. The hemoglobin level was 13.6 g/dl. Segmental uterine resection was performed and the uterus could be reconstructed. The bladder was not invaded as suspected in ultrasound, but surgical preparation and separation of the bladder wall from placental tissue resulted in a small bladder wall lesion which had to repaired (Figs. and ).
Right from the beginning of the surgery, a diffuse bleeding tendency was observed. The thromboelastometric analysis (ROTEM®, TEM International, Munich, Germany) at the beginning of surgery showed a prolonged clotting time (CT: 126 s (46–83 s)) as well as reduced amplitudes of the fibrinogen related clot formation at different time points [A5: 3 (5–30) mm; A10: 4 (6–21) mm; A20: 4 (6–21) mm; A30: 4 (6–21) mm] in the FIBTEM® Test (Fig. ). These results are in line with the reduced fibrinogen levels of the preoperative blood work-up. Furthermore, the INTEM® and EXTEM® analysis with prolonged clot formation times [CFT INTEM®: 151 (62–130) s; CFT EXTEM®: 178 (46–149) s.], the reduced clotting amplitudes at all time points (A5–A30; Fig. ) as well as the reduced Quick value of 41% in the preoperative blood work-up indicate an impaired coagulation due to fibrinogen consumption and a beginning DIC with a concomitant consumption of clotting factors (Fig. ) []. Hyperfibrinolysis could not be detected; TXA had been administered before, though (Fig. ). Nevertheless, an increased d-dimere level > 20 mg/l in the preoperative blood work-up suggests a sign of initially increased local hyperfibrinolysis before TXA was given. In consideration of the thromboelastometric analysis and the results of the blood work-up accompanied with ongoing intraoperative bleeding, two red blood cell concentrates (RBC) at a further decreasing hemoglobin level of 6.8 g/dl, three fresh frozen plasma units (FFP), prothrombin complex concentrate (PSSB, 1800 IE), 4 g of fibrinogen and tranexamic acid [15 mg/kg body weight (bw)] were administered until the bleeding could be controlled. A continuous application of norepinephrine in a dosage up to 0.2 μg/kg bw/min was temporally necessary for hemodynamic stabilization. Estimated blood loss was 3500 ml.
After surgery, the patient was admitted to the intensive care unit for 24 h without any signs of recurrent bleeding or cardiorespiratory limitations. Coagulation parameters had already normalized 8 h after the operation (Quick value 87%, fibrinogen 2.41 g/l) and the hemoglobin levels remained stable (around 8 g/dl). On day seven, the cystogram showed no persistent bladder lesion, the catheter could be removed. The patient was discharged on the seventh postoperative day (day 62 postpartum) in good health condition. Due to segmental resection of the uterine wall, we did not recommend a pregnancy for the next two years.


A 15-year-old boy was referred to our hospital because of elevated hepatobiliary enzymes and abnormal imaging findings. One week prior, he presented to a nearby hospital with itching (lasting 1 month), jaundice (lasting 2 weeks), grayish white stool, and abdominal pain. He had no remarkable medical and family history; however, he reported food allergies to Rosales and peanuts. On admission, laboratory studies revealed an elevated hepatobiliary enzyme level, with a total bilirubin level of 22.6 mg/dL, direct bilirubin of 16.3 mg/dL, aspartic aminotransferase of 83 IU/L, alanine aminotransferase of 75 IU/L, and alkaline phosphatase of 897 IU/L. Peripheral blood eosinophilia was not observed. Hepatitis B surface antigen, hepatitis C virus antibody, serum tumor markers, and autoimmune antibodies were all negative. Serum immunoglobulin G (IgG) 4 level was within the normal range.
Magnetic resonance cholangiopancreatography (MRCP) performed at the previous medical facility revealed a stricture of the intrahepatic and extrahepatic bile duct (Fig. ). Contrast-enhanced computed tomography (CT) revealed dilatation and wall thickness of the intrahepatic bile ducts. To rule out primary sclerosing cholangitis (PSC), the patient underwent a liver biopsy on the fifth hospital day. The liver biopsy specimen showed no evidence of an onion-skin lesion, a scar replacing the duct, nor malignancy. The patient then underwent upper and lower gastrointestinal endoscopy on the 10th hospital day. There was no evidence of inflammatory bowel disease (IBD); however, because of concerning ulcers on the terminal ileum and the ileocecal valve, the patient underwent intestinal biopsies. The intestinal biopsy specimens showed no evidence of IBD except for intestinal epithelial metaplasia. Furthermore, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) on the 12th hospital day for evaluation of bile duct strictures. ERCP findings revealed a stricture of the left and right intrahepatic and extrahepatic bile duct (Fig. ). A brush cytology of the extrahepatic bile duct stricture and endoscopic nasobiliary drainage was performed. Brush cytology revealed atypical cytology without evidence of malignancy. The patient underwent a second ERCP on the 19th day of hospitalization, and a biliary plastic stent was inserted after the extrahepatic bile duct stricture biopsy using normal forceps. The pathology showed no evidence of malignancy, although inflammation of infiltration cells mainly comprised lymphocytes, plasma cells, and eosinophils (at least 80 eosinophils per high-power field [HPF]) (Fig. ). Immunohistochemical staining of the pathology revealed no marked infiltration by IgG4-positive plasma cells. Peripheral blood eosinophils were elevated on the 16th hospital day, whereas they were within normal limits on admission (Fig. ), which caused us to suspect EC. We diagnosed EC based on the presence of hypereosinophilia and pathology findings of eosinophilic infiltration in the biliary epithelium. Because of the patient's young age, ursodeoxycholic acid (UDCA) with fewer side effects, rather than oral corticosteroids, was administered. The patient was discharged home with no events.


An 85-year-old woman with a history of dementia and previously treated osteoporosis presented for the treatment of a right proximal femur Vancouver B1 periprosthetic fracture after sustaining a mechanical ground level fall (Figure ). She had a remote history of a stroke with associated residual right-sided weakness and used a walker with ambulation at baseline. On admission, she was diagnosed with a urinary tract infection and appropriate antimicrobial therapy was initiated. Blood cultures were negative. She was medically optimized and taken to the operating room the following day for open reduction and internal fixation (Figure ). A subvastus approach to her femoral shaft was used, and after placing one cerclage wire around the fracture, a titanium alloy NCB Periprosthetic Plate (Zimmer Biomet) with a greater trochanteric attachment was placed. Fixation was obtained via the placement of an additional cerclage wire around the bone and NCB plate, several 3.5 mm and 4.0 mm titanium alloy proximal locking screws, and three 5.0 mm titanium alloy standard screws distal to the fracture. She was discharged on postoperative day 4 back to her assisted living facility. She was allowed to participate in the range of motion as tolerated but was limited to toe-touch weight bearing for 6 weeks. Before discharge, she was evaluated by our endocrinology team who obtained laboratory test results including comprehensive metabolic panel, vitamin D 25 hydroxy, and inorganic phosphate. Several laboratory values were found to be abnormal, and the patient was ultimately started on calcium, vitamin D, and nutritional supplements.
Given the patient's notable commute to our facility, her sutures were removed by her primary care provider and radiographs obtained approximately 7 weeks postoperatively were sent to the operating surgeon for review (Figure ). At that time, the patient was reported to be doing well. Radiographs demonstrated appropriate fracture healing without evidence of implant failure. Approximately 11 weeks after surgery, she again presented to our emergency department for right lower extremity pain after sustaining an additional mechanical ground level fall. Discussion with family noted that the patient had overall seemed to be recovering well from her previous injury and had recently started painless partial weight bearing activities. Radiographs at that time unfortunately revealed an acute right distal femur fracture and fretting of the distal-most screw through the plate (Figure ). Standard preoperative laboratory studies were obtained and found to have values within normal limits with the exception of a mild anemia. The patient again underwent open reduction and internal fixation of her acute fracture after medical optimization. She was discharged on postoperative day 6 back to her assisted living facility. The patient was ultimately lost to further follow-up because she entered hospice care on postoperative day 12.


A 73-year-old man with multiple medical comorbidities including multiple myeloma after chemotherapy, diabetes, and coronary artery disease presented for the treatment of a comminuted right periprosthetic supracondylar distal femur fracture after sustaining a mechanical ground level fall (Figure ). Before this injury, he was able to ambulate two blocks without difficulty but did use a stair lift at home secondary to chronic left lower extremity weakness, which he attributed to his previous multiple myeloma treatment. He was medically optimized and taken to the operating room the following day for open reduction and internal fixation (Figure ). After achieving adequate reduction of the fracture through indirect reduction techniques, a limited lateral approach to the distal femur was performed and the proximal end of a titanium alloy NCB Periprosthetic Plate (Zimmer Biomet) was placed submuscularly. Three titanium alloy 5.0 mm standard screws were placed in a percutaneous manner proximal to the fracture and multiple titanium alloy 5.0 mm locked screws were placed in the distal segment. Postoperatively, he was placed in a knee immobilizer to be worn at all times for 3 weeks, at which time the range of motion exercises were initiated. He was limited to toe-touch weight bearing for 8 weeks. Before discharge, he was evaluated by our endocrinology team who obtained laboratory test results including comprehensive metabolic panel, vitamin D 25 hydroxy, and inorganic phosphate. Several of these laboratory values were found to be abnormal, and he was ultimately started on calcium and vitamin D supplements.
The patient was discharged to a skilled nursing facility on postoperative day 5. At his 8-week postoperative appointment, new radiographs were obtained (Figure ). Adequate callous formation was noted, and no concerns for complications were noted. At that time, he did have notable quadriceps atrophy but denied pain with passive or active range of motion. He was advanced to weight bearing as tolerated and given home quadriceps strengthening exercises.
At his 14-week postoperative appointment, it was noted that the patient had not been compliant with his home strengthening exercises, and he reported 75% weight bearing with continued use of a walker for all ambulation. He endorsed stiffness in his right knee and intermittent mild pain described as muscle soreness in his distal thigh. Radiographs were obtained, which demonstrated slight varus malalignment of the fracture and fretting of the distal-most screw placed proximal to the fracture site (Figure ). He was referred to physical therapy but was unfortunately lost to further follow-up.


A 74-year-old male with a four-year history of CSM characterized by quadriparesis, decreased sensation on arm and legs, difficulty passing urine and hyperreflexia. He was treated with posterior cervical decompression and instrumented fusion two years prior at an outside institution. Initial magnetic resonance imaging (MRI) demonstrated cervical stenosis, most significant at C3-4 and a T2 hyperintensity within the spinal cord at that level (Figure ).
Postoperatively, he experienced a progressive improvement in the strength of all extremities, regaining the ability to walk. Six months after surgery, his neurological improvement plateaued and subsequently deteriorated. In the following months, the patient continued to decline neurologically, prompting a new cervical MRI. The new MRI demonstrated adequate decompression of the spinal cord and persistence of T2 hyperintense signal in the cervical cord, indicative of spinal cord injury (Figure ). Over the next two months, the patient continued to decline in motor function rapidly, with the development of diffuse muscle atrophy in all extremities.
On examination, the patient was wheelchair-dependent, found to have tongue fasciculations. Upper limbs showed muscle atrophy and bilateral weakness, proximal muscle group strength was three of five, and distal muscle group strength two of five (Medical Research Council {MRC} scale). Severe muscle wasting was observed in both hands, most profoundly in the dorsal interossei muscles (Figure ).
Lower limbs demonstrated noticeable atrophy and weakness (two of five). Decreased vibratory, positional, and pinprick hypoesthesia was noted in the upper and lower extremities. Areflexia was noted in all extremities.
An electromyography (EMG) and Nerve Conduction Study demonstrated lower motor neuron (LMN) involvement characterized by sharp waves, polyphasic potentials, reduced interferential pattern, and increased firing rate in upper and lower limb muscles. In addition, fasciculation potentials were observed in the genioglossus muscle. Also, The patient was referred to neurology for further evaluation and the diagnosis of anterior horn cell disease was confirmed.


A 60-year-old African-American man with a history of a VSD and non-ischemic cardiomyopathy (New York Heart Association [NYHA] Class III) presented to the hospital with complaints of worsening dyspnea and twenty-pound weight gain over three months. Physical exam revealed that he was significantly volume overloaded with bi-basilar crackles auscultated on lung exam and 3+ pitting edema up to his bilateral thighs. A grade 4/6 systolic murmur was heard at the left lower sternal border, and a grade 3/6 diastolic murmur was heard in the right upper sternal border. He was admitted for acute chronic decompensated heart failure requiring aggressive diuresis.
A transthoracic echocardiogram (TTE) was performed, which showed a dilated left ventricle with an ejection fraction (EF) of 40%, a small ventricular septal defect (VSD) in the upper part of the septum with a left to right shunt, and severe aortic insufficiency (AI). These findings were further evaluated with a transesophageal echocardiogram (TEE), which revealed a VSD located right below the right coronary cusp suggestive of a probable supracristal VSD. However, this VSD had an irregular track extending through the basal septum into the right ventricular outflow tract (RVOT), causing a left to right shunt. In addition, severe aortic regurgitation was noted (Figures -). Cardiac magnetic resonance imaging (MRI) was pursued for precise delineation of VSD and aortic valve anatomy (Figure ). It was clarified that the VSD is located in the supracristal septum under the right aortic cusp causing prolapse, leading to severe aortic regurgitation (Videos -). Interestingly, cardiac MRI also visualized aortic leaflets fenestration contributing to aortic insufficiency.
Due to the location of the VSD and concurrent severe aortic valve dysfunction, the patient was not deemed as a suitable candidate for percutaneous closure. Preoperative right and left heart catheterization was performed, which showed normal coronary arteries and mild pulmonary hypertension. The patient underwent surgical repair of VSD with a pericardial patch. Intraoperative surgical evaluation of the aortic valve confirmed the localization of the VSD and the presence of aortic leaflets fenestration. Aortic valve repair was attempted; however, there was residual moderate aortic regurgitation. The patient required aortic valve replacement with a 25 mm Medtronic Mosaic® tissue (Medtronic, Inc., Minneapolis, USA). Intra procedural TEE confirmed no flow across the patch that closed VSD and well-functioning aortic prosthesis.
On outpatient follow-up two weeks later, he endorsed reduced dyspnea and improved exercise tolerance with NYHA Class II functional status. Follow-up TEE in two months showed no residual leak of the VSD patch and well-functioning bioprosthetic valve.


A 73-year old female with a significant past medical history of congestive heart failure (CHF) status post biventricular pacemaker implantation, hypertension (HTN), lupus, and depression, presented to the emergency department with the chief complaint of left ankle pain after a fall. At the time of the fall, she was walking towards the stairs and accidentally tripped over her slippers, landing on her left ankle. She noted a history of falling several times in the past; however, this was the first time she recalled getting injured. After landing on the left ankle, she immediately experienced severe, sharp pain that was non-radiating but worsened by movement and weight-bearing. She denied hitting her head, loss of consciousness, experiencing chest pain, shortness of breath, palpitations, abdominal pain, nausea, and vomiting. While the patient takes multiple medications for CHF and HTN, her medication history was negative for any blood thinners.
Upon arrival to the emergency department, the patient’s vital signs were stable and within normal limits. Tachypnea, tachycardia, declining O2 saturation, and fevers were notably absent. Her physical exam was remarkable for an edematous, exquisitely tender left ankle that was warm to the touch. The dorsal pedis pulse was 3+ on bilateral lower extremities. Otherwise, the physical exam was unremarkable, and the patient was in no acute distress. She was awake, alert, and oriented, with heart rate and breath sounds within normal limits. Laboratory evaluation, including complete blood count, chemistries, and coagulation factors were unrevealing. An electrocardiogram was done to determine if the cause of the fall was an arrhythmia or heart block found normal intervals and a paced rhythm.
X-ray of the left ankle demonstrated a trimalleolar fracture dislocation. The talus was posteriorly dislocated in relation to the tibia (Figure ).
The patient was consented for left ankle open reduction and internal fixation by the orthopedic team once all relevant data had been reviewed. She was given 2 mg midazolam before the procedure and 67 mg of ketamine during the procedure. After a 6 cm vertical incision was made over the fibula, and the fracture was visualized, a bone holding clamp significantly reduced the fracture. A 7-hole 1/3rd tubular plate in combination with locking and nonlocking screws was used for secure fixation to the bone. A second 2 cm vertical incision over the medial malleolus revealed that the posterior malleolus portion of the fracture encompassed about 10% of the joint, with the rest of the joint remaining stable. Posterior subluxation of the joint was absent. This part of the fracture was operatively repaired with two K-wires in the medial malleolus and two 3.0 mm partially threaded screws holding the malleolus in place. The wounds were irrigated, and fluoroscopy confirmed good placement of the hardware (Figure ).
On postoperative day 2, the patient transitioned to a controlled ankle motion walker boot and denied numbness, tingling, or other complaints. Ambulation was appropriate, and a follow-up X-ray revealed a successful reduction (Figure ).


An 11-year-old Japanese boy who complained of abdominal pain and cough presented to a local hospital in December 2016. Enhanced computed tomography (CT) revealed bilateral pleural effusion and marked lymphadenopathy in the mediastinum, epigastrium, mesentery, neck, and axillae on both sides, as well as around the thoracoabdominal aorta. These findings were indicative of an advanced malignant lymphoma (Fig. a–c). The patient was transferred to our hospital for further treatment 16 days after presentation. He was 142.0 cm in height and weighed 42.1 kg at the time of admission.
Laboratory examination findings at the time of admission to our hospital were as follows: total white blood cell count, 22,900/mm3; C-reactive protein level, 2.35 mg/dL; lactate dehydrogenase level, 607 IU/L; and soluble interleukin-2 receptor level, 203,887 U/mL.
The pleural floating cell smear using cytospin (Fig. ) and the bone marrow smear showed that 90 and 1.2% of the cells, respectively, were large abnormal cells with vacuoles. Flow cytometry revealed abnormal cells that were strongly positive for CD4, CD25, CD30, and CD45RO and partially positive for CD7. Moreover, the abnormal cells were positive for ALK on fluorescence in situ hybridization (15% in the pleural effusion sample and 2% in the bone marrow sample). The level of nucleophosmin-ALK mRNA in the bone marrow was elevated to 8765 copies/ABL 10,000 copies. Stage IV ALK-positive ALCL was diagnosed based on the above findings.
Nasogastric feeding was initiated to supplement nutrition and prevent aspiration owing to bilateral laryngeal nerve palsy. Chemotherapy with the ALCL 99 regimen was administered [], resulting in temporary remission of the ALCL and improvement in the general condition of the patient; however, central nervous system infiltration was observed during the intermittent administration of chemotherapy (Fig. ). Therefore, treatment with brentuximab vedotin (BV) and high-dose methotrexate (HD-MTX) was initiated. At 5 months after diagnosis, remission was observed; however, the patient complained of dysphagia and vomiting, and esophagoscopy revealed a severe stricture in the middle thoracic esophagus (Fig. a). Lymphadenopathy, including that in the mediastinum, was reduced on CT (Fig. b), and no obvious tumor was observed near the stricture site on magnetic resonance imaging (Fig. c). Esophageal mucosal biopsy of the stricture site also revealed no malignancy. A second esophagoscopy was performed 3 weeks after the first one; the findings revealed that the stricture had progressed to the pinhole in the part with the most severe stricture, and barium examination revealed a complete esophageal obstruction in the middle thoracic esophagus with proximal dilation (Fig. d). Gastrostomy was performed for feeding.
After 5 courses of HD-MTX and 8 courses of BV (i.e., 9 months after diagnosis), the patient underwent allogeneic bone marrow transplantation (allo-BMT) from a human leukocyte antigen-matched unrelated donor, one form of allo-SCT. The reduced conditioning regimen included fludarabine (30 mg/m2 × 5), melphalan (70 mg/m2 ×2), and total body irradiation (2 Gy × 2). Tacrolimus and short-term methotrexate were administered for acute graft versus host disease (GVHD). Tacrolimus was gradually decreased and discontinued 6 months after allo-BMT. Even after the discontinuation of tacrolimus, no complications such as chronic GVHD developed.
After allo-BMT, complete remission continued to be maintained, and the patient was discharged; however, dysphagia and saliva retention did not improve. At approximately 10 months after diagnosis, esophagoscopy revealed a blind end—26 cm from the incisors—in the middle thoracic esophagus, similar to that observed in congenital esophageal atresia (Fig. a). Esophageal reconstruction was necessary for maintaining oral intake, and to wait for recovery from immunosuppression, we decided to perform esophagectomy more than 2 years after allo-BMT.
Approximately 2 years after diagnosis, esophagoscopy was performed again with findings similar to those obtained 1 year and 2 months previously. Esophagoscopy via gastrostomy revealed a blind end in the lower thoracic esophagus (Fig. b). At 2 years and 8 months after diagnosis, the patient was readmitted for esophageal reconstruction. He was 153.5 cm in height and weighed 52.4 kg at the time of operation. Laboratory examinations showed normal findings: white blood cell count, 7040/mm3; neutrophil count, 2640/mm3; lymphocyte count, 3650/mm3; serum albumin level, 4.4 g/dL; serum IgG level, 1752 mg/dL; CD4 T-cells, 33% of the total lymphocytes; CD8 T-cells, 40% of the total lymphocytes; CD4/CD8 ratio, 0.83 (normal range: 0.8–3.5); and proliferation in response to phytohemagglutinin stimulation, 36,280 cpm (normal range: 34,400–62,300 cpm). His immune function was restored to the normal state with no onset of chronic GVHD. His performance status score was 0, and his physical condition and nutritional status were good except for hoarseness and saliva retention. He underwent a minimally invasive subtotal esophagectomy under thoracoscopy and laparoscopy. First, the patient was placed in the prone position during thoracoscopy. We placed 5 and 3 mm thoracoscopic ports as shown in Fig. a and maintained the intrathoracic pressure at a positive pressure of 5 mmHg under two-lung ventilation. Fibrinous adhesions were observed across the entire mediastinum. We proceeded with dissection along the esophagus. The esophagus was significantly adhered to the aorta, trachea, and pericardium but was detachable. We did not perform lymph node dissection. Second, we placed the patient in the supine position and performed hand-assisted laparoscopic mobilization of the stomach. We removed the granulation tissue of the fistula that had formed in the anterior wall of the antrum of the stomach after the gastrostomy and sutured the fistula shut. We created a gastric conduit at the greater curve via the retrosternal route and performed a cervical esophagogastric anastomosis. The total operation time was 548 min, and the total amount of intraoperative bleeding was 80 mL.
Pathological examination of the surgical specimens revealed no esophageal epithelium, which had been replaced by hyalinosis and fibrosis (Fig. a, b). No viable cells were identified in the entire esophagus, stomach, and lymph nodes.
The patient did not experience any major postoperative complications, although he did complain of dysphagia for a while after the operation. As there was no problem with the passage on barium contrast imaging, the patient started receiving swallowing training. He was transferred to the local hospital for swallowing training on postoperative day 68. Subsequently, the symptoms of dysphagia disappeared, food could pass easily, and complete remission was still maintained at 14 month post-surgery.


A 32 year-old woman from a rural area, presented to the general surgery clinic with mild and continuous pain in the lateral aspect of her left thigh. Concomitantly, she was complaining of gradually increasing swelling in the lateral aspect of her left thigh for about 1 year duration. Family history and drug history was unremarkable. On examination, there was a round, non-tender, non-mobile mass in the lateral aspect of her left thigh. There was no overlying skin changes, ultrasound (US) showed 15cm × 5cm solid-cystic lesion in the lateral aspect of the left thigh with multiple well-defined cystic lesions. Magnetic Resonance Imaging (MRI) showed a relative large multisystem lesion in the lateral aspect of the thigh with connection to the femoral bone, in favor of hydatid cyst (1 and 2). Chest X-ray and abdominal ultrasound excluded lung and liver HDs. ELISA test of Echinococcus Granulosa titer test was negative. A primary muscular Hydatid cyst was diagnosed and a pericystectomy was chosen as the preferred surgical treatment. Treatment involved 400 mg of Albendazole twice per day for 10 days before and three months after surgery. The longitudinal incision (pericystectomy) was performed under spinal anesthesia in the anterolateral aspect of the left thigh (3). Cyst cavity was thoroughly irrigated with hypertonic saline and wound closed after putting a drain (3). The surgery has been carried out under the supervision of an attending general surgeon. Histopathological diagnosis confirmed the diagnosis of Hydatid Disease. The postoperative course of the patient was favorable. As Albendazole (400 mg twice per day) started 10 days before surgery, it was continued for three month after surgery and there was no evidence of recurrence of the lesion during the 8 month follow-up.


The 45-year-old male employee from a company in Wuhan, the epidemic center, returned to his hometown Dazhou in Sichuan Province on January 23, 2020. On the same day, he began to have chest tightness and fatigue. On January 25, 2020, he developed fever (37.8°C) (Figure ), but with normal hematological index and chest computer tomography (CT) scan (Figure ).
However, on illness day 5 (January 27, 2020), his symptoms became severe. He had chest tightness, lower limb weakness, accompanied by cough and fever. And his lungs CT showed ground glass near the pleura in the posterior segment of the upper lobe of the left lung. He was admitted to the local country hospital for isolation and treatment, as a suspected case of COVID-19. On admission, the medical examination findings revealed a body temperature of 36.5°C, oxygen saturation (SpO2) of 97% while breathing ambient air, partial pressure of oxygen (PO2) 78.5 mm Hg (inhaled air), oxygenation index 373 mm Hg, white blood cells (WBC) 6.3 × 109/L, neutrophil proportion 71.1%, lymphocyte count 1.25 × 109/L (Figure ), together with normal sensitive C-reactive protein and blood biochemical index. The influenza A and B virus antigens and mycoplasma pneumoniae antibody IgG tests were negative. And then he was treated with oral ɑ-interferon nebulization and lopinavir/ritonavir (Clitraz) as antiviral symptomatic supportive therapy.
And the 4 successive lungs CT images of the patient showed progressive enlargement of the left lung lesions, and a large invasion lesion of the right lung (Figure ). Both lungs progressed from ground glass shadow and patch shadow to consolidation and strip shadow.
On illness days 15 (February 6, 2020), the patient progressed to critical COVID-19 with moderate acute respiratory distress syndrome (ARDS), and was transferred to intensive care unit (ICU). His physical examination showed body temperature 36.7°C, arterial blood gas PCO2 34.2 mm Hg, PO2 53 mm Hg, oxygenation index 118 mm Hg (mask oxygen 6 L/min), highest WBC counts (13.8 × 109/L) and highest neutrophil counts (12.53 × 109/L), lowest lymphocyte counts (0.63 × 109/L) (Figure ). Meanwhile, the lungs CT showed large areas of patch, cord, and consolidation in both lungs (Figure ). Since his admission, he has received noninvasive positive-pressure mechanical ventilation, combined with prone ventilation, anti-infection, antiviral, dialectical treatment of traditional Chinese medicine and symptomatic supportive treatment. He was taken off the ventilator on February 12, 2020. His physical examination showed SpO2 96.7%, PCO2 42.8 mm Hg, PO2 87.7 mm Hg, oxygenation index 302 mm Hg, WBC 7.56 × 109/L, neutrophil proportion 74.2%, lymphocyte count 1.25 × 109/L (Figure ).
He was transferred to a general isolation ward from the ICU on illness day 22 (February 13, 2020). Three more rechecks of CT showed multiple patchy shadows and fibrotic changes in both lungs, from February 13 to February 27, 2020 (Figure ).
On February 24, 2020, the patient underwent the 9th bronchoscopic alveolar lavage fluid SARS-CoV-2 nucleic acid test and SARS-CoV-2 next generation sequencing (NGS) test with both negative outcomes. Although the outcome of total antibodies of COVID-19 test was positive. He received a total of 9 nucleic acid tests, and the results were all negative (Table ).


A 58-year-old man was admitted to our hospital due to abdominal distension for the last 2 months, accompanied by yellow staining of skin and sclera and darker color of urine for 13 days. Based on the physical examination, we observed no abnormalities except for an icteric appearance. Additionally, an irregular lump was observed in the right lobe of the liver with unclear boundaries on abdominal contrast-enhanced computed tomography. Multiple tubular and patchy images appeared around the lesion, while the dilated bile duct was inspected at the distal end of the lesion. We identified that the solid components of the lesion were slightly enhanced with an average computed tomography value of about 66 HU (Fig. ). We also viewed filling defects in the inferior vena cava with no clear enhancement (Fig. ). Magnetic resonance cholangiopancreatography revealed that the right hepatic intrahepatic bile ducts were dilated to varying degrees, some of which were cystic. In the dilated bile ducts, there was an irregular and slightly longer T2 signal lump shadow, some of which were “cauliflower-like,” whereas the partial liver margin was slightly sunken (Fig. ). Using an echocardiogram, we discovered an irregular mass-like echo filling in the right atrium, with divided lobes visible (Fig. ). In particular, the larger lobe was approximately 47 mm × 18 mm in size, starting from the entrance of the inferior vena cava. We also uncovered small filling defects in the posterior pulmonary artery in the left and right upper lobes using computed tomographic pulmonary angiography (CTPA). As the patient had space-occupying lesions in the inferior vena cava and atrium along with pulmonary embolism, the Caprini grade was high-risk. Without bleeding tendency, low molecular weight heparin (LMWH) was used for thromboembolic prophylaxis twice a day (100 IU/Kg). In addition to the mucus secreted by the tumor retained in the bile duct, there may also be a bile duct tumor thrombus that caused obstruction and then formed cystic dilatation, leading to jaundice due to the obstruction of bile (total bilirubin 103.56 umol/L; direct bilirubin 54.41 umol/L; urine bilirubin 17 umol/L). The tumor was close to the right hepatic vein, with probability of invading the blood vessel. Our preliminary diagnosis of the tumor was considered to be malignant with vascular and atrium tumor thrombi (CA-199 174.76 U/mL), and thus surgery was planned. However, hematologic abnormalities co-existed.
Here, the laboratory results showed moderate anemia categorized as normocytic and normochromic (red blood cells, 2.11 × 1012 /L; hemoglobin 68 g/L; mean corpuscular volume 90 fL; and mean corpuscular hemoglobin 32.20 pg/Cell). We observed that several coagulation indexes were slightly elevated, whereas fibrinogen and high D-dimer were decreased (prothrombin time 13.5 seconds; prothrombin time ratio 1.21; fibrinogen 0.97 g/L; D-dimer 7.15 mg/LFEU). Notably, transfusion of suspended erythrocytes failed to correct anemia. We further performed blood tests to establish the potential cause of the anemia. Direct evidence of erythrocyte destruction (indirect bilirubin, 49.15 umol/L; lactate dehydrogenase 460 U/L; peripheral morphological analysis of blood cells presented approximately 3% of broken erythrocytes) and indirect evidence (significantly elevated reticulocytes (%), 16.31%) were both present, thereby the diagnosis of hemolytic anemia was definite in spite of unclear pathogenesis. Accompanied by decreased platelets (from 176 × 109/L to 116 × 109/L), autoimmune hemolytic anemia combined with immune thrombocytopenia (Evans syndrome) were not excluded. Subsequently, the patient was empirically given glucocorticoid for 6 days (0.1 mg/Kg body weight). After 8 days, the patient presented no improvement of anemia with a further decreased count of platelets (64 × 109/L), and thus the patient was immediately transferred to the Department of Hematology for further treatment. Consequently, the autoimmune antibody, fluorescently labeled modified aerolysin (FLAER), CD55\CD59 expression, and direct antiglobulin (Coombs) tests were not abnormal, which ruled out paroxysmal nocturnal hemoglobinuria (PNH) and autoimmune hemolytic anemia. Regarding that, the patient had no fever (leukocyte 6.66 × 109/L; blood culture: no bacterial growth was observed), renal insufficiency, and neurological symptoms, and at the same time, the activity of ADAMTS13 was 68% and ADAMTS13 antibody was negative, thrombotic thrombocytopenic purpura (TTP) was also excluded. Moreover, 1 month after admission, the patient developed the following symptoms including sudden abdominal pain, fever, and decreased blood pressure (76/55 mmHg), together with increased infection indicators and deterioration of coagulation function [total bilirubin 690.4 umol/L, direct bilirubin 545.5 umol/L, C-reactive protein 74.17 mg/L, leukocyte 16.00 × 109/L (NEUT% 96.50%), platelets 54.00 × 109 /L, prothrombin time 16.5 seconds, prothrombin time ratio 1.47, and fibrinogen 1.63 g/L]. Acute cholangitis followed by shock were diagnosed, and decompression of the biliary tract was performed immediately. Thereafter, the patient was transferred to the intensive care unit (ICU) for supportive treatment, namely antimicrobial therapy and plasma and blood transfusion, but the anemia did not improve significantly. Due to the prolonged prothrombin time, LMHW was not given. Then, after 4 days, the patient was transferred to the general ward in a stable condition. At this time, anemia, thrombocytopenia, and hypofibrinogenemia still existed (hemoglobin 56 g/L; platelets 67 × 109/L; fibrinogen 1.27 g/L). After a multidisciplinary team discussion, the probability of chronic DIC was high. After 20 days of oral rivaroxaban treatment, the patient was checked again, and the platelet and fibrinogen levels had returned to normal (platelets 293 × 109/L, fibrinogen 3.87 g/L), while hemoglobin was significantly improved (122 g/L). Therefore, right trilobe hepatic resection plus thrombus removal from the inferior vena cava and atrium was performed.
Macroscopically, the intrahepatic cystic nodular lump presented size of 7 cm × 6 cm × 5.5 cm, in which the cut surface was multilocular cystic. We observed no solid area. Furthermore, the diameters of the cysts were between 1.5 and 5 cm, while the inner part of the wall of the cyst was attached with gray-red jelly-like substance and mucus (Fig. ). Histologically, intraductal papillary neoplasms of the intrahepatic bile duct showed a part of high-grade intraepithelial neoplasia, without invading the liver capsule (Fig. ). We established that cardiac and inferior vena cava emboli were fibrinoid mesh without neoplasms and thus were classified as thrombus. Conversely, biliary emboli were tumor tissue accompanied by hemorrhage and necrosis. Tumor immunohistochemical analyses were presented as follows: Inhibin-α (-), ER (-), Vimentin (mesenchyme +), CK7 (+), CK19 (+), CK20 (−), CEA (−), MUC-1 (+) (Fig. ), MUC-5AC (+) (Fig. ), MUC-6 (+) (Fig. ), MUC-2 (−), S-100p (focal+), and Ki-67 (12% +). Finally, the patient recovered well without complications, and was discharged 12 days after surgery, and followed up for 12 months. No signs of tumor recurrence were observed.


A 64-year-old man presented to our Department of Hematology due to the presence of leukocytosis in medical examination. He was asymptomatic and physical examinations revealed no abnormalities. He had no underlying diseases, notable medical history, or relevant family history. Initial complete blood count analysis showed a white blood cell count of 13.0 × 109/L (normal range, 3.6–9.6 × 109/L), 36.6% neutrophils and 56.7% lymphocytes, hemoglobin level of 13.8 g/dL (normal range, 13.2–17.2 g/dL), and platelet count of 159 × 109/L (normal range, 148–339 × 109/L). Blood chemistry revealed no abnormalities involving lactate dehydrogenase and soluble interleukin-2 receptor levels. Computed tomography findings showed mild splenomegaly, but no lymph node enlargement. Bone marrow aspiration was performed; the results demonstrated 23% abnormal lymphocytes with prominent nucleoli. Flow cytometry (FCM) revealed light-chain restricted B cells that were strongly positive for CD19, CD20, and CD22; positive for CD11c, κ-chain, and FMC7; and negative for CD5, CD23, CD10, and CD25. Cytogenetic analyses revealed the following abnormalities: 45, XY, der (8)t (8;13) (q24: q11), ins (8;?) (q24;?), del (11), and -13[1/20].
Accordingly, the patient was diagnosed with low-grade B-cell lymphoma. No further diagnosis could be made at that time. He received treatment with the CHOP regimen because his lymphocyte count was >5.0 × 109/L. Rituximab treatment was initially avoided because of the potential for strong infusion reactions due to spleen and peripheral blood lesions. Subsequently, abnormal lymphocyte counts slightly decreased and ≥30% of the white blood cell count comprised abnormal lymphocytes; thus, the CHOP regimen was determined to be insufficient after 3 weeks of treatment. The patient then began RB therapy (day 1: rituximab 375 mg/m2; days 2–3: bendamustine 90 mg/m2). His abnormal lymphocyte count rapidly decreased, such that no abnormal lymphocytes were present in peripheral blood after 1 week of RB. After 3 weeks of RB, bone marrow smear preparations showed no abnormalities; pathologic findings, FCM, and cytogenetic analyses revealed the absence of minimal residual disease (MRD). The treatment was well tolerated and the patient completed six planned cycles of the RB regimen. The only Grade ≥3 adverse event (according to the Common Terminology Criteria for Adverse Events, Version 4.0) was lymphocytopenia. At 8 months after initiation of RB, the patient exhibited CR consistent with the 2015 European Society for Medical Oncology guidelines,[ as indicated by absence of splenomegaly in computed tomography and blood count examinations. After treatment, the absence of MRD in peripheral blood was routinely checked by FCM. At 39 months after initial chemotherapy treatment, the patient did not exhibit MRD. However, at 42 months, κ-chain restricted, CD20 and CD11c double-positive cells were detected at a rate of 0.6% in peripheral blood. Nonetheless, the proportion of cells indicative of MRD remained below 2% for an extended period.
At 69 months after initial chemotherapy treatment, abnormal lymphocytes were countable in peripheral blood smears. Complete blood count analyses showed a white blood cell count of 10.6 × 109/L (30.0% abnormal lymphocytes), hemoglobin level of 13.6 g/dL, and platelet count of 118 × 109/L, which met the criteria for relapse. Blood chemistry showed an elevated soluble interleukin-2 receptor level (964 U/mL; normal range, 145–519 U/mL). Mild splenomegaly and no enlarged lymphocytes were observed. Bone marrow aspiration showed 60% abnormal lymphocytes, similar to the level at initial diagnosis. FCM also showed comparable findings, including light-chain restricted B cells that expressed CD19, CD20, κ-chain, and FMC7, but did not express CD5, CD23, CD10, or CD25. Cytogenetic analyses showed the following abnormalities: 44, XY, der(7)t (7;14)(q11.2:q11.2), der(8)t (8;13) (q24:q11), ins (8;?)(q24;?), del(11)(q?), -13, and -14[6/20]. Pathologic findings were negative for TRAP, Annexin A1, and DBA44. BRAF and MyD88 both exhibited wild-type mutation statuses. Watchful waiting was first implemented due to the patient's asymptomatic disease. Two months later, chemotherapy was initiated because the patient's platelet count was below 100 × 109/L and his splenomegaly had gradually progressed (ie, monthly). He received further RB treatment; abnormal lymphocytes disappeared after 1 cycle. After 3 cycles, FCM of peripheral blood showed absence of MRD. The patient completed 6 planned cycles of RB. At 79 months after initial chemotherapy treatment, computed tomography revealed absence of splenomegaly, indicative of CR.
At 104 months, abnormal lymphocytes were again detected in peripheral blood smear with leukocytosis, which met the criteria for a second relapse. Blood chemistry showed an elevated soluble interleukin-2 receptor level (4440 U/mL). Mild splenomegaly and no enlarged lymphocytes were observed (Fig. A). Bone marrow aspiration showed 15.7% abnormal lymphocytes, which was a similar finding to that of the first attachment (ie, small- to medium-sized irregular edges, with occasional clear nucleoli). FCM and cytogenetic analyses also showed abnormalities similar to those detected during the first relapse. Because the patient's abnormal lymphocyte count gradually increased (ie, weekly) and his platelet count decreased to 83 × 109/L, he received rituximab monotherapy; however, this did not reduce the abnormal lymphocyte count. Thus, differential diagnosis was repeated. The atypical cells had prominent nucleoli with condensed chromatin; most also had abundant cytoplasm, as detected in instrument-dried peripheral blood, and omnidirectional hairy projections, as detected in naturally dried peripheral blood (Fig. B–E). Because of limitations regarding FCM antibody reagents in our hospital, FCM including CD103 was performed by a third-party laboratory. The findings were strongly positive for CD103, CD19, CD20, CD11c, and IgM; positive for κ-chain, CD29, and CD54; and negative for CD5, CD23, CD10, and CD25 (Fig. F). Fluorescent in situ hybridization analysis of bone marrow was performed including del (17q), del (11p), t (11;14), t (14;18), and del (13); only del (11p) was observed in 30% of cells in the specimens. Taken together, the findings supported a diagnosis of HCL-v. The patient was treated with Cd and achieved partial response (Fig. ). The patient provided written informed consent for publication of this report.


A 63-year-old male, a current heavy smoker with a smoking history of over 100-pack years, was referred due to complaints of dyspnea at rest and productive cough over the last three days. He had a history of COPD; he was diagnosed the previous year and treated with a combination of inhaled beclomethasone, formoterol, and glycopyrronium, with more of three hospitalizations due to infectious exacerbations the last six months. He had also a history of coronary artery disease with coronary artery bypass done nine years ago and circumflex artery angioplasty four years ago, as well as aortic valve replacement with metallic prosthesis, arterial hypertension, and dyslipidemia. The patient mentioned no severe lung infection during his childhood.
Clinical examination revealed decreased breath sounds in both lungs and wheezing. Blood pressure was 110/60 mmHg, heart rate was 90 beats per minute, oxygen saturation was 94% on room air, and body temperature 36.5°C. Arterial blood gas analysis revealed partial pressure of oxygen (pO2) 66 mmHg, partial pressure of carbon dioxide (pCO2) 41 mmHg, pH 7.47, and bicarbonate (HCO3−) 29.8 mmol/L on room air. Electrocardiography showed no abnormal findings. Laboratory findings were normal. Chest X-ray showed emphysematous lesions with lungs of large volume, flattened hemidiaphragms, horizontal ribs, small size of the heart, and increased retrosternal space (Figure ).
The patient underwent computed tomography (CT) of the chest in our hospital, which showed bronchiectasis on the left lower lobe. In addition, a reduced density in the same region was observed (Figure ). Pulmonary function tests (PFTs) revealed a non-reversible mild obstructive pattern. The measured values of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were of 65%/67% and 99%/102% of predicted values, pre and post-bronchodilator administration, respectively (Figure ). Based on clinical manifestations and imaging findings, a diagnosis of Swyer-James-MacLeod syndrome was confirmed.
The patient was treated with nebulized salbutamol/ipratropium, intravenous prednisolone for five days, and empirical antimicrobial therapy with piperacillin-tazobactam while sputum culture did not reveal any microorganism. The patient recovered and was discharged from our hospital with strong advice for smoking cessation and vaccination to prevent pulmonary infections.


A 12-year-old girl presented with enlargement of the fourth left toe since early childhood. The toe was gradually increasing in size over the last two years and the parents were mainly concerned about its appearance. She felt embarrassed about her left foot as it was an object of ridicule among her peers.
On examination, there was a diffuse soft enlargement of the left fourth toe with the nail plate almost buried in the hypertrophied mass (Figure ). The toe was non-tender to touch, non-pulsatile without any dilated veinsx, and there was no Tinel’s sign on the toe or foot.
X-ray of the affected toe showed no bony abnormality (Figure ). Ultrasound examination showed diffuse but mildly heterogeneous subcutaneous soft tissue enlargement as well as an increase in vascularity.
Subsequent MRI scanning revealed a lobulated large subcutaneous homogeneous soft tissue mass of fat signal intensity with internal fibrous strands around the toe (Figure ). This was extending from the mid-proximal phalanx to the tip, mainly on the plantar aspect but extending both medially and laterally. No intralesional enhancement was seen.
The patient underwent the soft tissue debulking procedure under general anesthesia using a long dorsomedial incision to explore the medial neurovascular bundle, which was displaced by abnormal fat in the medial pulp. Removal of the skin and soft tissue was done preserving both the nerve and artery. The incision was extended laterally for further removal of abnormal fat. A physiological amount of normal-looking fat attached to the tip of the distal phalanx was retained to preserve form. Glabrous skin was trimmed adequately and the wound was closed directly without tension (Figure ).
The postoperative course was uncomplicated with discharge from the hospital on the second postoperative day and regular follow-up in the outepatient clinic. She started walking on the day of discharge. There was a lateral deviation of the toe seen immediately postoperatively, which was corrected by a four-week-course of neighbor strapping of the third and fourth toes. The final appearance of the toe at three months was a normal anatomical appearance on the dorsum but with a slightly reduced pulp on the volar side (Figure ). The sensation on the plantar aspect was preserved with a full range of motion of the toe. Postoperative biopsy report confirmed benign lipohamartomatous overgrowth of the left fourth toe.


A 40-year-old man suffered from intermittent left abdominal distension and pain for more than 1 month, and Computed Tomography (CT) in a local hospital revealed the possibility of lymphocele. Enhanced Magnetic Resonance Imaging (MRI) showed () with the maximum section of about 8.2 cm × 5.9 cm, the boundary of the mass was unclear. The patient was taken a transabdominal straight muscle incision in the right upper quadrant, and the mass was cystic and solid, with a complete capsule; the upper edge of the tumor raised the vein together with the left renal vein and right renal vein superiorly and laterally, the inner edge of the tumor was adjacent to the duodenum, the lower edge of the tumor was adjacent to the right renal artery and abdominal aorta, and the right renal capsule was squeezed inferiorly outside the tumor. The gastrocolic ligament was opened and the descending duodenum was mobilized with a Kocher incision to fully expose the anteromedial aspect of the tumor. Carefully separated the surrounding blood vessels along with the tumor capsule, completely dissected the tumor, ligated and cut it into the tumor vascular lymphatic tissue. The operation went smoothly and the bleeding was about 100 ml. The postoperative histology showed that combined with the results of immunohistochemistry, it was consistent with schwannoma, accompanied by significant degeneration and cystic degeneration. Immunohistochemical staining was positive for S100, SOX10 and vimentin, negative for Syn, CD34, CD117 and SMA, and ki-67+ (2%).


A 41-year-old woman had upper abdomen pain and discomfort for a week, which worsened after eating. MRI at the local hospital showed neurogenic tumor or pancreatic tumor. Enhanced CT showed () a retroperitoneal soft tissue mass with a maximum section of about 10.0 cm × 8.7 cm. The three-dimensional reconstruction clearly showed the left renal vein and pancreas in front of the tumor, the left renal vein, right renal artery and abdominal aorta on the left, the inferior vena cava and right renal vein on the right, and the right renal artery and vein and right renal hilum at the back. This patient was taken a right abdominal transabdominal right muscle incision, about 20 cm in length. The tumor was located in the right upper abdomen, posterior to the duodenum, smooth surface, tough texture, relatively complete capsule, clear boundary, the vein was squeezed to the right flexion, the left posterior of the tumor closely adhered to the abdominal aorta, and no lymphadenopathy was observed in the hepatoduodenal ligament. The duodenum was lifted, the posterior peritoneum was opened, the loose space between the duodenum and the tumor was freed, the level of the abdominal aorta was freed along the left side of the tumor, the adhesion between the tumor and the abdominal aorta was bluntly and sharply separated, the active bleeding point was ligated, the tumor was freed from the retroperitoneum, the right renal artery and left and right renal veins were exposed to protect during the operation, the vein was exposed, the space between the tumor and the vein was bluntly and sharply freed, the tumor was completely removed. The operation was uneventful, with intraoperative bleeding of about 100 ml. The postoperative histopathology was consistent with retroperitoneal schwannoma. Immunohistochemical staining was positive for S100 and PGP9.5, negative for NF, CD34, Desmin, CD117 and Dog-1, and ki-67+ (3%).


A 41-year-old woman had pain in right upper abdomen for 1 week. There was no abnormality in colonoscopy at the local hospital and CT considered lymph node metastasis. Enhanced CT after admission revealed () a type of round soft tissue density lesion and a maximum section of about 4.1 cm × 3.8 cm. Three-dimensional reconstruction clearly showed the confluence of the splenic vein and superior mesenteric vein, main portal vein, common hepatic artery, and pancreas were anterior to the tumor; the main abdominal aorta was posterior to the left; the main inferior vena cava was posterior to the right; the celiac trunk was superior to the left; the splenic vein and pancreas were middle to the left; the main superior mesenteric artery was inferior to the left; the main portal vein and proper hepatic artery were inferior to the right; the superior mesenteric vein was anterior to the inferior; the left renal vein was posterior to the inferior; the coronary vein and liver were superior to the left. This patient was taken a reverse “L” incision in the upper right abdomen. The mass was posterior to the head and neck of the pancreas, and was locally surrounded by the common hepatic artery and splenic vein, which was hard and solid, with an intact capsule. The loose tissue between the tumor and the vein was separated and dissected along with the capsule from the right side of the tumor. It was completely dissected along the tumor surface, ligated and cut into the tumor vascular lymphatic tract tissue, and the specimen was removed en bloc. The operation was uneventful, with intraoperative bleeding of about 50 ml (). The postoperative histological report suggested retroperitoneal schwannoma with abundant local cells. Immunohistochemical staining was positive for S-100 and SOX10, negative for CD34, CD117, Dog-1 and CD57, and ki-67+ (1–2%).


A 42-year-old man with a history of well-controlled hypertension presented to the hospital complaining of progressively worsening headaches associated with dizziness and blurry vision for three days. The patient denied any history of fever, chills, vomiting, head trauma, or loss of consciousness. He also denied any history of alcohol, vitamins, or anabolic drug use. Upon presentation, the patient was hemodynamically stable with normal physical and neurological examinations. All blood tests were within normal limits. CT head without contrast revealed acute right crescent-shaped subdural blood collection measuring up to 6 mm in thickness with mild falx herniation and right to left midline shift of 4 mm (Figures and ). CT cerebral angiogram showed no aneurysm and no active bleeding within the hematoma with prominent cortical veins on the right peri-sylvian region. CT angiogram of the neck revealed no abnormalities, and CT cervical spine reported no evidence of acute spine fracture. Diagnostic angiogram revealed no evidence of vascular malformation. The patient underwent a successful right craniotomy for evacuation of his atraumatic acute right-sided SDH with coagulation of the bleeding veins and placement of a subdural drain and a bone flap to the skull. A postoperative CT head showed successful evacuation of the SDH (). The patient remained hemodynamically and neurologically stable. The drain was removed, and the patient was then discharged home with outpatient follow up plan.
However, one week later, the patient returned to the hospital complaining of persistent dizziness and headaches not improving with pain medications. A repeat CT head showed mixed density right hemispheric SDH that has increased in size with increased mass effect and midline shift suggestive of chronic reaccumulating SDH. Neurosurgery team recommended a repeat CT head after 24 hours or earlier if any change in his neurological exam. CT head was subsequently done and showed stable hematoma with mild decreased midline shift for which the patient was started on steroids and ultimately discharged home with follow-up in outpatient clinics.
Two weeks after discharge, the patient started reexperiencing severe headaches with subjective fever of one-day duration for which the patient returned to the hospital. In ER, the patient was febrile with normal vital signs. Blood test was significant for leukocytosis with neutrophilic shift and elevated CRP and ESR. CT head without contrast revealed decrease in size of previous right SDH with a new area of diminished attenuation in the right frontal lobe suggestive of vasogenic edema (). MRI brain was performed confirming the CT findings with presence of right subdural empyema (Figures –). The patient underwent a right craniectomy for removal of previously placed bone plate and for exploration washout of the subdural collection. During the procedure, a yellowish purulent material was seen in the subdural space from which multiple specimen swabs were taken and sent for culture. The subdural space was well debrided. The patient was started on broad-spectrum antibiotics with intravenous vancomycin, cefepime, and metronidazole, awaiting cultures result. The previous bone flap was not placed back due to underlying infection. Swab culture remained negative for 96 hours before growing P. acnes bacteria. Antibiotics were then de-escalated to aqueous crystalline penicillin for a total treatment duration of 6 weeks.
Two months later, after completion of the full course of antibiotics and during a follow-up visit to the infectious disease clinic, the patient reported improvement of symptoms. Repeat blood test was negative for any sign of persistent infection. Appointment was then set with neurosurgery office for cranioplasty scheduling.


A 54-year-old man had intermittent chest tightness for 49 years. There was no obvious inducement of facial and eyelid edema 2 months ago, and it was aggravated when he got up in the morning. However, physical examination found that the patient did not have dyspnea, hemoptysis, cyanosis, limb edema, sensory abnormalities and other symptoms. There is no previous history of surgery or other diseases. Laboratory examination showed that hemoglobin 115.0 g/L, erythrocyte 3.63 × 1012, 24-h urine protein and tumor markers were not abnormal.
After admission, the cardiac function of the patient was examined. First, echocardiography showed that the right atrium near the entrance of the superior vena cava could be hypoechoically attached to the heart wall, with an area of about 22 mm × 16 mm (Fig. a). The fluid dark area was detected in the pericardium. Ultrasound doctors considered the formation of emboli extending from the right atrium to the entrance of the inferior vena cava. Subsequently, the patient underwent cardiac magnetic resonance imaging, showing a massive low-signal shadow in the right atrium on the trufi sequence (Fig. b). The right atrium was small and the right ventricle was large, so delayed contrast-enhanced scan was performed 2 h later. After intravenous injection of contrast medium, the lesions in the superior vena cava near the heart and adjacent right atrium showed mild enhancement (Fig. c), multiple nodular mild to moderate enhancement foci could be seen in the mediastinum, and a small or moderate amount of effusion could be seen in the pericardial cavity. Dr. MRI considered the mass in the proximal end of the superior vena cava and adjacent right atrium. Further CT examination showed patchy low density shadow in right atrium and superior vena cava (Fig. d), inhomogeneous and moderate enhancement on enhanced scan (Fig. e–f), multiple enlarged lymph nodes and spotted calcification in mediastinum and bilateral axillary fossa, localized thickening of pericardium and fluid density in pericardium and bilateral chest. In addition, PET-CT examination showed that the density of soft tissue was concentrated in the right atrium and superior vena cava, SUVmax was about 10.7, the length of the lesion was about 6.7 cm, multiple enlarged lymph nodes were seen in mediastinum, bilateral hilum and bilateral armpit, some of them were slightly concentrated, SUVmax was about 3.3, and the size of larger patients was about 1.3 cm × 1.5 cm.
The patient underwent surgical resection. During the operation, it was found that the left and right brachial trunk vein and superior vena cava were enlarged, the tumor was located in the right atrium, the size was about 6.5 cm × 3.0 cm × 2.5 cm (Fig. g), and the capsule was intact. The tumor section is gray–yellow–gray–red soft, locally cystic, and the boundary with the heart tissue is still clear. the tumor pedicle was located in the atrial septum, part of the tumor grows upward to the vena cava, attaches part of the thrombus, and completely blocks the blood flow of the superior vena cava. After the tumor was sent for histopathological examination, it could be seen that the tumor tissue was composed of scattered heterosexual epithelial cells and spindle cells, the mitosis of the cell core was rare, and the vascular lumen-like structure could be seen in some eosinophilic cytoplasm (Fig. h). Immunohistochemistry showed CK(−), CK7(−), CEA(−), TTF-1(−), CK5/6(−), CR(−), HBME-1(−), D2-40(−), WT-1(−), P63(−), CD31(+), CD34(−), ERG(+), Ki-67(12%+), FLI-1(+), TFE-3(−), F8(+)。. The patients were followed up every 3 months after operation. 15 months after operation, the patients were in good condition and there were no obvious complications.


We present the case of a mid-60-year-old male who suffered a tear of the right posterior tibial tendon due to a motor vehicle accident years ago. After fixation and immobilization, the foot remained painful and swollen, while the healing of the fracture was considered to be favorable. After six months, CRPS was suspected and the patient referred to a pain medicine specialist. CRPS diagnosis was confirmed according to the following criteria: continued pain disproportionate (allodynia) to the inciting event, foot hyperesthesia, skin color (redness), stiffness, and weakness of the foot and ankle (positive Budapest criteria). The patient was offered a DRGS trial at right L5 and S1 with 90% pain reduction; however, his commercial insurance plan failed to cover the DRGS implantation, deeming it experimental. He then underwent a Boston Scientific SCS trial with >50% relief and was implanted with an Boston Scientific (Marlborough, MA, USA) SCS system (16-contact lead placed at the top of T8) in 2019. After a successful trial, the patient reported 80% pain relief with the SCS system. Unfortunately, the patient reported worsening of pain symptoms after four months. Imaging was obtained to rule out lead migration. The system was reprogrammed several times without success for pain relief, with multiple wave forms being trialed. Unfortunately, none could recreate his pain relief and functional improvement from the prior DRGS trial.
The patient presented to our clinic with right foot pain that he reported as eight out of ten on the numeric rating scale (NRS). He complained that he is easily fatigued with walking. Physical examination of the right foot was notable for allodynia and nail discoloration.
With a change in his insurance plan, he subsequently proceeded with a DRGS implantation that was approached in the same manner as described by Liem et al. []. The Abbott DRGS System (Abbott, TX, USA) was utilized.
DRG leads were placed at the right L5/S1 and S1 neural foramen. Adequate paresthesia mapping was achieved intraoperatively over his painful right lower extremity. Three days after the implantation, the patient reported greater than 90% improvement in CRPS pain. Furthermore, the patient was ambulating with one out of ten on the NRS.
On his six month follow-up appointment, the patient mentioned rare pain flare ups of eight to nine out of ten on the NRS and had weaned himself off opioid medication (oxycodone/acetaminophen tablets). He occasionally felt “flutter” of his posterior distal leg muscles. These issues were remedied when the DRG system was reprogrammed. His pain score has remained one out of ten most times. The device has been used 24 hours a day. The patient’s SCS system was explanted after achieving superior relief with his Abbott DRG neurostimulation system. Verbal informed consent was obtained from the patient for anonymized patient information to be published in this article.