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Subungual squamous cell carcinoma (SCC) is a rare malignant tumour with an indolent course and unknown aetiology. It is usually misdiagnosed as a benign lesion, resulting in delayed treatment. Although psoriasis is not a precancerous skin condition, the treatment modalities cyclosporine and psoralen with ultraviolet A (PUVA) might increase the risk of developing cutaneous SCC, although a relationship has not been confirmed. We describe a patient with psoriasis who had been treated with cyclosporine and PUVA 6 years previously. He developed back SCC 2 years later, a subungual skin lesion after another 2 years and presented to us 1 year later, when nail elevation and biopsy revealed SCC., Learning Points: Subungual squamous cell carcinoma (SCC) is often misdiagnosed as a benign condition so most cases are invasive by the time of diagnosis; nail elevation and biopsy are recommended in all suspicious cases.Although psoriasis is not an independent risk factor for subungual SCC, the cyclosporine and PUVA used to treat psoriasis are risk factors for cutaneous SCC.The aetiology for subungual SCC is still unclear, but it should be suspected in patients with psoriasis and a suspicious presentation., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2020.)

Lactating adenomas are benign breast tumours which normally present in the peripartum period. Aetiology, pathogenesis, best diagnostic modality and management are not yet clear in the literature. We present a case of a 32-year-old pregnant patient who was re-referred to us with a progressively increasing left breast lesion, pre-existing prior to pregnancy, which was found to be a huge lactating adenoma., Learning Points: Pregnant and lactating women should stay breast aware and perform monthly breast self-examinations to detect any abnormalities at an early stage.In the absence of specific ultrasound features to identify lactating adenoma, triple assessment, including core biopsy, is the mainstay of diagnosis.Lactating adenomas, especially those potentially related to a pre-existing breast lesion or large in size, should be reported in order to develop evidence-based management guidelines., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2020.)

Penile strangulation is a rare clinical entity which if left untreated can cause serious urogenital problems. We present the case of 45-year-old male patient who presented with penile strangulation after applying a metallic ring. Strangulation of the external male genitalia is a serious problem that requires urgent intervention in order to avoid serious complications. If left untreated, it can result in gangrene and penile amputation. Management of penile strangulation is a real challenge for the treating surgeon and should be treated as an emergency in order to avoid vascular compromise., Learning Points: Penile strangulation by metallic rings is not routinely encountered in daily emergency practice and can be a challenge for the treating surgeon.Problem awareness is a crucial part of the management of such a rare entity.Every attempt should be made as early as possible to preserve penile arterial supply., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interest, (© EFIM 2019.)

Gallbladders have been reported in various ectopic locations. An intrahepatic gallbladder is one where the gallbladder lies within the liver parenchyma or has a subcapsular location along the anterior inferior right lobe of the liver. Intrahepatic gallbladders can have impaired function leading to the formation of gallbladder stones. We present the case of a 57-year-old man who was found to have an intrahepatic gallbladder which was not detected before a retrograde open cholecystectomy was carried out without intra-operative or postoperative complications. Awareness of ectopic gallbladders and their recognition allows proper intra-operative planning., Learning Points: Gallbladder disease in intrahepatic gallbladders poses an additional surgical risk for patients and complicates cholecystectomy or other biliary procedures.Awareness of this rare entity as well as optimum management will prevent patient morbidity and improve outcome.Preoperative MR cholangiopancreatographyis recommended if an intrahepatic gallbladder is identified on ultrasound or CT.Expert hepatobiliary surgeon involvement as well as an intra-operative cholangiogram is recommended in complex cases with abnormal biliary or hepatic vascular anatomy., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests.

In addition to the most likely diagnoses for umbilical signs in adults (umbilical hernia, metastatic tumour, endometriosis, congenital abnormalities such as umbilical-urachal sinus and gallstones retained or spilled at the umbilicus), the differential diagnosis should also include epidermoid cyst arising from the skin of the umbilicus. We describe the case of a young man who presented with a persistent umbilical discharge which was initially thought to be umbilical-urachal sinus, but later found to be a sebaceous cyst., Learning Points: Umbilical sebaceous cysts are rarebut should be included in the differential diagnosis in patients presenting with umbilical discharge, erythema, pain or a palpable mass.They should be considered even when the cystic lesion involves the white line, where remnants of embryonic structures are more likely, as they have been described both above and belowthe fascia, extending and penetrating the white line.Preoperative imaging including ultrasound as well as CT helps to differentiate between umbilical sebaceous cysts and urachal sinus, thusfacilitating adequate preoperative planning to ensure a better outcome., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests.