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Key Clinical Message Cholecystocolic fistula, a rare complication of long‐standing gallstone disease, is a diagnostic challenge owing to nonspecific clinical presentation and lack of accurate preprocedural diagnostic modalities. In case of incidental discovery of the fistula during the surgical procedure, excision of the fistula with repair of the colonic defect is imperative.

PE remains a clinically challenging diagnosis, more often missed than found, with no decline in its incidental discovery at autopsy over the past 30 years. Pulmonary embolism should be considered in the differential diagnosis of every dyspnoea event that presents at an emergency department. We describe a case of 68 years old man with symptoms of dyspnoea who later diagnosed as pulmonary embolism. This case report emphasizes early diagnosis and treatment to avoid fatal outcome.University Heart Journal Vol. 12, No. 1, January 2016; 40-44

Laryngeal cysts are rare lesions of the larynx that are often described on incidental discovery. We report an unusual presentation of a large ductal cyst located on the laryngeal surface of the epiglottis. The patient presented with a low tone voice while displaying bilateral normal appearing vocal cords with normal mobility. Computed tomography scans and flexible laryngoscopy showed a round supraglottic mass approximately 2 cm in diameter on the right lateral laryngeal surface of the epiglottis. The mass was removed surgically during microsuspension laryngoscopy with excision of the mucocele utilizing a gold laser. Postoperatively, the patient’s voice returned to baseline with no complications.

In the current and rapidly worsening pandemic, patients with COVID-19 may undergo imaging with FDG PET/CT. Because a significant proportion of infected patients may be asymptomatic, incidental discovery on a PET/CT scan performed for unrelated reasons can occur. Because of the highly infectious nature of this agent, it is important that interpreting physicians be aware of the typical imaging findings to identify potentially affected patients. We present the case of an asymptomatic patient referred for FDG PET/CT imaging of a lung nodule who demonstrated the typical CT findings of COVID-19 infection and was subsequently found to be positive on testing.

A patient in her 70s presented with confusion, agitation and psychotic symptoms. No cause was found until the incidental discovery of urothelial carcinoma. Upon removal of the tumour, the psychiatric symptoms largely improved leaving residual symptoms indicative of dementia. The patient had not been diagnosed with dementia previously and this made for an interesting disease presentation and progression. We discuss the challenges of diagnosing delirium and dementia in complex patients such as these and the importance of identifying a cause when cognition has been impaired by a suspected delirium.

Tc-TRODAT-1, as a tropane-derived compound with highly selective binding to the dopamine transporter, has been extensively used as an in vivo biomarker to evaluate parkinsonism. There have been few reports indicating various etiologies about extrastriatal findings on the Tc-TRODAT-1 SPECT. We herein present an interesting case about the incidental discovery of brain lymphoma with increasing uptake of Tc-TRODAT-1.

The anatomical variations of the internal jugular vein (IJV) is a well-documented phenomenon which may depend on the course of drainage, fenestration in the vein, bifid formation, variations in the tributaries and so on. However, a true duplication of the IJV is a rare entity on its own and is seldom reported in the literature. We report a case of true duplication of IJV which is an incidental discovery during the course of neck dissection.

Primary bladder amyloidosis is rare. Hematuria is the most common form of it's revelation. There are no specific clinical and paraclinical signs to differentiate it from urothelial tumors. The diagnosis is histological. We are reporting you a case of incidental discovery.

Adult pancreatic hemangioma is a rare disease. We presented a case of a woman with pancreatic tail mass mimicking a distant metastasis from the kidney. A 68-year-old woman was found with a left kidney mass on medical checkup. Computed tomography scan showed a 4.3 cm-sized mass in the left kidney, suggesting renal cell carcinoma (RCC), and a strongly enhancing tiny nodule in the pancreatic tail. We could not rule the possibility of RCC metastasis, hence, surgical resection of the pancreatic mass simultaneously with radical nephrectomy for RCC was conducted. Gross pathologic examination revealed hemangioma. Immunohistochemistry revealed that the tumor was positive for CD34, CD31 and factor VIII-related antigen. There were no significant postoperative events, and the patient was discharged on postoperative day 7 without any complications. Treatment strategies for pancreatic hemangioma have not been established. To our knowledge, this was the first case report of asymptomatic pancreatic hemangioma. In previous literature, treatment differed on a case-by-case basis, ranging from observation to surgical resection. The most important factor in deciding whether to perform surgery is possibly risk-benefit effectiveness; however, tumor location, patient symptoms, and other factors are also important.

Cardiac lipomas (CL) are uncommon. Symptoms occur based on size and location. A 55 year old man presented after incidental discovery of a cardiac mass. Echocardiography (Panel A) showed a large inferoseptal mass partly obstructing the left ventricular outflow tract (LVOT) without dynamic outflow

The ascending/descending (or ACDC) horn is a single horn with ascending high E-flat and descending F valves. Its design is simple and composed of a standard 3-valve single B-flat horn fitted with these additional E-flat alto and F valves. This horn can be set to A stopping functionality by pressing simultaneously on both these valves. This latter incidental discovery allows us to propose the first 5-valve single horn which admits a complete range of tonalities, including stopped harmonics, without the need of any additional slide or clutch valve, and with fingerings similar to the standard F/B-flat double horn. With this model, we think the single horn becomes now a serious alternative to the standard double horn.

Situs inversus totalis (SIT) which is also known as dextrocardia with situs inversus is a congenital anomaly of lateralization or sidedness. Although dextrocardia of itself is detectable on obstetrics sonography, it frequently goes undetected and these individuals are often diagnosed later in life. This is a case of SIT in a 72-year-old man, who has had normal life expectancy by Nigerian standards, detected incidentally on imaging evaluation for unrelated complaints. He presented with features of chest infection and intestinal obstruction. While on admission, he was also diagnosed with systemic hypertension and diabetes mellitus. He had no features of Kartagener's syndrome. SIT could be suspected clinically, but a definitive diagnosis often requires imaging. Medical personnel must always maintain a high index of suspicion for this relatively uncommon condition with a profound impact on administration and/or interpretation of clinical, investigative, and resuscitative procedures as well as management of ailments.

We report an incidental discovery of the superior pulmonary vein coming from a strange anatomical location when performing a robotic left lower lobectomy. When trying to identify the superior pulmonary vein, an aberrant pulmonary vein was found leading into the innominate vein.

There has been a dramatic evolution in both the clinical presentation and the methods used to diagnose pheochromocytoma and paraganglioma (PPGL) over the past nine decades. Due to the advances in biochemical testing and cross-sectional computed imaging, we have progressed from prior to 1970 when 90% of patients with PPGL were detected because of symptoms (paroxysms or hypertension) to 2018 when 60% of patients with PPGL are diagnosed due to an incidental discovery on cross-sectional imaging done for other reasons. Thus, the clinician should recognize the imaging phenotype typical for a pheochromocytoma. The differential diagnosis for those patients who present with symptoms spans the field of medicine. Biochemical case detection testing relies on measurement of fractionated metanephrines and catecholamines by tandem mass spectrometry or high-pressure liquid chromatography. The clinician should assess the relative likelihood of pheochromocytoma in each patient. Decisions for the type of test performed may be subject to clinical availability, cost, clinical experience of the ordering physician, and the local laboratory. However, it is key to understand the medications and clinical situations that may cause false-positive biochemical testing.

International audience; Although a large amount of data supports early surgical resection for symptomatic diffuse low-grade glioma, the therapeutic strategy is still a matter of debate regarding incidentally discovered diffuse low-grade glioma. Indeed, early and "preventive" surgery has recently been proposed in asymptomatic patients with silent diffuse low-grade glioma with better outcomes. The present review discusses the importance of an early diagnosis and of a preventive surgical treatment to improve the outcomes of incidental diffuse low-grade glioma and suggests the possible relevance of a tailored screening policy.

There are numerous records of conjoined twinning in humans and domesticated animals, but many fewer for wild animals because of the early death of conjoined twins. We here describe the incidental discovery and skeletal anatomy of a wild-caught bat fetus with two heads. To our knowledge, this is only the second conjoined bat fetus described, and the first conjoined Artibeus phaeotis. We also revisit the anatomy of the first conjoined bat that was described, a stillborn Eptesicus fuscus.

Bladder malignancy in patients with congenital bladder anomalies who have undergone bladder augmentation is a rare but well-recognized condition. These patients present with locally advanced or metastatic disease and have poor survival. We report a case of a patient with myelomeningocele who was incidentally found to have a high-grade intestinal type adenocarcinoma of her bladder augment at the time of cystolithotomy. This case highlights the need to continue to follow patients with congenital bladder anomalies and highlights the lack of adequate screening methods available.

To describe a novel biochemical marker in dried blood spots suitable to improve the specificity of newborn screening for Pompe disease. The new marker is a ratio calculated between the creatine/creatinine (Cre/Crn) ratio as the numerator and the activity of acid α-glucosidase (GAA) as the denominator. Using Collaborative Laboratory Integrated Reports (CLIR), the new marker was incorporated in a dual scatter plot that can achieve almost complete segregation between Pompe disease and false-positive cases. The (Cre/Crn)/GAA ratio was measured in residual dried blood spots of five Pompe cases and was found to be elevated (range 4.41–13.26; 99%ile of neonatal controls: 1.10). Verification was by analysis of 39 blinded specimens that included 10 controls, 24 samples with a definitive classification (16 Pompe, 8 false positives), and 5 with genotypes of uncertain significance. The CLIR tool showed 100% concordance of classification for the 24 known cases. Of the remaining five cases, three p.V222M homozygotes, a benign variant, were classified by CLIR as false positives; two with genotypes of unknown significance, one likely informative, were categorized as Pompe disease. The CLIR tool inclusive of the new ratio could have prevented at least 12 of 13 (92%) false-positive outcomes.

Extramedullary plasmacytomas (EMPs) are defined by the presence of clonal plasma cell proliferation outside of the bone marrow, portending an overall poor prognosis. This case highlights extramedullary plasmacytomas as an unusual presenting manifestation of multiple myeloma. Through incidental discovery during a delayed hemolytic transfusion reaction workup, EMPs were found in the liver, spleen, and possibly the lung. Though rare at presentation, this case emphasizes that the presence of EMPs should be considered at the outset as it not only impacts the treatment regimen for such patients but also considerably affects prognosis.

Introduction: Aneurysm of membranous interventricular septum is a rare cardiac abnormality and the prevalence is not known. It can be isolated but is usually associated with congenital heart disease, most often with ventricular septal defect. Most patients are asymptomatic but special caution should be taken in considering potential risk.1, 2 Case report: 58-year-old female came because she had chest pressure with discomfort in back, fatigue and weakness. The blood pressure was 140/80 mmHg, heart rate 80 BPM and no heart murmur was discovered on clinical examination. Electrocardiography showed sinus rhythm, normal axis and right bundle branch block. The transthoracic echocardiogram discovered and the transesophageal exam confirmed the aneurysm of the membranous intraventricular septum without septal defects, pathological flows or intracavital masses. Conclusion: Aneurysm of membranous interventricular septum is occasional cardiac abnormality and the patients are often asymptomatic. Transthoracic echocardiography, transesophageal echocardiography, cardiac CT and MR imaging are the methods of choice for diagnosis of VSA aneurysm. Patients with VSA have risk of thrombus formation and stroke, ventricular tachycardia and AV block, aortic regurgitation, intracardiac shunts, ruptures and endocarditis.

Summary Improvements in medical imaging have resulted in the incidental discovery of many silent and unrecognized adrenal tumors. The term “adrenal incidentaloma” (AI) is applied to any adrenal mass ≥ 1 cm in its longest axis that is discovered incidentally during abdominal imaging that was not performed to specifically evaluate adrenal pathology. These incidentalomas may be either secretory or non-secretory, benign or malignant. Distinctive characteristics of these lesions must be determined by the clinician to determine appropriate management. Such distinctions are based on laboratory findings and imaging, principally CT with and without contrast injection. Investigations must be carefully chosen to avoid ordering unnecessary and expensive tests for too many patients while, at the same time, avoiding the risk of failing to diagnose a secreting malignant or tumor. These examinations will determine patient care: surgery or surveillance. When simple surveillance is chosen, specific criteria must be met with regard to diagnostic modalities (clinical, imaging, laboratory testing) and its duration.

INTRODUCTION Arteriovenous fistula (AVF) is the abnormal connection between an artery and vein. Congenital AVF of the popliteal artery is very rare. PRESENTATION OF CASE 89 year old lady presented with right acute lower limb ischaemia. She had unilateral chronic venous hypertensive change in the right leg. Femoral embolectomy was performed. Backflow was achieved. Arteriotomy was closed. The patient's leg continued to deteriorate. She returned to theatre. On-table angiogram showed an occluded SFA. Thrombectomy was completed. SFA was patent but no blood flowed into the distal popliteal artery. A second on table angiogram revealed AVF between popliteal artery and vein. Dissection to the posterior aspect of the knee revealed the fistula. The vein was arterialized and enlarged. The AVF was ligated. Normal distal blood flow was achieved. Retrospectively we measured the leg lengths. Right leg was 3 cm longer than the left. The right leg circumference was 7 cm greater than the left. She reported chronic venous change from a young age. She did not report any history of trauma to the limb. DISCUSSION Popliteal artery to popliteal vein fistula is a rare. Trauma is the most common cause of popliteal AVF. Should the condition develop before closure of the epiphyses, there may be an increase in leg measurements. CONCLUSION We postulate that this case of AV fistula may be congenital due to discrepancy in leg measurements and unilateral chronic venous hypertensive change. Rarely persistent remnants of the embryonic sciatic artery can lead to arteriovenous anastomoses, which may be a possible aetiology.

We report the incidental discovery of a flexor carpi radialis brevis tendon, a rare anatomical variant identified during a surgical procedure. Magnetic resonance imaging of the contralateral side helped to delineate the anatomy of the flexor carpi radialis tendon and to differentiate the flexor carpi radialis brevis tendon from it. We describe the use of this rare tendon in ligament reconstruction of the basal joint of the thumb.

We report the incidental discovery of supernumerary breast changes on sequential ⁶⁷Ga scans in a woman with dermatofibrosarcoma protuberans excised 5 years before. The appearance of the accessory breast fluctuated with physiological ⁶⁷Ga uptake of the breast tissue was evident. Awareness of the concomitant changes in accessory breast with breast tissue could help narrow the differential diagnosis.

Over the past few decades the widespread application of non-invasive, high resolution imaging techniques such as MRI and CT has led to the incidental discovery of asymptomatic adrenal masses with increasing frequency. These masses, named “adrenal incidentalomas” (AIs), raise challenging questions for physicians and their patients. The diagnostic approach has to be focused on distinguishing benign and non-secreting from malignant or hormone secreting adrenal masses, and this approach combines radiological and functional evaluations. The aim of this chapter is to review the main techniques for the functional evaluation of AIs.

Highlights • Lymphangiomas of the colon are benigne tumors. • They may lead to life-threatening conditions. • Infection, volvulus, obstruction and bleeding into the lumen of a cyst are usually very difficult to manage., Introduction Colonic lymphangioma is an unusual benign malformation. The clinical presentation of lymphangiomas vary from incidental discovery on imaging to presenting with acute abdomen. Presentation of case We present the case of a 73-year-old male, undergoing surgery due to acute abdomen associated with severe anemia, in whose case a lymphangioma of the cecum was recognised only in the postoperative histopathological examination. Discussion The management of colonic lymphangioma depends on the individual situation; close surveillance or endoscopic therapy may be appropriate for asymptomatic lesions smaller than 2.5 cm in diameter. Surgical intervention can be considered for larger lesions or in patients who develop complications. Conclusion The interest in our case lies in the relatively rare diagnosis of colon lymphangioma and how the cardinal sign was anemia, which may be due to the serosanguineous cystic contents of lymphangiomatosis from the internal bleeding and can cause fatal complications that require emergency surgery.

Einleitung: Phäochromozytome sind seltene katecholamin-produzierende Tumore des neuroektodermalen Gewebes. Neben extraadrenalen Manifestationsorten stellt das Nebennierenmark als größte Ansammlung chromaffiner Ganglienzellen die häufigste Prädilektionsstelle dar. Etwa ein Viertel aller Phäochromozytome ist genetisch disponiert. Exzessive Hormonproduktion führt zu einem heterogenen Symptomkomplex, aus welchem die klassische Trias mit Kopfschmerzen, Palpitationen und Hyperhidrosis herausragt. Eine begleitende arterielle Hypertonie kann permanent oder paroxysmal vorliegen, aber auch gänzlich fehlen. Die Diagnostik besteht aus biochemischer Hormonanalyse und bildgebenden Verfahren, die Operation ist die Therapie der Wahl. Methodik und Fragestellung: Ein nicht unerheblicher Anteil aller Phäochromozytome scheint inzidentell entdeckt. In dieser retrospektiven Studie wurden Registerdaten von vier deutschen endokrinologischen Zentren ausgewertet. Dabei konnten schlussendlich Daten von 137 Patienten mit Phäochromozytomen und Paragangliomen aus dem Zeitraum 1973 bis 2008 hinsichtlich epidemiologischer, klinischer, diagnostischer und therapeutischer Gesichtspunkte analysiert werden. Hauptziel der Arbeit war es, exakte Diagnoseumstände von intra- und extraadrenalen Phäochromozytomen zu eruieren und dabei Häufigkeit sowie Einflussgrößen der inzidentellen Diagnosefindung zu ermitteln. Ergebnisse: Bei 134 Patienten mit Phäochromozytom (49,3% Frauen; mittleres Alter 48,5±14,8 Jahre) zeigten sich keine signifikanten geschlechtsspezifischen Unterschiede hinsichtlich Alter, Diagnosedauer und Symptomatik. In der Gesamtkohorte präsentierte sich die typische Symptomtrias nur in 11,6% der Fälle. 8,3% der Patienten wurden als asymptomatisch gewertet, 8,5% als normotensiv beschrieben. 36,5% aller Patienten mit arterieller Hypertonie waren ohne antihypertensive Medikation zum Zeitpunkt der Diagnosestellung. Knapp zwei Drittel aller Patienten mit arterieller Hypertonie präsentierten paroxysmale Blutdruckanstiege. In 49 Fällen (38,6%) konnte eine inzidentelle Diagnosefindung nachvollzogen werden. Vor 1985 lag die Inzidentalom-Rate bei 12,5% und stieg in den Folgejahren auf etwa 40% an. Patienten mit inzidentell entdecktem Phäochromozytom waren im Mittel signifikant älter (53,0±13,4 vs. 46,0±14,3 Jahre, p=0,007) und zeigten deutlich weniger paroxysmale Blutdruckanstiege (38,8% vs. 73,1%, p=0,0002) als Patienten mit klinisch bereits vermutetem Phäochromozytom. Kein Unterschied ergab sich in Bezug auf allgemeine Symptomatik, Tumorlage und Tumorgröße sowie Hormonaktivität, auch wenn die Katecholaminspiegel im 24-Stunden-Sammelurin beim Inzidentalom teilweise signifikant niedriger gemessen wurden. Schlussfolgerung: Aufgrund zunehmender Verfügbarkeit und verbessertem Zugang zu bildgebenden Verfahren, wie CT und MRT, ist der Anteil inzidentell diagnostizierter Phäochromozytome in den letzten Jahrzehnten deutlich gestiegen. Es zeigt sich kein Unterschied hinsichtlich der Prävalenz der arteriellen Hypertonie im Vergleich zu den klinisch bereits vermuteten Phäochromozytomen. Jedoch scheinen fehlende paroxysmale Blutdruckanstiege das Stellen der korrekten Verdachtsdiagnose negativ zu beeinflussen. Vor dem Hintergrund der potentiellen malignen Entartung sollte jedes adrenale Inzidentalom auf das Vorliegen eines möglichen Phäochromozytoms diagnostisch aufgearbeitet werden., Background: Pheochromocytomas are rare catecholamine-producing tumours arising from chromaffin cells of the adrenal medulla or from extra-adrenal chromaffin tissue. About one fourth of patients with pheochromocytomas are carriers of germline mutations. The excessive release of catecholamines leads to a wide variety of symptoms. Pheochromocytomas are discovered due to the classical symptom triad of headache, sweating and palpitations combined with a persistent or paroxysmal arterial hypertension, which might also be missing. Imaging techniques and biochemical evidence of catecholamine overproduction help finding the correct diagnosis. Surgery is the core of an appropriate therapy. Methods and objective: An increasing proportion of pheochromocytomas seems to be discovered incidentally. Four German endocrine centres participated in this retrospective study. Finally, medical records of 137 patients with pheochromocytoma and paraganglioma who were diagnosed between 1973 and 2008 were analyzed. This study aims at investigating the circumstances of the discovery of adrenal and extra-adrenal pheochromocytoma and trying to specify the frequency and contributing factors of incidental finding. Results: There were no gender-related differences regarding age, time of diagnosis and clinical presentation among 134 patients with pheochromocytoma (49.3% women; average age 48.5±14.8 years). The typical triad of symptoms was only found in 11.6% of cases. 8.3% of patients presented were without any clinical symptoms and 8.5% were normotensive. 36.5% of patients with arterial hypertension were without antihypertensives at presentation. Documented blood pressure peaks occurred in two-thirds of cases. Before 1985, 12.5% of cases were incidentally discovered, whereas thereafter the frequency was around 40% (38.6% of the total study population). Patients with incidentally detected pheochromocytoma were significantly older (53.0±13.4 vs. 46.0±14.3 years, p=0.007) and often had less blood pressure peaks (38.8% vs. 73.1%, p=0.0002) than patients whose diagnosis was suspected on clinical grounds. There was no significant difference concerning clinical presentation, size and location of the tumour, as well as endocrine activity even if incidentalomas seem to be associated with lower levels of urinary catecholamines. Conclusions: Owing to better availability and accessibility of imaging procedures like CT and MRI, the number of incidentally discovered pheochromocytomas is increasing during the last decades. There is no significant difference in the prevalence of arterial hypertension compared to the suspected tumours. The lack of paroxysmal blood pressure peaks seems to influence the finding of the correct diagnosis negatively. Due to the potential malignant degeneration, every adrenal incidentaloma should be investigated concerning the presence of pheochromocytoma.

A 58-year-old woman was referred to Hospital Tuanku Ja’afar (Seremban, Malaysia) for contrast-enhanced CT abdomen and pelvis following discovery of a solid mass in the right adnexa on ultrasonography. CT findings revealed a well-defined, fat-containing mass with calcifications in the right adnexa measuring 4.5×7.8×4 cm, consistent with ovarian teratoma (figure 1). Incidentally, the vermiform appendix appeared to be elongated and extended into the right inguinal canal. It was not enlarged, and there was no surrounding fat streakiness (figures 1 and 2). A diagnosis of Amyand’s hernia was made. She was advised for conservative (non-surgical) treatment as she was asymptomatic for both ovarian mass and Amyand’s hernia. She was then given appointment for ultrasound follow-up. Figure 1 Contrast-enhanced CT abdomen and pelvis in axial sections showing the appendix (arrows) extending into the right inguinal canal. Right ovarian teratoma is also …

Objectives To present a rare case of the incidental discovery of two misplaced intrauterine devices in the same patient, and to discuss risk factors for uterine perforation and appropriate management.Case A 37-year-old woman complaining of chronic lower back pain presented with an X-ray of her abdomen showing two misplaced LNG-IUSs in the peritoneal cavity. More than two years before the patient had submitted within two months to two successive attempts at insertion of a Mirena® IUS. The threads of the first IUS were not seen at the follow-up visit and the IUS was not detected on ultrasound either. As it was assumed to have been expelled, insertion of a second IUS of the same type was attempted. Again, the threads were not seen at the control visit. This time, no further action was undertaken.Conclusions Radiography is helpful in confirming migration of an intrauterine contraceptive. Removal of the latter is recommended, due to the potential for serious complications.

Introduction/Background Ectopic nephrogenic rests (ENR) are rare. The incidental discovery of these lesions in children has particular clinicosurgical implications, especially given the association between ENR and the development of extrarenal Wilms' tumors (ERWT). Methodology We reviewed the hospital records of patients with ERWT and ENR treated at our hospital over a 10-year period to identify those patients with histopathologically confirmed ENR and/or ERWT. Results Ninety-five children with Wilms' tumor (WT) were identified, but only 1 case of ENR and ERWT. This patient was a 14-month-old boy who was incidentally found to have a mass in the left inguinal canal during orchiopexy. After histology, a provisional diagnosis of ENR was made. Six months later, the child went on to develop an ERWT at the same site. Periodic postsurgical follow-up has been uneventful. Discussion and conclusions This was the only case of ENR and ERWT in child in a 10-year review of patients with WT at our hospital. Our experience stresses the importance of including ENR in any working differential diagnosis of unexpected masses in the inguinal canal in children and underscores why careful long-term follow-up is mandatory. The reasons for the malignant transformation of ENR into primary ERWT are unknown, but our experience lends support for the theory that ENR are precursor lesions to the development of WT even in ectopic sites. The case also provides an example of the kind of technical difficulties presented by paratesticular masses during laparoscopy.

We present a case of a 24-year-old man who was treated for gynecomastia with bilateral mastectomy and free nipple grafts with subsequent discovery of bilateral breast cancer in the submitted specimens. Surgical treatment of gynecomastia is becoming more popular with over 16,000 procedures of gynecomastia reduction performed in 2005, an increase of 17% compared with the previous year. This case underscores the rare but real possibility of detecting breast cancer in men who present with gynecomastia to plastic surgeons. We caution that male breast tissue should be regarded with the same oncologic principle as female breast tissue. In cases in which ultrasound-assisted suction lipectomy is used, the inability to analyze the breast tissue should be disclosed to the patient.

Introduction The technique of balloon remodeling allows the endovascular treatment of wide-neck intracranial aneurysms. For many years the only available devices were the Hyperform and the Hyperglide balloon catheters. Recently, other companies have developed newer devices, single or dual-lumen. We present our initial experience with the TransForm occlusion balloon catheter for the treatment of intracranial aneurysms. Methods We retrospectively analysed from our prospectively gathered aneurysm database all aneurysms that were treated with balloon remodelling using TransForm occlusion balloon catheters from January 2013 to February 2014. We assessed patient demographics, morphological features of the aneurysms, procedure feasibility, technical and clinical complications. Results Thirty-three patients harbouring 36 intracranial saccular aneurysms were treated during 33 procedures. Clinical finding were: 15 incidental discovery, 13 subarachnoid haemorrhage (SAH), five aneurysms with mass effect, one ruptured aneurysm with SAH and mass effect, one recanalisation and one intraparenchymal haematoma. Thirty-five aneurysms were in the anterior and one in the posterior circulation. Mean dome and neck size were, respectively, 5.8 mm and 3.6 mm. Twenty-three aneurysms were treated with TransForm C and 13 with TransForm SC. We had two procedural thromboembolic complications, without permanent clinical events. No early rebleeding occurred. Conclusions In our small series, the TransForm occlusion balloon catheter seems to be safe and effective for the treatment of intracranial aneurysms, in ruptured and unruptured cases.

A 65-year-old man with a history of hyperplastic polyps underwent a surveillance colonoscopy, which revealed a large, smooth cystic bulge at the appendicular orifice (Figure 1). Subsequently, a computed tomography (CT) of the abdomen with contrast revealed an appendiceal mucocele measuring 13.3 × 4.5 cm (Figures 2a and 2b). Because of the abnormal imaging findings, an elective laparoscopic appendectomy and cecectomy was performed with minimal spillage. A gross specimen measuring 9 cm in length and 3 cm in diameter was collected with the appendiceal lumen, which was filled with yellow mucoid material. Histopathologic evaluation of the appendix revealed a low-grade appendiceal mucinous neoplasm (LAMN)-I (Figure 3). The patient had an uneventful recovery and was doing well at the time of writing. Repeat CT of the abdomen and pelvis was scheduled at 6 months and 12 months, and a colonoscopy at 1 year after surgery. Figure 1. Colonoscopy image showing a large cystic lesion at the appendicular orifice. Figure 2a (left) and 2b (right). Computed tomography (coronal [2a] and transverse [2b]) with contrast, demonstrating a large appendix with diffuse wall thickening indicative of appendiceal mucocele neoplasm. Figure 3. Histopathologic image (10x magnification) demonstrating villiform mucinous epithelium, glandular epithelium with tall columnar mucinous cells, and pseudostratified nuclei at the base. On endoscopic visualization of this 65-year-old patient, lipoma or mucocele were considered the differentials. On the basis of the CT of the abdomen and of the endoscopy, we considered LAMN, with the rare possibility of pseudomyoma and peritoneal metastasis. LAMN is a rare entity with an incidence ranging from 0.2% to 0.7% of all excised appendixes.1 Approximately 25% to 50% of LAMN are incidental findings with the initial discovery during radiologic or endoscopic examinations, or during surgery.2 Initial presentation can range from asymptomatic to right lower quadrant abdominal pain or a palpable abdominal mass. Initial clinical differentials include acute appendicitis, diverticulitis, ovarian mass (in women), large cecal mass, peritoneal carcinomatosis originating from colon cancer, peritoneal sarcomatosis, peritoneal mesothelioma, disseminated peritoneal fungal infections, pseudomyxoma peritonei, or retroperitoneal cyst.1,3 LAMN is divided into two major classes. LAMN-I is found in a younger group of patients, with the tumor confined to the appendix lumen.4 LAMN-I is rarely progressive, so a “wait-and-watch” policy is recommended with measurement of tumor markers, CT of the abdomen and pelvis at six months, and an annual work-up.4 LAMN-II is usually found in older patients, with mucin and/or neoplastic epithelium in the submucosa, the intestinal wall, or in the area around the appendix with or without perforation.1,4 Recommended treatment for LAMN-II includes hyperthermic intraperitoneal chemotherapy, prophylactic cytoreductive surgery, greater omentectomy and splenectomy, left upper quadrant peritonectomy, right upper quadrant peritonectomy, lesser omentectomy with cholecystectomy, pelvic peritonectomy with rectosigmoid resection, and anterectomy with a more aggressive follow-up.3,5 In women with concomitant peritoneum, ovarian, or appendix tumors, many authors believe that the appendix is the primary site with secondary involvement of ovary and peritoneum, whereas others believe that each tumor has an independent origin.5 The topic continues to be debated. Since intact mucoceles are benign, the worst outcomes are perforation or spillage of the mucoceles into the peritoneal cavity, causing pseudomyxoma peritonei to develop.3