Lymphangiomatosis of the ileum with perforation: A case report and review of the literature

Intermittent melena and refractory anemia due to jejunal cavernous lymphangioma: A case report

BACKGROUND

Lymphangiomas in the gastrointestinal tract are extremely rare in adults. As a benign lesion, small intestine lymphangiomas often remain asymptomatic and pose challenges for definitive diagnosis. However, lymphangiomas can give rise to complications such as abdominal pain, bleeding, volvulus, and intussusception. Here, we report a case of jejunal cavernous lymphangioma that presented with intermittent melena and refractory anemia in a male adult.

CASE SUMMARY

A 66-year-old man presented with intermittent melena, fatigue and refractory anemia nine months prior. Esophagogastroduodenoscopy and colonoscopy were performed many times and revealed no apparent bleeding. Conservative management, including transfusion, hemostasis, gastric acid secretion inhibition and symptomatic treatment, was performed, but the lesions tended to recur shortly after surgery. Ultimately, the patient underwent capsule endoscopy, which revealed a more than 10 cm lesion accompanied by active bleeding. After single-balloon enteroscopy and biopsy, a diagnosis of jejunal cavernous lymphangioma was confirmed, and the patient underwent surgical resection. No complications or recurrences were observed postoperatively.

CONCLUSION

Jejunal cavernous lymphangioma should be considered a cause of obscure gastrointestinal bleeding. Capsule endoscopy and single-balloon enteroscopy can facilitate diagnosis. Surgical resection is an effective management method.

Generalized cystic lymphangiomatosis incidentally diagnosed in an asymptomatic adult: Imaging findings of a very rare case

Lymphangiomas are benign lesions of vascular origin with lymphatic differentiation, most commonly found in the head and neck. Generalized lymphangiomatosis is a very rare condition in adults, which is characterized by a diffuse proliferation of lymphatic vessels. The lymphangioma is composed of lymphatic endothelium-lined cystic spaces. This condition can be histologically differentiated from other vascular disorders such as cavernous or capillary hemangioma. However, many cases of lymphangioma can be confused with other vascular disorders, because of overlapping histologic findings. radiologic examinations, such as CT scan and MR imaging, are useful for assessing the morphologic feature and also the extent of disease, it is important to know the radiologic findings of generalized lymphangiomatosis. In this paper, we report a case of generalized lymphangiomatosis in a 42-year-old male who presented with left flank pain and hematuria. The first differential diagnosis was renal colic; hence he underwent an abdominopelvic computed tomography scan (CT scan). In the performed CT scan multiple cystic lesions were seen in the liver and spleen. Also, lytic lesions were seen in bones. CT-guided biopsy was performed and the result was compatible with generalized lymphangiomatosis, confirmed by cytology. Generalized lymphangiomatosis is a rarely reported disease in children and young adults. Delayed diagnosis in older patients or misdiagnosis is common due to its rarity and nonspecific clinical presentation. Different imaging modalities can incidentally diagnose the disease in asymptomatic patients. So radiologists should be aware of the disease manifestations in imaging modalities to diagnose the disease sooner and help the clinician start the therapy if needed.

Colonic Lymphangiomatosis

Lymphangiomas are benign malformations of the lymphatic vessels which can be primary or secondary in etiology. Colonic involvement is rare, and the diagnosis is mostly incidental. Sometimes, the initial endoscopic appearance can be misleading. We present a case of colonic lymphangiomatosis presenting with free air under the diaphragm requiring surgical removal of the involved portion of the colon. The diagnosis was confirmed by the pathology of the resected specimen and its correlation with prior clinical information. The patient recovered well with an uneventful postoperative course and follow-up. This case demonstrates a rare complication of colonic lymphangiomatosis prompting definitive treatment by surgical resection.

Lymphangiomatosis presented with melena and chylous ascites: A case report

INTRODUCTION

Lymphangioma, a rare benign tumor of the lymphatic system, is called lymphangiomatosis when it involves >1 organ, which is more rarely complicated with thoracic obstruction, the relationship between them remains unclear. With the development of enteroscopy, clinicians know more about small intestinal lymphangioma and attempt to treat it through enteroscopic injection sclerotherapy(EIS).

PATIENT CONCERNS

A 59-year-old male firstly manifested with gastrointestinal bleeding after a gastric perforation, who was diagnosed with lymphangiomatosis by balloon-assisted enteroscopy and abdomen CT showing >1 organ with multiple cysts besides the small intestine. The patient received an EIS, then the melena disappeared. Surprisingly he came back because of refractory ascites confirmed to be chylous by chemical tests 7 months later.

DIAGNOSIS

Lymphangiography could not determine the location of lymphatic leakage, Ultrasonography showed stenosis of the left cervical part of the thoracic duct.

INTERVENTION

On the condition that medical treatment is ineffective, thoracic duct exploration and lysis of fibrous adhesion were performed.

OUTCOMES

Ascites significantly reduced at last.

LESSONS

Lymphangiomatosis is the malformation of the lymphatic system involving multiple organs, it has a possibility to be associated with thoracic obstruction. Capsule endoscopy and enteroscopy are effective methods to diagnose small intestinal lymphangioma, and EIS is an effective therapy.

Resection of primary lesion with chemotherapy improves the survival of patients with metastatic colorectal neuroendocrine carcinoma

OBJECTIVE

To evaluate the effect of resection of primary lesion and chemotherapy on survival of patients with metastatic colorectal neuroendocrine carcinoma (CRNEC).

METHODS

Clinical data of 393 patients with metastatic CRNECs between January 2010 and December 2016 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database, including 171 patients who received resection of primary lesion and 221 patients who did not undergo surgery. With the propensity score matching method 172 non-operated patients were selected as controls. Kaplan-Meier method and Log-rank test were used to evaluate the survival differences, while the prognostic factors were analyzed by Cox proportional-hazards model. Metastatic CRNEC patients from January 2001 to December 2021 in Affiliated Jinhua Hospital, Zhejiang University School of Medicine were selected for validation.

RESULTS

Compared with non-operated patients, patients who received resection had longer cause-specific survival ( P<0.05). Patients with resected positive lymph nodes>8 had a poorer prognosis compared to those with resected positive lymph nodes≤8 ( P<0.05). Multivariate analysis showed that gender, location of primary lesion and treatments were independent risk factors for cause-specific survival in patients with metastatic CRNEC (all P<0.05). For metastatic CRNEC patients with resection of primary lesion, rectal neuroendocrine carcinoma, positive resected lymph nodes≤8 and resection of primary lesion combined with chemotherapy were associated with better cause-specific survival (all P<0.05).

CONCLUSIONS

Patients with metastatic CRNEC may benefit from resection of primary lesion, and resection of primary lesion combined with chemotherapy might be the better strategy for metastatic CRNECs. The number of positive lymph nodes resected is correlated with the prognosis of patients.

Laparoscopy for evaluating mesenteric lymphangiomatosis: A case report

Background

Lymphangiomatosis is an extremely rare disease with potential soft tissue, bone, and spleen involvement, which can be characterized by lymphangioma. Only a few cases of colon and mesenteric lymphangiomatosis have been reported. We report a case presenting with fatigue, periumbilical pain, and intermittent bloody stools. This patient underwent a series of examinations. Exploratory laparoscopy, in particular, yielded very valuable images and videos for this disease, which can provide evidence for the diagnosis of this disease.

Case summary

The current patient had fatigue, periumbilical pain, and intermittent bloody stools. Colonoscopy indicated numerous variable-sized hyaline cysts in the colon. Submucosal puncture was performed during colonoscopy. The patient was readmitted to the hospital due to periumbilical pain. B-ultrasound and abdominal CT showed multiple hypoechoic nodules in the mesenteric area. Exploratory laparoscopy was performed, and histopathology revealed that D2-40 was positive. Based on auxiliary examination and laparoscopic biopsy, surgeons and pathologists reached the diagnosis of mesenteric lymphangiomatosis.

Conclusion

Clinicians need to comprehensively improve their knowledge of lymphangiomatosis, and the combination of clinical symptoms, histological characteristics, and colonoscopy biopsy findings should be considered to improve lymphangiomatosis diagnosis, thereby reducing misdiagnosis.

Core tip

Colon and mesenteric lymphangiomatosis is an extremely uncommon benign condition of unknown etiology and pathogenesis in adult patients. We report a case of mesenteric lymphangiomatosis in a 37-year-old woman who presented with fatigue, periumbilical pain, and intermittent bloody stools, as well as lesions in the kidney, spleen, and bones. This case provides new insights into the diagnosis and treatment of this disease.

Clinical manifestation and treatment of small intestinal lymphangioma: A single center analysis of 15 cases

Background

Small intestinal lymphangioma is a very rare benign lesion. Thus far, the literature on small intestinal lymphangioma has mainly involved case reports. The present study retrospectively examined the clinical features of patients with a pathological diagnosis of small intestinal lymphangioma.

Materials and methods

From January 2010 to January 2021, 15 patients were pathologically diagnosed with small intestinal lymphangioma. The age, gender, clinical manifestation, computed tomography (CT) findings, endoscopic findings, localization of the lesion, treatment method, complications, and follow-up were retrospectively analyzed.

Results

Most of the patients had no symptoms, and those with symptoms had melena or abdominal pain. Lymphangioma was located in the duodenum in nine cases (60.0%), jejunum in two (13.3%), jejunal-ileal junction with mesentery involvement in one (6.7%) and ileum in three (20.0%). Three cases (20.0%) had multiple lesions, and the other 12 (80.0%) had single lesions. The median size of the lesions was 0.8 cm. Thirteen cases were found by endoscopy, and nine cases of them had white-colored spots on the surface. Ten cases (66.7%) underwent endoscopic treatment, three (20.0%) underwent surgical treatment, and two (13.3%) were followed up. Postoperative acute pancreatitis developed in one patient after endoscopic resection of duodenal papillary lymphangioma; postoperative abdominal bleeding occurred in one patient with jejunal lymphangioma who underwent partial small bowel resection.

Conclusion

Small intestinal lymphangioma is extremely rare, and its clinical manifestations are non-specific. Endoscopy is of great value in the diagnosis of small intestinal lymphangioma. Depending on the clinical manifestations, the size, location and scope of the lesions, follow-up, endoscopic treatment and surgery can be selected.

Bowel perforation following percutaneous sclerotherapy of an intra-abdominal lymphatic malformation

Mesenteric lymphatic malformations result from abnormal proliferation of disorganized mesenteric lymphatic channels. Sclerotherapy is often preferred over surgery as it is less invasive and has lower post-procedure morbidity. Sclerotherapy has been described as durable and effective with a low complication rate. We describe a serious complication from sclerotherapy of a lymphatic malformation extending from the mesentery through the bowel wall, highlighting the spectrum of this pathology and the need for multidisciplinary management of complex cases.

T-Cell Non-Hodgkin Lymphoma of the Ileum Presenting as Perforation and Peritonitis: A Case Report

Background

Non-Hodgkin lymphoma (NHL) of the ileum, presenting as perforation and peritonitis, is a rare disease, derived from intestinal intraepithelial T lymphocytes. The degree of malignancy is extremely high. The pathogenesis of ileal perforation caused by NHL remains unclear, as well as the chromosome and immune system abnormalities, which may be related to NHL, and are indistinguishable from other benign and malignant conditions and are clinically nonspecific.

Case Report

We describe an 84-year-old man with abdominal pain for 4 days, which was aggravated for 3 h. The pain was in the upper abdominal region and was initially considered to be due to gastrointestinal perforation. He had persistent insidious pain, accompanied by nausea, vomiting, and fever. Physical examination indicated that the patient had pain all over the abdomen; also, rebound pain and muscle tension, and bowel sounds were reduced on auscultation. An abdominal CT scan showed free gas in the abdominal cavity. The patient was diagnosed with peritonitis due to hollow viscus perforation. A prompt exploratory laparotomy was performed. Intraoperative findings showed perforations in the ileum that are approximately 40 cm from the ileocecal region, which were 3–8 mm in size. A segmental distribution was observed, and the intestinal contents overflowed with purulent discharge around the perforation surface. Resection and ileostomy were performed, and the clinical histopathological examination confirmed T-cell lymphoma. The patient was advised to visit the Oncology Department for further chemotherapy.

Conclusion

Timely emergency surgery is the key to the treatment of ileal perforation caused by T-cell lymphoma. Resection and ileostomy were performed as intervention measures, and subsequent histopathological examination manifested T-cell lymphoma.

Laparoscopic Resection for Lymphangioma Originating From Small Intestine: A Case Report

Background

Lymphangioma originating from the small intestinal wall is a very rare finding. There have been only 15 case reports on the disease. Here, we report a case of lymphangioma in the small intestine that was resected laparoscopically. We also provide a literature review.

Case Presentation

A 37-year-old man came to our hospital with a chief complaint of abdominal pain. Physical examination showed mild tenderness in the lower abdomen, but rebound tenderness or guarding was absent. A contrast-enhanced computed tomography scan showed local poor enhancement in distal ileum, suggesting the possibility of mucous necrosis. Conservative therapy was started. On the eighth hospital day, although his abdominal symptoms improved, a follow-up computed tomography scan showed no improvement in the distal ileum lesion. Laparoscopic tumor resection was performed. The patient's postoperative course was unremarkable, and he was discharged on postoperative day 7. The pathologic result of the surgical specimen was lymphangioma of the ileum. The patient is still alive with no sign of recurrence 19 months after surgery.

Conclusion

Lymphangioma originating in the small intestinal wall is a very rare disease. Laparoscopic resection seems to be a preferable method for surgery.

Extensive abdominal lymphangiomatosis involving the small bowel mesentery: A case report

BACKGROUND

Abdominal lymphangiomatosis is a rare benign condition accounting for less than 1% of all the cases of lymphangiomatosis. Management usually involves radical surgical excision; however, depending upon the extent of involvement, patient condition, and absence of complications, conservative management can be also considered.

CASE SUMMARY

We present the case of a 32-year-old male who presented with short onset abdominal pain and melena. Physical examination findings were within normal limits, except for left lower abdominal tenderness. Upper gastrointestinal endoscopy was within normal limits. Abdominal and pelvic ultrasound and computed tomography (CT) scan revealed numerous, variably-sized cystic lesions within the abdominal cavity, exclusively and extensively affecting the small bowel mesentery with sparing of the retroperitoneum. The diagnosis was confirmed by CT and cytological examination. Radical surgical excision was technically impossible in this patient because of the extensive involvement of the mesentery; therefore, the patient was managed conservatively.

CONCLUSION

Extensive and exclusive small bowel mesentery involvement in abdominal lymphangiomatosis is rare. Imaging modalities play an important role in establishing the diagnosis and conservative management can be considered when surgery is technically impossible.

Lymphangiomatosis associated with protein losing enteropathy: A case report

BACKGROUND

Lymphangiomatosis is a multisystem disorder that is rarely localized to the gastrointestinal tract. Lymphangiomatosis usually has no specific clinical presentation and is easily misdiagnosed. A case report and review of the literature on lymphangiomatosis associated with protein-losing enteropathy will help to improve the overall understanding of this disease.

CASE SUMMARY

We report a case of lymphangiomatosis of the bowel and other solid organs. A 78-year-old man presented with recurrent bowel bleeding and protein-losing enteropathy, as well as cystic lesions in the spleen, liver, and kidney. Imaging examinations revealed many cystic lesions on the spleen, liver, kidney, and thickened wall of the ascending colon, as well as pleural effusion and ascites. Colonoscopy revealed a strawberry mucosa, variable spontaneous bleeding, and surface erosion located in the terminal ileum. Several cystic masses with a translucent and smooth surface as well as diffuse white spots were located in the colon. A laterally spreading tumor (LST) was located in the ascending colon. Pathology indicated highly differentiated adenocarcinoma (LST) and lymphangiomatoid dilation, and D2-40 was positive. The final diagnosis was lymphangiomatosis. The patient underwent surgery for LST and then was administered thalidomide 75-150 mg/d. His condition, however, did not improve. He eventually died 6 mo after the initial diagnosis.

CONCLUSION

Lymphangiomatosis usually occurs diffusely and can involve many organs, such as the spleen, kidney, liver, lung, mesentery, and bowel. Recurrent bowel bleeding or protein-losing enteropathy is an important indicator that should alert clinicians about the possibility of this disease when it afflicts the bowel. Doctors should improve the medical understanding of lymphangiomatosis.

Haemorrhagic ileal haemolymphangioma: a case report and review of the literature

We describe herein a 37-year-old woman with a 2-week history of melena who was eventually diagnosed with ileal haemolymphangioma, a rare benign tumour. Local mucosal congestion and swelling were found through single-balloon enteroscopy, which showed an irregular protuberance approximately 10 cm long, located 3.2 m from the Treitz ligament. We performed a laparoscopic-assisted partial resection of the small intestine combined with intestinal adhesiolysis. According to postoperative pathology, the final diagnosis was ileal haemolymphangioma with haemorrhage.

Partial agenesis of dorsal pancreas. Report of two cases

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Agenesis of the dorsal pancreas is a rare congenital anomaly.

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The possibility of finding this disorder is increasing with the use of advanced radiological techniques.

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Some patients experience no symptoms.

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Rarely, they may also develop pancreatic exocrine insufficiency or pancreatic adenocarcinoma.

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This diagnosis could be missed by US, due to difficulty on visualization of body and tail of pancreas.

Introduction

Agenesis of the dorsal pancreas (ADP) is a rare congenital anomaly resulting in missing corpus and cauda of the pancreas. The possibility of finding this disorder is increasing with the use of advanced radiological techniques like CT scan or MRI.

Presentation of case

We reported 2 cases of a partial ADP as radiological finding: the first one was a 79-year-old asymptomatic patient who presented to perform a CT staging scan for bladder tumor, while the second case was a 73-year-old patient with obstructive jaundice and with suspected common bile duct calculi. In the second patient US, CT scan and MRI were performed, and after that also an ERCP was scheduled.

Discussion

The prevalence of agenesis of the dorsal pancreas is not exactly known; in the literature, only 50 cases have been reported. Its cause and pathogenesis are not fully understood. Some patients experience no symptoms, while others may develop hyperglycemia, diabetes mellitus, bile duct obstruction, abdominal pain, pancreatitis, or other conditions.

Conclusion

Considering that dorsal agenesis is sporadically found, often do not have related symptoms and it does not require a specific treatment, whether further examinations are needed to determine the type of agenesis remains questioned.

A rare case of cardiac tamponade masquerading as acute abdomen

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Acute abdomen is any acute abdominal condition requiring a quick response.

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The abdominal discomfort associated with extra-abdominal pathologies could mimic acute abdomen.

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Cardiac tamponade is a medical emergency.

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The differential diagnosis could be kept in mind to avoid a delayed treatment.

Introduction

Acute abdomen is any acute abdominal condition requiring a quick response. The incidence varies according to age and disease aetiology. The abdominal discomfort associated with extra-abdominal pathophysiology and thoracic conditions could mimic acute abdomen. In this case we report a rare case of a young patient with cardiac tamponade masquerading as acute abdomen.

Presentation of case

A 25-years-old African man presented to the Emergency Department with abdominal pain. An EKG was performed, which revealed sinus tachycardia, with electrical alternans and borderline reduced voltage. At the time of the admission to our unit, he had a clinical worsening and a CT scan of abdomen was performed, which demonstrated hepatomegaly, abundant pericardial effusion and thin right pleural effusion at the lung bases. An echocardiogram confirmed a circumferential pericardial effusion with initial collapse of the right ventricular free wall. It was decided to immediately transport the patient to the Cardiosurgery Unit of another hospital to undergo pericardiocentesis.

Discussion

Our experience with this case underlines the important point that patients with a large pericardial effusion may present with the clinical features of acute abdomen and peritonitis. Abdominal pain was the primary symptom that prompted this patient to seek medical attention.

Conclusion

Acute abdomen is any acute abdominal condition requiring a rapid, often surgical, treatment. Cardiac tamponade is a medical emergency. The differential diagnosis could be kept in mind by any emergency physician, surgeon and anaesthesiologist, because an incorrect diagnosis and therefore an incorrect treatment or a delay in pericardial evacuation can be life-threatening.

TNM: a simple classification system for complicated intra-abdominal sepsis after acute appendicitis

BACKGROUND

Delayed diagnosis in case of acute appendicitis (AA) could lead to complicated intra-abdominal sepsis (IAS). Grading systems are not commonly employed in the clinical practice, because they are too complicated or too specific. Therefore, we suggest grading the severity of complicated IAS after AA with a simple system: TNM, an acronym borrowed by cancer staging where T indicates temperature, N neutrophils, and M multiple organ failure (MOF). This prospective observational study evaluates the predictive value of the TNM score on mortality of patients with complicated IAS after AA.

METHODS

Sixty-eight patients with complicated IAS after AA were treated. Three classes of attributes were chosen: temperature (T), neutrophils count (N), and MOF (M). After defining the categories T (T0-T4), N (N0-N3) and M (M0-M2), these were grouped in stages (0-IV). Variables analyzed for their possible relation to death were age, sex, temperature, neutrophils count, preoperative organ failure, immunocompromised status, stage (0-IV). Odds ratios were calculated in a univariate and multivariate analysis.

RESULTS

TNM staging was: one patient stage 0; 16 patients at stage I; 26 patients at stage II; 16 patients at stage III; nine patients at stage IV. Death occurred in 15 patients (22%). Neutrophil count, preoperative organ failure, immunocompromised status, stages III-IV were potential predictors of postoperative death in univariate analysis; only stage IV was significant independent predictor of postoperative mortality in multivariate analysis.

CONCLUSIONS

TNM classification is very easy to use; it helps to define the mortality risk and is useful to objectively compare patients with sepsis.

Squamous cell anal cancer: Management and therapeutic options

The incidence of anal cancer has increased during the second half of the 20th century, with an incidence rate over 2.9% greater than in the decade of 1992-2001. Yet, it still constitutes a small percentage, about 4%, of all anorectal tumours. Its risk factors are human papillomavirus infection, a history of sexually transmitted diseases, a history of vulvar or cervical carcinoma, immunosuppression related to human immunodeficiency virus infection or after organ transplantation, haematological or immunological disorders, and smoking. The most frequent symptom is rectal bleeding (45%), followed by anal pain, and sensation of a rectal mass. The diagnosis requires clinical examination, palpation of the inguinal lymph nodes, high resolution anoscopy followed by fine-needle aspiration biopsy or core biopsy. Subsequent histologic diagnosis is necessary, as well as computed tomography or magnetic resonance imaging evaluation of the pelvic lymph nodes. Since 1980, patients with a diagnosis of anal cancer have shown a significant improvement in survival. In Europe during the years 1983-1994, 1-year survival increased from 78% to 81%, and the improvement over 5 years was between 48% and 54%. Prior to 1974, patients with invasive cancer were routinely scheduled for abdominoperineal amputation, after which it was demonstrated that treatment with 5-fluorouracil and radiotherapy associated with mitomycin or capecitabine could be adequate to treat the tumour without surgery. Today, numerous studies have confirmed that combined multimodal treatment is effective and sufficient.

Gastrointestinal bleeding as a result of entero-iliac fistula due to intestinal foreign body

Ingested toothpicks are a relatively rare event, but they may cause serious gut injuries and can be listed among rare causes of perforation, peritonitis, sepsis or death. Unless the foreign bodies were intentionally swallowed, many patients who ingested them fail to remember the event and they do not refer it during the medical history collection; this makes diagnosis problematic. In this work, a case of perforation of the sigmoid colon is described, caused by a toothpick ingestion. The patient had to be surgically treated because of a complication: the formation of an entero-iliac fistula with subsequent development of a pseudoaneurysm of the right external iliac artery. Vascular perforation due to toothpick ingestion has rarely been reported. In similar cases, it could be difficult to establishing the correct diagnosis because of the low sensitivity and accuracy rates of diagnostic investigations. The ingestion of foreign bodies should be kept in mind as an important differential diagnosis in patients with acute abdomen or chronic abdominal pain of unknown origin.

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Ingested toothpicks are a relatively rare event.

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These can be listed among rare causes of perforation, peritonitis, sepsis or death.

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It could be difficult to establishing the correct diagnosis because of the low sensitivity of diagnostic investigations.

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Vascular perforation due to toothpick ingestion has rarely been reported.

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The ingestion of foreign bodies should be kept in mind as an important differential diagnosis.

A rare case of retroperitoneal and mesenteric lymphangiomatosis

Lymphagiomatosis are rare benign malformations of the lymphatic system. They are more commonly seen during childhood and are frequently asymptomatic and incidentally found in the adult patient. We report a case of a 31-year-old male who presented initially with melena. Computer tomography scan revealed multiple confluent, fluid-density lesions encasing the retroperitoneum and mesentery. A laparotomy and incisional biopsy of the mesenteric lesion was performed. Histologic examination demonstrated fibrofatty tissue with prominent, thick-walled endothelial-lined vessels. The histologic and computer tomography findings were consistent with a diagnosis of retroperitoneal and mesenteric lymphangiomatosis. The patient was subsequently discharged home well.

Poorly differentiated neuroendocrine rectal carcinoma with uncommon immune-histochemical features and clinical presentation with a subcutaneous metastasis, treated with first line intensive triplet chemotherapy plus bevacizumab FIr-B/FOx regimen: an experience of multidisciplinary management in clinical practice

Background

Neuroendocrine tumors (NETs) are heterogeneous, widely distributed tumors arising from neuroendocrine cells. Gastrointestinal (GI)-NETs are the most common and NETs of the rectum represent 15, 2% of gastrointestinal malignancies. Poorly differentiated neuroendocrine carcinomas of the GI tract are uncommon. We report a rare case of poorly differentiated locally advanced rectal neuroendocrine carcinoma with nodal and a subcutaneous metastasis, with a cytoplasmic staining positive for Synaptophysin and Thyroid Transcription Factor-1.

Case presentation

A 72-year-old male presented to hospital, due to lumbar, abdominal, perineal pain, and severe constipation. A whole-body computed tomography scan showed a mass of the right lateral wall of the rectum, determining significant reduction of lumen caliber. It also showed a subcutaneous metastasis of the posterior abdominal wall. Patient underwent a multidisciplinary evaluation, diagnostic and therapeutic plan was shared and defined. The pathological examination of rectal biopsy and subcutaneous nodule revealed features consistent with small-cell poorly differentiated neuroendocrine carcinoma. First line medical treatment with triplet chemotherapy and bevacizumab, according to FIr-B/FOx intensive regimen, administered for the first time in this young elderly patient affected by metastatic rectal NEC was highly active and tolerable, as previously reported in metastatic colo-rectal carcinoma (MCRC). A consistent rapid improvement in clinical conditions were observed during treatment. After 6 cycles of treatment, CT scan and endoscopic evaluation showed clinical complete response of rectal mass and lymph nodes; patient underwent curative surgery confirming the pathologic complete response at PFS 9 months.

Discussion and conclusions

This case report of a locally advanced rectal NEC with an unusual subcutaneous metastasis deserves further investigation of triplet chemotherapy-based intensive regimens in metastatic GEP NEC.

Primary Intestinal Lymphangiectasia Causing Intussusception and Small Bowel Obstruction

Abdominal lymphangiectasia is a rare disease manifestation with a variety of anatomic locations and clinical presentations. The gastrointestinal tract may be affected, and lymphangiectasia originating in the wall of the intestine has rarely been described. We present a case of primary small bowel lymphangiectasia causing intussusception in a 30-year-old woman who presented with emesis and gastrointestinal bleeding. This case emphasizes the clinical presentation, diagnosis, and management in adults with abdominal lymphangiectasia. We highlight the importance of a high clinical suspicion for lymphangiectasia in an adult with acute abdomen to avoid catastrophic morbidity.