History Of Total Abdominal Hysterectomy Research Articles

Benign metastasizing uterine leiomyoma with lymphatic and pulmonary metastases: a case report and literature review

BackgroundBenign metastasizing leiomyoma (BML) is a rare disease usually observed in women of reproductive or premenopausal age with a history of uterine myomectomy or hysterectomy. The most common sites of metastases are the pulmonary, and other sites include heart, bones, liver, lymph nodes, bladder, skeletal muscles, and central nervous system. Here, we report a case of a 50 year-old woman with a history of hysterectomy who was initially suspected of uterine sarcoma but was finally confirmed to have BML with lung and lymph node metastases, and discuss the treatment and prognosis of BML.Case presentationA 50 year-old woman with a history of total abdominal hysterectomy presented with mild but persistent abdominal pain for more than 3 months. She was suspected of having uterine sarcoma before surgery and laparoscopic extensive debulking surgery including bilateral oophorectomy, pelvic and para-aortic lymph node dissection to the level of the left renal vein, and transcutaneous dissection of the right inguinal lymph nodes. Pathology confirmed a benign leiomyoma, and the patient was diagnosed with BML. No medication was administered after the surgery, and the follow-up was of no significance.ConclusionBenign metastasizing leiomyoma (BML) is a rare disorder in which histologically benign smooth muscle tumors metastasize to extrauterine sites. Metastases are commonly observed in the lung, liver, lymph nodes, skin, bladder, esophagus, and skeletal muscles. BML is usually misdiagnosed as a malignant tumor before surgery until the pathology confirms its benign nature. However, this treatment remains controversial and undetermined. The prognosis is usually favorable owing to its benign nature.

A Rare Case of a Left Ovarian Remnant Syndrome Associated with a Symptomatic Right Ovarian Cyst

Ovarian Remnant syndrome (ORS) is the presence of residual ovarian tissue after an oophorectomy was performed whether associated with a hysterectomy or not. We report the case of a 39-year-old woman with a past surgical history of total abdominal hysterectomy and left salpingo-oophorectomy with an indication of placenta accreta incidentally discovered during a caesarian section. The patient presented with pelvic pain and was diagnosed with ORS. She was successfully managed by laparoscopy with removal of the cyst and the surrounding ovarian tissue, confirmed by histopathological analysis. The post operative period was uneventful, and the patient was discharged after 2 days of good evolution. In our context, surgery remains the main treatment option, however, other treatment options including radiotherapy or medical management need to be considered as either adjunct or main therapy.

A Rare Case of a Left Ovarian Remnant Syndrome Associated with a Symptomatic Right Ovarian Cyst

Ovarian Remnant Syndrome (ORS) results from the presence of residual ovarian tissue after an ovariectomy. We report the case of a 39-year-old woman with a past history of total abdominal hysterectomy and left salpingooophorectomy who presented with pelvic pain and was diagnosed as having ORS. She was successfully operated by laparoscopy with the surgical gesture being the removal of the cyst and the surrounding ovarian tissue with the postoperative course being uneventful.

TFE3-associated perivascular epithelioid cell tumor with complete response to mTOR inhibitor therapy: report of first case and literature review

BackgroundPerivascular epitheloid cell tumor (PEComas) are characterized by expression of both muscles, most often smooth muscle actin (in ~80% of cases) and melanocytic markers (mainly HMB-45 and Melan A). TFE 3-associated PEComas are new variant which are poorly defined due to their limited reports in literature. These tumors lack response to targeted mTOR inhibitor therapy due to lack of mutation in TSC gene. Hereby, we are reporting a case of TFE3 associated pelvic PEComa showing excellent response to Everolimus.Case presentationA 45-year-old female presented with complaint of abdominal mass and bleeding per vaginum for 4 months. She had a history of total abdominal hysterectomy 3 years back in view of abnormal uterine bleeding and exploratory laprotomy 7 months back to remove some pelvic mass. Imaging suggested of ill-defined heterogenous mass of 9.3 x 9.2 x 16 cm involving the uterus, cervix, and upper 1/3 vagina. Multiple omental and peritoneal deposits were also seen, making probable diagnosis of carcinoma endometrium. USG guided biopsy showed cores of fibrous tissue with the presence of cells in sheets with granular eosinophillic cytoplasm; IHC showed positivity for TFE-3, H Caldesmon, GATA-3, and Melan A- and HMB-45; and Ki 67 index was 35%. The basis of above diagnosis of PEComa was made and she was started on Everolimus; repeat imaging after 3 months of therapy showed complete response.ConclusionWe are reporting first case of malignant pelvic TFE 3 PEComa showing response to mTOR therapy. Identification of TFE 3 PEComa is important because they showed different biologic behavior then their conventional PEComa.

Intracaval Leiomyoma with Intracardiac Extension.

AbstractThe aim of the study is to provide a guide on how to achieve a complete resection of an intravascular leiomyoma. A 48-year-old female was referred to our institution with progressive dyspnea on exertion, lightheadedness, and previous history of total abdominal hysterectomy and bilateral salpingoophorectomy for a uterine leiomyoma echocardiography, CT and MRI of heart and abdomen/pelvis were performed and an intracaval mass with extension into the right heart and pulmonary artery was identified. After multidisciplinary review, a single stage sternotomy-laparotomy procedure on cardiopulmonary bypass (with beating heart, mild hypothermia, and no deep hypothermic circulatory arrest) ensured complete resection of a giant intravenous leiomyoma. Multidisciplinary approach, multimodality imaging, and single stage sternotomy-laparotomy procedure on cardiopulmonary by-pass (with heart beating and mild hypothermia) ensure complete resection of intravenous leiomyoma.

Vesico-Vaginal Fistula Repair Through Abdominal Approach

Background: Vesico-Vaginal Fistula (VVF) is a major cause for concern in many developing countries with significant morbidity. Among the different techniques abdominal approach of VVF repair is important one.
 Objective: To find out the outcome of VVF repair by abdominal approach.
 Materials and Methods: It is a prospective study. Twenty-three patients with VVF were operated with abdominal approach from the period of January 2016 to January 2019. Age of patients, co-morbidities, cause, size and location of VVF were evaluated. Then abdominal approach of VVF repair was done. Operative time and need of blood transfusion were encountered. Post operative (POD) urine leakage, wound infection or other complications were enlisted. Patients were discharged with keeping urethral catheter for 14 days. Follow up was done after 1 and 3 month and in each follow up history and physical examination was done. All collected data were evaluated.
 Results: Mean age of the patient was 40 years. Among the 23 patients 12 (52%) patients had history of total abdominal hysterectomy, 9 had history of caesarian section and 2 cases had history of pelvic surgery. VVF repair was done at least 12 weeks after its occurrence. Operative time ranged from 90 minutes to 150 minutes. In the immediate POD no obvious complications were noted except one patient developed wound infection on 7th POD. Follow-up done as per schedule and no recurrence of VVF noted.
 Conclusion: VVF repair through abdominal approach is a feasible, safe and effective technique if performed meticulously.
 KYAMC Journal Vol. 11, No.-3, October 2020, Page 129-132

IgG4 Related Disease Presenting As a Solid Ovarian Mass with Ureteric and Bladder Involvement: A Case Report

Study Objective IgG4-related disease (IgG4-RD), a systemic immune-mediated condition, presenting as a solid ovarian mass concerning for malignancy resected using a minimally invasive approach. Design A case report of a 43-year-old G3P3 with a history of total abdominal hysterectomy for fibroids presenting with pelvic pain and a newly diagnosed pelvic mass on imaging. Medical history was significant for diabetes. Setting N/A Patients or Participants N/A Interventions The procedure performed included laparoscopic resection of the right ovarian mass, enbloc resection of the lower right ureteral, partial radical cystectomy, uretoneocystotomy and bladder reconstruction. Measurements and Main Results CT abdomen and pelvis demonstrated prominent retroperitoneal lymph nodes and moderate right-sided hydronephroureterosis secondary to compression by the pelvic mass. Pelvic MRI demonstrated heterogeneous enhancement of the mass with possible bladder invasion. Tumor markers, CA -125 and CEA, were within normal limits. Intraoperative findings included a solid, complex right adnexal mass adherent to the right pelvic side wall incasing the right ureter with no clear ability to delineate tissue planes. In addition, the mass was found to be infiltrating the bladder around the ureteral orifice mimicking tumor invasion. Pathology report demonstrated extensive sclerosing fibrosis with ureteral obliteration, lymphocytic infiltrates and obliterative phlebitis highly suggestive of IgG4-RD. The pelvic washings were negative for malignant cells. On follow up, patient with resolved pelvic pain and no evidence of recurrence on imaging. Adjuvant corticosteroid treatment was initiated by Rheumatology to reduce recurrence risk. Conclusion IgG4-RD is a rare diagnosis that has yet to be described as an adnexal mass. Due to the close resemblance to malignancy, recognizing this disease clinically becomes very important. Given the evidence that there is response to early glucocorticoid therapy, it is important for gynecologists to be aware of this disease to facilitate an expedited diagnosis to prevent potential unnecessary invasive procedures.

A report of a case: unusual portosystemic shunt in a hernia sac who has portal hypertension due to cirrhosis

Variations in the origin and branching pattern of splenic vein (SV) are relatively rare and asymptomatic. We describe here only the first case in the literature of accessory SV in hernia sac due to previous operation and increased portal pressure because of cirrhosis. This report describes a 66-year-old female, with a history of total abdominal hysterectomy (TAH) due to uterine myomatosis, signs of cirrhosis onset due to hepatitis B, who had been presented with recurrent abdominal pain attacks. Ultrasonography (USG) findings were nothing pathologic except a gallstone in the gallbladder without cholecystitis signs. Incisional hernia was found to contain an accessory SV in the hernia sac arising from a branch of main SV in the hilum, ongoing to the subcutaneous fat tissue and draining to the superficial femoral vein on computed tomography (CT). Videoendoscopy showed wide gastritis and multiple ulcers. The patient's symptoms diminished with proton pump inhibitor (PPI) treatment and they then underwent a hernia repair surgery with Prolene mesh patch as elective surgery. A thorough knowledge of the normal anatomy, most frequent variations and congenital or acquired anomalies of the spleno-portal axis has great importance for hepatopancreaticobiliary and emergency surgical procedures. It is, therefore, essential for preoperative evaluation of the anatomical details of the spleno-portal venous axis and should be evaluated with imaging methods in detail.

Benign Metastasizing Uterine Leiomyoma: Case Report with Review of the Literature

Benign metastasizing leiomyoma is a rare disorder involving distant metastases secondary to a smooth muscle tumor of the myometrium. Oftentimes, it is easy to be misdiagnosed as a malignant tumor when nodules are found in multiple tissues. In most cases, there is a previous history of total abdominal hysterectomy for uterine leiomyoma. However, the pathogenesis of this disease has not yet been elucidated. In order to raise clinicians’ awareness of BML, we present a short review of the literature in combination with an unusual case.

1525 Atypical Presentation of Colon Cancer: Colon-Vaginal Fistula

INTRODUCTION: A fistula is an abnormal communication between two epithelialized surfaces. Colovaginal fistulas usually present with stool or flatus per vagina, foul-smelling vaginitis resistant to treatment, previous hysterectomy, and history of diverticulitis. In this case report, we present colon cancer as a possible new risk factor for colo-vaginal fistula. CASE DESCRIPTION/METHODS: 53 years old female with a past medical history of external hemorrhoids and GERD presented to the emergency department (ED) for evaluation of right lower quadrant abdominal pain for over a month associated with passing fecal material through her vagina for the past 2 days. The patient also reported having loose stools approximately 2 weeks prior to ED visit. She also reported decreased appetite, lightheadedness, 60 lb weight loss since last year, and significant rectal bleeding with straining which she attributed to hemorrhoids. She reported having an unremarkable colonoscopy 10 years prior to presentation. She denied any history of diverticulosis, ulcerative colitis, Chron's disease, radiation therapy, or family history of cancer. However, she did have a history of hysterectomy for the treatment of endometriosis 15 years ago. On arrival, she was found to have a hemoglobin of 5.4 g/dl. Physical exam was significant for pale mucous membranes, tachycardia, and fecal material in the vaginal canal. CT scan showed a ring-enhancing fluid collection interspersed between the vaginal cuff, and sigmoid colonic bowel loop, a colovaginal fistula between the vaginal cuff and the sigmoid colon, and wall thickening of the sigmoid colon measuring up to 1.5 cm. Colonoscopy showed a large friable obstructive mass seen at 20 cm from the anal verge. Biopsies of the sigmoid mass showed invasive, moderately differentiated adenocarcinoma. DISCUSSION: This patient has a history of total abdominal hysterectomy which is a known risk factor for the development of fistula; however, the hysterectomy was done 15 years before the appearance of the fistula, suggesting that the surgical procedure was not the primary cause of the development of the fistula. Inflammatory bowel disease and infectious process were ruled out by colonoscopic and histologic findings. From this case, we can learn that colon cancer can mimic other conditions such as Crohn's disease or complicated infectious process, therefore colon cancer should be part of the differential diagnosis of colo-vaginal fistulas and peri-colonic abscesses.

Malignant Mixed Mesodermal Tumour (MMMT) of the Ovary: An Unusual Primary Tumour

Ovarian carcinosarcoma (Malignant Mixed Mesodermal Tumour) is rare malignant tumour with a poor prognosis. We here present a case of ovarian carcinosarcoma in a 72-yearswoman suffering from intermittent lower abdominal pain for 5 months with previous history of Total Abdominal Hysterectomy (TAH) with Unilateral Salpingo-Oophorectomy (USO) due to leiomyoma 27 years back. Explanatory laparotomy and right salpingo-oophorectomy with complete surgical staging was done at Dhaka Community Medical College Hospital. Histopathology revealed both sarcomatous and carcinomatous component. Surprisingly the patient had no metastatic foci and consulted with a medical Oncologist, who didn’t recommend any chemotherapy and was cancer free during last one and half years follow up.
 Bangladesh J Obstet Gynaecol, 2019; Vol. 34(2): 124-126

MON-323 Metastatic Adrenocortical Carcinoma Presenting with Mixed Cushing's and Virilization Syndrome along with Bilateral Pulmonary Emboli

Background: Adrenocortical carcinoma is a rare, often aggressive tumor that is more common in women than men. The tumors are more often than not biochemically active in adults, and the majority secrete glucocorticoids alone (1,2).Clinical case: A 57yo woman w/ longstanding hypertension and history of total abdominal hysterectomy presented with shortness of breath. She reported worsening of her hypertension over the past six months associated with male pattern balding, body hair growth, anxiety, facial and abdominal swelling for the past four months. Computed tomography PE protocol showed bilateral pulmonary emboli and multiple pulmonary nodules. Subsequent computed tomography chest/abdomen/pelvis revealed pulmonary nodules in both lungs, the largest being 3.7cm x 2.5cm in the right upper lobe, and a large right retroperitoneal mass centered at the expected position of the right adrenal gland measures 12.4cm x 10.5cm causing mass effect on the inferior surface of the liver along with bulky mediastinal, hilar, paratracheal, gastrohepatic, portocaval, and retroperitoneal lymphadenopathy. Exam was significant for cushingoid habitus with central obesity, rounded facies, supraclavicular and dorsocervical fat pads, proximal muscle weakness, frontotemporal balding, severe hirsutism consistent with modified ferriman-gallwey score of 13, and an annular, scaly rash along gluteal cleft. 8am serum cortisol was 65mcg/dL. 24 hour urinary cortisol was 450mcg/24 hour. ACTH was undetectable <2.0pg/mL. Total Testosterone was 835ng/dL. DHEAS was 1,000mcg/dL. Renin, aldosterone, plasma fractionated metanephrines were normal. Excisional supraclavicular lymph node biopsy was positive for metastatic adrenocortical carcinoma. Subsequent FDG PET/CT also showed metastatic disease in the liver, right humeral head, sacrum, and bilateral iliac bones. Punch biopsy of the rash was consistent with tinea cruris. The patient was moved to the oncology service and started on therapy with mitotane, cisplatin, doxorubicin and etoposide.Conclusion: Rapid virilization is concerning for an underlying malignancy and should always include androgen evaluation with a high index of suspicion for ovarian or adrenal tumors.

Use of observed ureteric catheter movement to facilitate laparoscopic identification and dissection of the ureter in complex gynaecological procedures

Ureteric injury is a serious complication in gynaecological surgery. Identification and dissection of the ureter is important to minimise the risk of injury. However, some pelvic pathologies and previous pelvic surgery can render laparoscopic identification and dissection of the ureter difficult and risky. This video demonstrates the use of observing ureteric catheter movement to facilitate identification and dissection of the ureter in complicated laparoscopic gynaecological procedures. A 42-year-old woman with previous history of total abdominal hysterectomy underwent laparoscopic removal of her right ovary, which was plastered over the course of the ureter. A 5-F ureteric catheter was inserted, and observing its movement facilitated identification and dissection of the ureter from the ovary. The procedure was completed safely, and the patient was discharged the same day. This video demonstrates that moving the ureteric catheter laparoscopically to facilitate identification and dissection of the ureter in complex gynaecological procedures may be useful for urogynecologists when assisting ureteric dissection in complex cases.

Recurrencia colónica tardía de adenocarcinoma endometrial

La tasa de recurrencia del carcinoma endometrial después de la cirugía más radioterapia es baja y la mayoría de los casos ocurren dentro de los primeros 3 años. La cúpula vaginal es el sitio más común de recurrencia. La recurrencia del cáncer endometrial al colon es muy rara. Se presenta el caso de una mujer de 69 años que presentaba dolor en fosa ilíaca izquierda, anorexia y pérdida de peso de 5 meses de evolución, con antecedentes de histerectomía abdominal total y ooforosalpingectomía bilateral por carcinoma endometrial estadio IA hacía 7 años. La colonoscopia reveló constricción circunferencial en el tercio medio del colon transverso, sospechosa de compresión extrínseca. La tomografía computada no reveló si la tumoración se originaba en el colon sigmoides o lo rodeaba. Durante la laparotomía, se observó enfermedad macroscópica que afectaba colon transverso y mesenterio del intestino delgado, con estenosis vascular. Se realizó la resección intestinal de las porciones afectadas y omentectomía total, sin dejar enfermedad residual macroscópica durante el procedimiento. El análisis inmunohistoquímico reveló adenocarcinoma endometrial pobremente diferenciado. La paciente se recuperó sin complicaciones y fue tratada con quimioterapia adyuvante.

A rare case of benign metastasizing leiomyoma†

Benign metastasizing leiomyoma is a rare disorder involving distant metastases secondary to a smooth muscle tumour of the myometrium. This case report describes a 48-year-old woman with multiple pulmonary nodules noted on post-operative chest x-ray. Further investigation revealed a history of total abdominal hysterectomy for benign fibroids of the uterus, 6 years prior to the scan. CT-guided fine needle aspirate of the pulmonary nodules showed smooth muscle proliferation within lung parenchyma, suggesting smooth muscle tumour confirmed with immunohistochemistry. Management is still controversial in view of low case numbers; however, treatment with hormone therapy and castration has been attempted.

Malignant presentation of uterine lymphangioleiomyomatosis

ObjectiveThe main aim of this case report was to present the method of diagnosis, management, and the 12-year-follow-up of a patient diagnosed with primary uterine lymphangioleiomyomatosis (LAM). Case ReportA 47-year-old woman was admitted to the Department of Thoracosurgery due to pulmonary lesions suspected to be metastatic. The potential primary site of the neoplasm was not identified by previous imaging studies and specialist counseling. The patient had a history of total abdominal hysterectomy without ovaries due to a uterine tumor recognized as cellular leiomyoma and left salpingo-oophorectomy due to a solid ovarian tumor also recognized as leiomyoma. She had previously undergone the removal of a left kidney angiomyolipoma. After histopathological examination of the pulmonary lesions and repeated evaluation of the ovarian and uterine tumors, the diagnosis of primary uterine LAM with metastases to the ovary and the lungs was established. Although new metastatic lesions occurred, the patient remained in good condition during the 12-year-follow-up. ConclusionThe history of our patient and review of the literature suggest that although uterine LAM presents malignant features (i.e., metastasis), the disease is long lasting and the patient can be in good condition for a number of years.

Progressive Development of Pseudomyxoma Peritonel After Resection of Low-Grade Mucinous Adenocarcinoma of the Appendix

Introduction: Pseudomyxoma peritonei (PMP) is a rare condition, commonly originating from the appendiceal tumors. We present a case of progressive PMP after surgery for low grade mucinous adenocarcinoma of the appendix. Case Report: A 58-year-old female with history of total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) for fibroids and appendectomy 10 years ago remained asymptomatic until she presented with abdominal pain and weight loss 2 years ago. Review of surgical history revealed that appendectomy was also done while TAH-BSO was being performed because of abnormal-appearing appendix with mucin. Biopsy showed low-grade mucinous adenocarcinoma. EGD and colonoscopy did not reveal any acute pathology. CT abdomen revealed extensive peritoneal cystic masses with scalloping of the liver, spleen, and mesentery, consistent with PMP. She underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Biopsies revealed low-grade mucinous adenocarcinoma with nonsignificant right colon and distal ileum. She was started on systemic chemotherapy for progressive disease on follow-up CT imagings. Progression of disease continued on repeat imagings after 3 months of chemotherapy, but the patient had no symptoms. CEA and CA 19-9 remained elevated. The patient is being monitored and further CRS with HIPEC will be planned if she develops more progressive disease with symptoms. Discussion: Appendiceal tumors are most commonly found incidentally when obtained for unrelated condition. A large National Cancer Institute series has shown the most frequent histology as mucinous adenocarcinoma with carcinoid tumors in only 11%. PMP commonly originates from benign tumors of appendix and characterized by diffuse intraabdominal collections of gelatinous material with mucinous implants on the peritoneal surfaces. It has also been described to arise from adenocarcinomas of the appendix and other intra-abdominal organs as well as breast, ovary, and fallopian tubes. The most common symptoms are abdominal distension and pain. Scalloping of the liver, spleen, and mesentery, as well as calcifications on CT imaging are typical. Tumor markers (e.g. CEA, CA 19-9, CA 125) correlate with prognosis and recurrence rates. Optimal treatment with CRS and HIPEC have been reported to improve 5-year survival as 62.5-100% for low-grade and 0-65 % for high-grade disease. Conclusion: PMP can be progressive after many years of surgical resection of the primary tumor, as in our case. Optimal treatment such as CRS and HIPEC have been shown to improve survival. Periodic close follow-up visit with tumor marker and CT abdomen are important to assess the progression of disease, which can determine the further management.

Fatal Case of Luteinized Thecoma With Sclerosing Peritonitis in a 40-Year-Old Woman

We describe the pathologic and clinical presentation of a very rare, fatal case of luteinized thecoma with sclerosing peritonitis in a 40-year-old woman, who had a history of total abdominal hysterectomy and a left salpingo-oophorectomy in 2003. The patient presented with abdominal pain, and radiologic examinations revealed a 10-cm heterogenous right pelvic mass with partial necrosis. The patient eventually underwent an exploratory laparotomy, which revealed an ovarian tumor with multiple implants in the peritoneal cavity. The ovarian lesion was made up of spindle cells among clusters of luteinized stromal cells that expanded to the ovarian cortex. Tumor cells were positive for vimentin, estrogen and progesterone receptors, and CCD68 (focally) and negative for CD34, α-smooth muscle actin, β-catenin, and desmin by immunohistochemical studies. Luteinized cells were positive for α-inhibin and calretinin. Tumor cells exhibited low Ki-67 proliferation indices. The patient died because of the sclerosing peritonitis component of the disease.

Metastatic involvement of the spleen by endometrial adenocarcioma; a rare asylum for a common malignancy: a case report

BackgroundMetastatic involvement of the spleen by solid tumors is a rare clinical entity; those coming from endometrial adenocarcinomas are exceptionally rare. Spleen is an uncommon site for metastatic deposits due to its specific anatomy and microenvironment. Typically, splenic metastasis from endometrial carcinomas present months to years after curative surgery, chemotherapy or radiotherapy. The most common complaint in symptomatic patients is abdominal pain localized to the left hypochondrium. Most however, are asymptomatic only to be picked up on vigilant routine ultrasonography or computerized tomography during follow up. We report the case of a 54-year-old woman who presented to us after 50 months of total abdominal hysterectomy and bilateral salpingo-oophorectomy for an endometrial adenocarcinoma. She had severe abdominal pain localized to the left hypochondrium as the presenting complaint. To the best of our knowledge, this is the 1st case to be reported from Pakistan with 14 cases reported prior to our report. All past cases report the endometroid variant of endometrial adenocarcinoma as the primary tumor and our patient was a victim to the same variant.Case presentationA 54-year-old, nulliparous widowed woman presented with severe abdominal pain in the left hypochondrium for the last 4 months. The pain radiated to the left shoulder and was exacerbated with deep breathing. She had a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy done 50 months back for stage 1a endometroid endometrial adenocarcinoma. Clinical examination revealed tenderness in the left hypochondrium but no visceromeglay was appreciable. Ultrasonography and computerized tomography revealed a space-occupying lesion within the spleen with associated splenomegaly. Computed tomography further suggested a large splenic abscess however the patient did not have fever, vomiting or leukocytosis which are the hallmarks of a splenic abscess. A splenectomy was performed for her complaints. On histopathology a metastatic adenocarcinoma was identified consistent with the primary tumor. The tumor was CK7, CA-125 and epithelial membrane antigen positive (EMA). The patient was then referred for further chemotherapy.ConclusionFrom this case we conclude, that although very rare, the spleen is a potential site for metastasis in endometroid endometrial adenocarcinoma. Since most patients are asymptomatic, routine examinations and imaging can identify its presence and avoid complications. If the practice is employed with vigilance, we may expect the clinical event to be diagnosed more frequently. The standard treatment is a classic splenectomy followed by chemotherapy.

Melioidosis Presenting as Pseudomyxoma Peritonei: Yet Another Pretense of the Great Mimicker: An Unreported Entity

Melioidosis, a lethal infectious disease caused by Burkholderia pseudomallei, an important human pathogen in tropical regions, is notorious for its diverse clinical presentations. We report a case of a 55-year-old woman with a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy for ovarian mucinous cystadenocarcinoma five years back, who presented with complaints of chest pain, abdominal distention, and breathlessness for one week. Ultrasound-guided aspiration of the peritoneal free fluid revealed a thick gelatinous material consistent with pseudomyxoma peritonei. Cytologic analysis of the aspirate was negative for malignant cells, but bacterial culture proved positive for Burkholderia pseudomallei. She was started on ceftazidime, and she improved symptomatically and was discharged on oral doxycycline and chloramphenicol after three weeks of intravenous antibiotic therapy. This case is being reported to emphasize an unusual presentation of melioidosis and the significance of timely appropriate antibiotic therapy.