Introduction: The posterior retroperitoneoscopic adrenalectomy or laparoscopic adrenalectomy posterior approach had been the most popular technique for adrenal tumor resection. The direct approach through retroperitoneal space to the adrenal gland and clear anatomical visualization allows safe access to the procedure. We report our experiences in this surgery at Hospital Sultanah Nur Za- hirah, Terengganu, east coast Malaysia from 2011 – 2019. Methodology: We retrospectively gathered a total of 13 cases from the year 2011 to 2019. Indications were mainly: Conn’s syndrome (8 cases), adrenocorticotrophin hormone (ACTH) independent Cushing syndrome (4 cases) and 1 case of suspected adrenal corticocar- cinoma. All the patients have body mass index (BMI) of 35kg/m2. A tumor size of less than 6cm was chosen for the study, with mean tumor size around 2.6cm. All cases were done through posterior retroperitoneoscopic approach with patients in a jackknife position. Preoperative information, intraoperative events, postoperative events, and follow up details within 6 months were documented. Results: We removed a total of 7 right and 6 left adrenal tumors. The average operating time was 101 minutes (excluding conversion) with no significant difference comparing right and left adrenalectomy. There were 3 cases with minor complications and 1 case of mortality due to post-op complication. The average length of hospital stay was 4 days. The result showed good pain control with just paracetamol, a non-steroidal anti-inflammatory drug and occasional weak opioid. Conclusions: Posterior retroperitoneoscopic adrenalectomy is the ideal approach in a small tumor. It provides a fast recovery period and less postoperative pain.

Background: In the modern medical science there are several studies showing the effectiveness of simultaneous one-step surgical treatment of patients with combined surgical diseases, however, the proportion of this type of surgery is very low. Among the factors that may have contributed to the formation of such a low rate of simultaneous surgical interventions is lack of recommen- dations and guidelines for curation and simultaneous surgical treatment of this category of patients. Material and Methods: The results of the implementation of ERAS protocols in the context of simultaneous laparoscopic surgery was obtained during the curation of 21 patients, including 13 (61.9%) women and 8 (38.09%) men with two or more diseases requiring one-step surgery on the abdominal organs. The mean age was 36.47 ± 10.3 years Results: The average duration of surgery was 134,52 ± 9,4 minutes. One (4.7%) case of major early postoperative complications appeared in the form of intra-abdominal bleeding. Postoperative nausea and vomiting was observed in 4 bariatric patients. Aver- age value of VAS was 3,0 ± 1,09 points. Average inpatient treatment was 3,04 ± 1,24 days Conclusion: The integration of the basic principles of ERAS allows to achieve low complications, low postoperative pain, rapid activation and recovery of patients thereby reducing the duration of inpatient treatment and improving quality of life after simul- taneous operation.

Background: Intra-abdominal infections (IAIs) are a significant cause of morbidity and mortality, aggravated by multidrug-resistant pathogens. Prompt clinical diagnosis, resuscitation, adequate source control, and appropriate antimicrobials are pivotal in managing IAIs. Pathogen surveillance and antimicrobial susceptibility patterns are key in selecting the most appropriate empiric antimicrobial agents for IAIs. Aim of the study: The aims of the study were as follows: (a) To determine the aetiology, distribution and drug susceptibility of pathogens causing intra-abdominal sepsis. (b) To determine if the current empiric antimicrobial policy for community and hospital- acquired intra-abdominal sepsis is appropriate. (c) To provide evidence for accurate and effective empiric therapy for intra-abdominal sepsis. Methods: This retrospective study was performed over a period of 12 months (1st January -31 December 2018) at a regional hospital in KwaZulu-Natal (KZN), South Africa. Microbiological information from intra-abdominal samples sent to the National Health Labora- tory Services (NHLS) situated at Prince Mshiyeni Memorial Hospital (PMMH) was extracted from the TRAKCARE computer database. For every sample, pathogen identification and antimicrobial susceptibility was performed using standard operating procedures. A descriptive analysis of the data was performed. Results: A total of 185 samples from 140 patients was submitted for microbiological analysis. Of the 185 samples,163 (88%) yielded positive cultures. Of the pathogens isolated, 96 (59%) were Gram-negatives, 57 (35%) were Gram-positives, and 10 (6%) cultured fungi. Amongst the Gram-negative group of organisms, Escherichia coli (48%) was the predominant pathogen followed by Klebsiella pneu- moniae (14%). Notably, 22% of Escherichia coli and 62% Klebsiella pneumoniae were extended spectrum beta-lactamase (ESBLs) pro- ducers. Amongst the Gram-positives, Staphylococcus aureus (24.5%), was the predominant pathogen with One isolate being methicillin resistant Staphylococcus aureus (MRSA), followed by Streptococcus milleri (19%). Overall, > 90% of all Escherichia coli isolates were susceptible to gentamicin, amikacin and piperacillin-tazobactam. Notably, 78.2%, 65 % and 15 % of all Escherichia coli isolates were susceptible to ceftriaxone, amoxicillin-clavulanic acid and ampicillin respectively. More than 80% of all isolates of Escherichia coli were susceptible to ciprofloxacin. All Candida spp. were susceptible to fluconazole. Conclusion: The results highlight that combination therapy using amoxicillin-clavulanic and gentamicin is adequate first line empiric antimicrobial therapy in patients presenting with intra-abdominal sepsis at PMMH

Aims/objective: CEA increases in various benign as well as malignant breast lesions. The present study aims to evaluate the serum CEA level in carcinoma breast and compare its levels with benign neoplastic lesions and normal control (age and sex matched). The values were further compared with invasive and noninvasive as well as different histological grades of malignant lesions. Methods: This was a multicentre prospective descriptive follow up study conducted by the department of Surgery, Gynaecology and Pathology and PSM (Biostatistics) from January 2018 to December 2021. One hundred and twenty patients with breast lump of size more than 2 cm diameter were included in the study. The female patients with breast lump were selected randomly irrespective of socioeconomic status and nature of the pathology. Association between categorical variables was calculated by Chi-square test and association between quantitative variables was by student’s t test. The level of significance was set at P0.05. Results: Out of 72 patients 38 patients having localized breast cancer while 34 patients were having metastatic breast cancer. On histological grading 10 cases were non invasive (ductal carcinoma in situ). Most of the breast cancer (4 cases) was grade II while 16 cases were grade III. Conclusion: serum CEA is an important, cheap, non-invasive, easily available marker for carcinoma breast. It is an accurate method and early predictor. It should be utilized wherever feasible. However, a larger, multi-institutional study is required to further strengthen and establish its accuracy.

Background: Intra-abdominal abscesses continue to be a major source of morbidity and mortality in today’s surgical practice. Localized intra-abdominal abscesses usually tend to form in relation to the affected viscus. A proper diagnosis and abscess localization are mandatory for prompt treatment. Laparoscopic drainage for a massive intra-abdominal abscess is minimally invasive, enabling exploration of the abdominal cavity without the use of a wide incision. Aim: To evaluate the outcome of laparoscopic management of abdominal abscesses not amenable to percutaneous or transrectal CT guided or ultrasound US-guided drainage. Results and conclusion: Laparoscopic drainage was a feasible, safe, and effective therapeutic modality for pelvic-abdominal abscesses. Laparoscopic drainage is a minimally invasive procedure with low PO morbidities.

Introduction: This systematic review and meta-analysis aimed to evaluate early versus late cholecystectomy outcomes after percutaneous cholecystectomy. Methods: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and MOOSE guidelines. Heterogeneity was measured using Q tests and I2 statistics. The random-effects model was used. We evaluated cholecystectomy performed at different periods after percutaneous cholecystostomy as per the literature. Results: Six studies including 18640 patients were included in the final analysis. There was no difference in overall complications within or after 72 hours of cholecystectomy group, but mortality and biliary complications were significantly high in the less than 72 hours group (p=0.05 and 0.0002 respectively). There was no difference in mortality, overall complication, or biliary tract complications in the less than 1 week versus more than 1 week and less than 10 days versus more than 10 days group. Overall complications were significantly less in the less than 2 weeks group compared to the more than 2 weeks group. There was no difference in mortality and biliary tract complications between the less than 2 weeks and more than 2 weeks groups. Overall complication rate (risk ratio 0.67, p 0.0001), postoperative mortality (risk ratio 0.46, p=0.003), and bile duct injury (risk ratio 0.62, p=0.01) was significantly less earlier than the 4- week group. Hospital stay was not significantly different between the less than 4 weeks versus the more than 4 weeks group. (Mean difference= -2.74, p=0.12). Overall complication rates were significantly more in the less than 8 weeks group. (Risk ratio 1.07, p=0.01). Hospital stay was significantly less in the less than 8 weeks group. (Mean difference 0.87, p=0.01). Conclusion: Early cholecystectomy preferably within 4 weeks after percutaneous cholecystostomy is preferable over late cholecystectomy.

Background: Laparoscopic Cholecystectomy (LC) is the gold standard management for symptomatic cholelithiasis. However, LC might be difficult by the various risk factors. Preoperative risk factors are very important for the surgeon and patient in anticipating of difficulty during surgery. This study is to identify clinical, radiological, and perioperative risk factor with difficult elective laparoscopic cholecystectomy in HUSM. Methods: This is a retrospective record review of patients who underwent elective laparoscopic cholecystectomy from 2013-2018 in Hospital Universiti Sains Malaysia. The patient’s characteristics, clinical history, laboratory data, ultrasonography results and intraoperative details were retrospectively analysed to evaluate predictors of difficult LC. Results: A total of 154 patients who underwent elective laparoscopic cholecystectomy and fulfil the criteria were included in our study. The conversion to open surgery rate was 4.5%, the mean operative length was 91.71 minutes and the mean hospital stay post operative was one day. The prevalence of difficult elective laparoscopic cholecystectomy in HUSM was 55.2% (95% CI = 47.3, 63.0). The multivariate analysis showed the patient history of cholangitis (p value=0.006), history of ERCP (p value=0.028), thick gallbladder wall on ultrasound (p value=0.011), dense adhesion (p value=0.001) and fibrosed Calot’s triangle (p value=0.008) intraoperatively had significant association with difficult laparoscopic cholecystectomy. Conclusion: From our study, we can conclude that patient history of cholangitis, history of ERCP, thick gallbladder wall on ultrasound, dense adhesion and fibrosed Calot’s triangle intraoperatively were found to be the predictive factors of difficult LC.

Aim: The aim was to do a retrospective analysis and audit of our 90 days and in-hospital mortality after gastrointestinal and hepatopancreatic biliary surgery performed in our department and analyze factors predicting it. Patients and methods: All patients who underwent gastrointestinal and hepatopancreatic biliary surgery in our department in the last 3 years were evaluated for 90 days postoperative and in-hospital mortality and various factors affecting it. Categorical values were analyzed using the chi-square test or fisher`s exact test wherever appropriate. Continuous variables were analyzed using the student test for parametric data and the Mann Whitney U test for nonparametric data after skewness and kurtosis analysis. Multivariate analysis was done using logistic regression analysis. A p-value less than 0.05 was considered statistically significant. Statistical analysis was done using SPSS version 23(IBM). Results: 412 patients underwent gastrointestinal and hepatobiliary surgery in the last 3 years at our institute. Ninety days all-cause mortality was 5.8%, and all-cause in-hospital mortality was around 4.6%. 90 days mortality in elective and emergency surgeries were respectively 3.2% and 18%. In-hospital mortality in elective and emergency surgeries were respectively 2.35% and 15.2%. On multivariate analysis age, nontechnical complications, open surgery, and emergency surgery independently predicted 90 days mortality. On multivariate analysis age, acute kidney injury, non-procedural complications, and emergency surgeries independently predicted in-hospital mortalities. Conclusion: Age, non-technical complications, open surgery, and emergency surgeries are independently associated with 90 days mortality, and age, acute kidney injury, non-procedural complications, and emergency surgery independently predict in-hospital mortality.

Background: Human amniotic membrane (AM) is suitable for use as a dressing over ulcers and warrants its evaluation in comparison to other routinely used dressings. Current study was aimed to compare the efficacy and safety of human AM dressing versus routine dressing in the management of ulcers. Methods: The study included 100 patients, aged >18 years, and diagnosed with an ulcer measuring >1cm2 but 25cm2 , and divided them equally and randomly into 2 groups - test group (TG) who received AM dressing; and control group (CG) who received routine dressing. At the end of the 1st, 2nd and 3rd weeks of follow-up, the TG and CG were evaluated and compared. The parameters recorded at each evaluation included epithelialization, presence of infection, exudation, and local pain score measured by visual analog scale (VAS). Results: The TG showed significantly faster healing in a greater proportion of patients (p=0.00099) compared to the CG. The TG was also found to have significantly lower incidences of wound infection (22%) and exudation (36%) in comparison to the CG (74vs 70%, respectively) (p=0.00049 for each). The odds of infection were 9.8 times more in CG than in TG (p=3.133e-07 and CI of 3.68-28.21). The odds of exudation were 4.084 times more in CG than in TG (p=0.0012 and CI of 1.66-10.44). TG patients also experienced significantly less pain (mean VAS score of 3.48 ± 2.07) compared to CG (mean VAS score of 5.26 ± 2.08) (p=0.00014). Conclusion: AM is an effective and safe dressing for cutaneous ulcers, providing better wound healing, infection control, fluid conservation and analgesic effects than routine dressings.

Background: There are some debates in the use of laparoscopic hysterectomy for the morbidly obese patients as some surgeons find it superior to open hysterectomy. Others reported that laparoscopic surgeries for obese patients with gynecologic malignancy associated with technical difficulties and a smaller number of harvested lymph nodes compared to open surgery. Patients and Methods: Thirty-seven morbid obese patients with gynecological diseases underwent laparoscopic hysterectomy in the period between December 2017 and May 2021 at the Department of Surgical Oncology, Oncology Center, Mansoura University (OCMU). Results: The operative time was 175.14 min, the estimated blood loss (EBL) was 404.32 ml. Three patients (8.1%) had intraoperative blood transfusion. Conversion to laparotomy was done in 1 patient. The patients were ambulant in POD 1 and the oral intake was started in POD zero. Postoperative complications occurred in 4 patients in the form of wound infection, blood transfusion and 2 cases with port-site hernia. The patients had a median duration of hospital stay of 3 days (range: 1-5 days). Conclusion: laparoscopic hysterectomy for obese patients is a safe procedure and preferable to open hysterectomy in the terms of cost per patient and of peri-operative complications.

Background : Gastrointestinal bleeding (GIB) has been reported in 2%–13% of patients hospitalized with coronavirus disease 2019 (COVID-19). However, it remains a diagnostic and therapeutic dilemma in district hospital. The aim for this study wasto determine risk factors for GIB in COVID-19 patients, and to discuss outcomes, prognosis and therapeutic approaches. Matherial and methods: 21 patients who had confirmed COVID-19 infection and presented with GIB at Hospital Tawau between April 2020 and March 2021 were included in this retrospective study. GIB was defined as evidence of hematemesis, coffee-ground emesis, melena or hematochezia. Results: All 21 patients presented with GIB symptoms during hospital stay for COVID-19 illness, and majority presented in clinical stage 4 (28.6%) and 5 (47.6%). The use of methylprednisolone and anticoagulant were found in 61.9% and 28.6%, respectively. 15 (71.4%) presented with upper GIB, and 10 (66.7%) underwent upper endoscopy. The commonest cause of upper GIB was peptic ulcer disease (80%). The 70% who required endoscopic intervention all achieved successful hemostasis. 50% of lower GIB were due to bleeding rectal ulcer. 2 patients (33.3%) with lower GIB required lower endoscopy for endoscopic hemostasis. In-hospital mortality was 52.3%. Interestingly, initial presentation of GIB was entirely seen during in-hospitalstay for COVID-19 disease instead of acute admission with overt GIB, thus this might be related to treatment-related GIB with the use of anticoagulants and steroids. This warrants a matched control study with larger sample size. Conclusion: Risk factors such as severity of COVID-19, use of anticoagulant and steroids might increase the incidence of GIB. Diagnostic and therapeutic intervention through endoscopy remain the mainstay in the management of GIB in COVID-19 patients.

Objective: In this survey, we attempted to reveal the incidence and reasons of fear and anxiety caused by endoscopic procedures in patients who will have upper gastrointestinal endoscopy, which is more common in this population. Methodos: The study included adult patients who had an upper gastrointestinal endoscopic appointment in the General Surgery Endoscopy Laboratory. The study participants were asked to read and complete two questionnaires while being observed in the endoscopy department before the procedure. Results: The study comprised a total of 145 patients, 73 of whom were men. The pre-procedure questionnaire showed that the anxiety scores of patients who answered yes to the question "Are you afraid of undergoing an endoscopy?" were statistically significantly higher than those of patients who responded no (T-Anxiety: p=0.003, S-Anxiety: p0.001). When comparing the genders according to the responses to this question, it was found that the rate of yes responses was significantly higher in females [57 (78.1%)] than in males [30 (41.1%)] (p0.001). The S-Anxiety scores of patients who answered "Yes, he gave me sufficient information" to the question "Did your doctor give you sufficient information about the procedure to be performed?" in the questionnaire completed before the procedure were significantly lower than those of patients who answered, "He gave information, but not sufficient." Conclusion: Pre-procedure briefing by the physician is an essential factor in reducing the anxiety of endoscopy. So, it is important to be informed by the doctor before the procedure is an applicable factor.

Background: Renal complications afflict up to 0.8% of non-cardiac surgery patients. Postoperative urea and electrolyte (U&E) panels, comprised of 7 biochemical analyte tests, are methods used to assess perioperative renal function. However, inappropriate testing (i.e. ordering a subsequent test when there is no indication/risk of renal impairment based on a preceding test) isfinancially wasteful, increases laboratory workloads and increases unnecessary phlebotomy. African studies on inappropriate U&E postoperative tests are rare. A better understanding of this would assist with improving resource utilization and patient-friendly practices around perioperative testing in this setting. This study sought to address the gap in the knowledge. Methods: This was a retrospective audit involving data from vascular, gynaecology, specialized surgery patients who attended an academic hospital in Durban, South Africa during 2012-2016. Data was collected from the hospital and laboratory administrative systems. The number/proportion of inappropriate U&E tests was computed. The laboratory costs of unnecessary testing (in South African Rands – ZAR, and US$) were also computed. Results: The study sample was comprised of 704 patients. There were 1443 U&E panels ordered, equating to 10101 individual analyte tests. Of the 10101 individual analyte tests, 5161 (51.0%) were unnecessary. The total cost of unnecessary testing was ZAR 135734.30 (US$ 9647.07) based on a currency conversion rate of US$ 1 = ZAR 14.07. Conclusion: Given the high level of unnecessary postoperative U&E testing in our setting and the additional costs incurred, surgical departments should consider implementing algorithms for postoperative renal function testing and electronic gatekeeping for laboratory orders.

Background: Carotid endarterectomy (CEA) is a popular management strategy for carotid stenosis, but there is a risk of cerebrovascular accident (CVA) or death following this procedure. Studies investigating predictors of adverse outcomes following CEA have an overall role in improving patient management through risk stratification. We used data from a large national hospital discharge survey to identify predictors of in-hospital CVA or death in elderly patients undergoing CEA. Methods: We analyzed data from the National Hospital Discharge Survey (NHDS). Our study cohort consisted of 2023 CEA cases ≥65 years old between 2005 and 2008. We determined preoperative comorbidities and postoperative in-hospital outcomes from ICD-9-CM codes recorded on the NHDS database for each case. Predictors of CVA and death post-CEA were identified using multivariate logistic regression. Receiver operator characteristic (ROC) curve analyses were used to test the prognostic utility of the identified predictors. Results: Only a prior history of symptomatic cerebrovascular disease was identified as a predictor of CVA (Odds Ratio 47.71; 95% CI 18.65-122.1) or CVA/Death (Odds Ratio 51.32, 95% CI 21.15-124.6). A prior history of symptomatic cerebrovascular disease also had good prognostic utility for postoperative CVA or CVA/Death, with an area under the curve from the ROC curve analysis ranging from 0.786 to 0.791. Conclusions: Prior symptomatic cerebrovascular disease is a predictor of poor outcomes following CEA in patients ≥65 years old. Reducing the waiting time for CEA and the medical optimization of CEA cases prior to surgery are crucial for reducing perioperative neurological morbidity and mortality

Background: Anal fissure is a very common condition and is debilitating for the patient because of the severe pain it causes. Traditionally chronic anal fissures have been treated surgically with anal dilatation or gold standard procedure which is lateral internal sphincterotomy. Last decade has seen a shift to more conservative approach towards treatment of anal fissure mainly due to better physiological and pharmacological understanding of anal sphincter. Methods: This prospective study was conducted at KIMSDU Karad, on patients with chronic anal fissure treated in OPD or admitted to the wards and taken up for comparative study on randomized trial. Our primary aim was to compare the efficacy of topical 2% Diltiazem gel with lateral internal sphincterotomy in the management of chronic anal fissures. Results: Of the 100 cases included in this study, majority of the patients were found to be males less than 30 years of age. All the patients who underwent lateral internal sphincterotomy were relieved of pain and had their fissures healed whereas 4 patients in the diltiazem gel group were not free from pain and had to undergo lateral internal sphincterotomy. Conclusion: Topical 2% Diltiazem gel have proven to be as good as surgical treatment with better side effect profile and achieves high healing rates and should be considered as first line for treatment of chronic anal fissure. A few patients in whom fissure doesn’t heal or have recurrence should undergo lateral internal sphincterotomy

Background: Appendicitis is a commonly encountered condition in clinical practice. It is a difficult diagnosis and a high rate of negative appendectomy increases complications, morbidity and mortality among patients. Histopathological examination is the modality for definitive diagnosis, which requires patients to undergo appendectomy. This predisposes possibly normal individuals to postoperative complications. Scoring systems for diagnosing appendicitis have been developed and we attempt to validate one such recently developed scoring system, RAMA-AS. Our study also compared RAMA-AS with a more commonly used Alvarado scoring system. Materials and Methods: A prospective observational study of 100 clinically suspected patients of appendicitis was conducted in a tertiary care center. They were given scores according to the RAMA-AS and Alvarado scoring systems. Patient scores according to both scoring systems were subjected to analysis with USG findings. Results: We found a significant association between the RAMA-AS and USG diagnosis with a sensitivity, specificity and positive predictive value of 51.35%, 92.30% and 95% as compared to the Alvarado scoring system, which showed a sensitivity, specificity and positive predictive value of 28.37%, 84.61% and 84%. Conclusions: The incorporation of scoring systems can help in detecting patients with high scores as probable cases of appendicitis. RAMA-AS was found to have a significant association with appendicitis. RAMA-AS showed a better sensitivity, specificity, positive predictive value and negative predictive value than the Alvarado scoring system. But, patients with low scores should utilize other diagnostic modalities to decrease the chances of missing positive cases.

Aim of the study: To determine major predictors for limb salvage (or major amputation) in chronic limb threatening ischemia (CLTI) in Egyptian people Design: Pilot study, observational analytical study. Patients and Methods: This study was conducted on 224 cases in the Department of Vascular Surgery in Kasr Al-Ainy Hospital – Cairo University between March 2018 to February 2019. The clinical, radiological and operative variables were collected and detect patients who need major amputation in 30 days and verify predictors of limb salvage, which was subjected to univariate analysis in order to determine the most important factors of failure of limb salvage. Results: The TLC, total CK, serum urea level and incomplete foot arch are independent factors directly proportional to the possibility of major amputation. Open interventions and presence of inline distal runoff enter the foot are independent factors inversely proportional to the possibility of major amputation. Anemia and active cardiac condition are risk factors for major amputation. Conclusion: We obtained factors that predict the limb salvage by using of univariate and multivariate analysis. These factors can help the practitioners to predict the limb salvage and guides the consumption of health care resources and personnel.

Isolated tuberculous epididymo-orchitis (TBEO) is an exceptionally rare type of genitourinary tuberculosis (GUTB). It carries a very small percentage of incidence and most of the time are missed or picked up late due to its benign presentation. The clinical presentation can be varied and due to its nature of presentation, the diagnosis can be misleading and lead to a delay in treatment. We report a peculiar case of disseminated tuberculosis (TB) with tuberculous epididymo-orchitis in a middle-aged man who presented to us with a chronic right testicular swelling which initially worked-up for testicular malignancy. Patient underwent high ligation right orchidectomy and the histopathology examination (HPE) reported as necrotizing granulomatous inflammation of the right testis. Patient is treated with anti-tuberculous chemotherapy and a complete recovery is achieved after 6 months of treatment. Sufficient and detailed evaluation of testicular mass, particularly in the middle-aged population is important as the timing of diagnosis may yield a better prognosis. Tuberculous epididymo-orchitis has very similar clinical presentation with other testicular pathology. Due to lack of highly sensitive investigations preoperatively to diagnose it, no wonder it is considered as a “great mimicker”.

Angiosarcoma of the breast is a rare soft tissue breast cancer. It represents only 0.1-0.2% of all breast cancer cases worldwide. It can be divided into primary and secondary angiosarcoma. It usually present similar to other breast cancer mainly breast lump and or axillary swelling. Some patients may have bruises of the overlying skin. Angiosarcoma of breast possess significant challenged in its management since it is an aggressive tumor with limited treatment modalities. Furthermore, currently angiosarcoma of the breast also has very poor prognosis as patient initial presentation usually already has metastasis and 5-year survival for localized disease only around 55%. Herein we report a case of a young patient diagnosed with advanced primary angiosarcoma who presented with huge breast lump and changes of overlying skin after 3 months of her initial operation at another center. She undergone contrast enhanced computerised tomography scan (CECT-scan) of thorax, abdomen and pelvis and positron enhanced tomography scan (PET-scan) as her imaging modalities. She underwent surgical resection; mastectomy to secure hemostasis and subsequently adjuvant high dose radiotherapy as part of the treatment as she has spine metastasis. Chemotherapy was not commenced due to overall patient condition deteriorating over time. She succumbed to this disease after 3months of her mastectomy. Managing angiosarcoma is devastating as no proper treatment available currently due to the complexity of the disease and aggressiveness of this disease. Hence, hopefully in future better disease and treatment modalities available for this disease.

Inguinal swellings usually occur as a result of inguinal hernia, lymphadenopathy, granuloma inguinale, femoral hernia, hydrocele of spermatic cord, ectopic/undescended testis. Soft tissue sarcomas comprise most common malignant tumours of the groin. We report an interesting case an inguinal swelling, which was evaluated and initially diagnosed as malignant Extra gastrointestinal stromal tumour (e-GIST), operated to be finally reported as Extra skeletal Ewing sarcoma. This case is being reported for its rarity in occurrence, rarity in such a presentation and for the diagnostic misinterpretation following the initial biopsy. We present a case of a 49-year-old gentleman presented with a painful swelling over the right inguinal region for 1 week, with gradual increase in size. Examination revealed a tender, firm swelling above right inguinal crease with a smooth surface. Ultrasound was suggestive of lymph-nodal mass, CECT revealed a giant soft tissue sarcoma in the pelvis involving anterior vesical and para-vesical spaces, extending into right inguinal canal along the spermatic cord. Biopsy was suggestive of malignant Extra-Gastrointestinal stromal tumor (E-GIST). Following a multidisciplinary team discussion, exploratory laparotomy with right orchidectomy was performed. Histopathology of the operative specimen was suggestive of Extra skeletal Ewing Sarcoma. It is because the immuno-histochemical expression of epithelioid GIST could mimic that of Ewing sarcoma’s, there was an oversight in arriving at an accurate diagnosis. One must be vigilant that there might be a discrepancy between initial diagnosis on biopsy and the final diagnosis on histopathology and IHC, in especially in such rare tumours.

Malignant transformation of ectopic thyroid is considered very rare. We report a case of a woman with malignant ectopic thyroid in the right axilla with multifocal metastasis into the mediastinum, liver, peritoneum, mesocolon and intrabdominal nodes .Total thyroidectomy showed concomitant papillary microcarcinoma at left superior thyroid pole. We discuss the challenges in distinguishing primary neoplastic involvement of ectopic thyroid with multifocal metastasis from a metastatic thyroid carcinoma with primary local tumour in the thyroid gland and its management