{"paper_id":"51cb47b7-371f-4bc8-bd64-14e59d22a871","body_text":"International Journal of Case Reports and Images, Volume 14, Issue 2, 2023; Pages 46–52. ISSN: 0976-3198\nInt J Case Rep Images 2023;14(2):46–52.   \nwww.ijcasereportsandimages.com\nNagy et al. 46\nCASE SERIES PEER REVIEWED | OPEN ACCESS\nExtrauterine adenomyomas managed by laparoscopic  \nexcision: Three case reports with different theories of  \norigin\nCharles B Nagy, Szabolcs Papp, Nesreen Alaa Eldin, Samar M El-Maadawy\nABSTRACT\nIntroduction: We present three case reports of \nextrauterine adenomyoma (recto-vaginal/retro-cervical, \nbroad ligament, abdominal). The common presenting \nsymptoms in our patients were pelvic pain, dysmenorrhea, \nand deep dyspareunia. The cases were successfully treated \nwith laparoscopic excision by a multidisciplinary team of \ndoctors. One patient showed adenomyoma co-existing \nwith endometriosis on histopathological examination of \nthe tissue sample.\nCase Series:  We present 3 cases of extra uterine \nadenomyomas in 3 different sites, each case representing \na different theory of origin and all cases managed \nlaparoscopically with successful outcome without any \ncomplications. First case represent the implantation \ntheory following antecedent myomectomy. Second \ncase represents origin of adenomyoma as direct \nextension from the uterus with background of severe \ndiffuse adenomyosis. Third case represents origin from \nMüllerian remnants in the recto-vaginal septum with no \nadenomyosis or obliteration of the pouch Douglas.\nCharles B Nagy 1, Szabolcs Papp 2, Nesreen Alaa Eldin 3,  \nSamar M El-Maadawy4\nAffiliations: 1FRCOG, MSMEC, Consultant Gynecologist, \nEndometriosis Specialist, Medcare Women and Children \nHospital, Sheikh Zayed Road, Dubai, UAE; 2Consultant Colo-\nrectal Surgeon, Laparoscopic Surgeon, VPS Burjeel Hospital, \nAbu Dhabi, UAE; 3Radiologist, Medcare Women and Children \nHospital, Sheikh Zayed Road, Dubai, UAE; 4MD, FRCR, Spe-\ncialist Radiologist, Medcare Women and Children Hospital, \nSheikh Zayed Road, Dubai, UAE.\nCorresponding Author: Dr. Charles B Nagy, Medcare Wom -\nen and Children Hospital, Sheikh Zayed Road, Dubai, UAE; \nEmail: charlesnagy@hotmail.com\nReceived: 04 March 2023\nAccepted: 03 August 2023\nPublished: 16 October 2023\nConclusion: We propose the theory that adenomyoma \nwhich is a form of adenomyosis should be regarded as a \nform of deep endometriosis involving the uterus rather \nthan a separate entity. We believe that multidisciplinary \nlaparoscopic treatment is the way forward for accurate \ndiagnosis and treatment of adenomyosis in patients \nrequiring to preserve fertility. Future research needs to \nfocus on studying endometriosis behavior and recurrence \naccording to the tissue host to understand the disease and \ntailor the management according to patient symptoms.\nKeywords: Endometriosis, Extrauterine adenomyoma, \nInfertility, Laparoscopy\nHow to cite this article\nNagy CB, Papp S, Eldin NA, El-Maadawy SM. \nExtrauterine adenomyomas managed by laparoscopic  \nexcision: Three case reports with different theories of  \norigin. Int J Case Rep Images 2023;14(2):46–52.\nArticle ID: 101409Z01CN2023\n*********\ndoi: 10.5348/101409Z01CN2023CR\nINTRODUCTION\nAdenomyoma of the uterus is a circumscribed nodular \naggregate of benign endometrial glands surrounded \nby endometrial stroma with leiomyomatous smooth \nmuscle bordering the endometrial stromal component \n[1]. Adenomyoma is a localized and focal form of \nadenomyosis. It is classified as focal, diffuse, and cystic \n[2]. The prevalence of adenomyosis fluctuates between \n5% and 70% [3, 4]. Diagnosis of adenomyosis is made \non histological examination of the uterus. Extrauterine \n\nInternational Journal of Case Reports and Images, Volume 14, Issue 2, 2023; Pages 46–52. ISSN: 0976-3198\nInt J Case Rep Images 2023;14(2):46–52.   \nwww.ijcasereportsandimages.com\nNagy et al. 47\nadenomyomas are extremely rare and located outside \nthe uterus [2]. Clinical symptoms of adenomyosis are \nmenorrhagia, pelvic pain, and dysmenorrhea; and \nrisk factors associated are spontaneous and induced \nabortions, multiparity, endometrial hyperplasia, \nendometriosis, smoking, and surgical trauma [5, 6]. \nCurrent treatment options for symptomatic adenomyosis \ninclude hysterectomy, medication, conservative surgery, \nor minimally invasive techniques including uterine artery \nembolization [7, 8]. We present three case reports of \nextrauterine adenomyoma (recto-vaginal/retro-cervical \nspace, broad ligament, and large abdominal) managed by \nlaparoscopic excision.\nCASE SERIES\nCase 1: Combined laparoscopic-vaginal \napproach for the excision of large ex-\ntrauterine (recto-vaginal, retro-cervical) \nadenomyoma\nA 33-year-old female patient presented with a long-\nstanding complaint of severe pelvic pain, dysmenorrhea, \nand deep dyspareunia with irregular heavy periods and \nlately persistent vaginal bleeding, severe pain in bowel \nopening, and a sense of incomplete bowel emptying. \nShe had primary infertility for three years. Her blood \ninvestigations showed iron deficiency anemia with \nnormal CA-125 levels.\nClinical examination revealed a large mass occupying \nthe space behind the cervix and upper half of the vagina \npressing on the rectum, with evidence of bleeding coming \nfrom the mass. A colonoscopy showed normal findings \nof the bowel wall. A pelvic ultrasound scan (Figure 1) \nconfirmed the presence of a large mass behind the cervix \nattached to the rectum and extending behind the upper \npart of the vagina, a picture highly suggestive of a deep \ninfiltrating endometriosis nodule. A pelvic MRI of the \npatient confirmed the above findings and suspicion of \nmalignancy could not be ruled out.\nThe multidisciplinary team decided to proceed with \nsurgical excision of the mass using the laparoscopic route \nwith the possibility of bowel resection and ureteric stents.\nThe patient was treated with Decapeptyl (triptorelin) \n3.75 mg GnRh agonist injections for two months prior \nto surgery to stop menstruation and irregular bleeding. \nThe surgery was conducted jointly by the consultant \ngynecologist and colorectal surgeon using a novel \noperative technique of combined vaginal and laparoscopic \napproach to excise the mass from behind the cervix and \nupper vagina without the need for bowel resection to avoid \nthe serious effects on the quality of life and fertility. The \nvagina was reconstructed to cover the large defect after \nremoving the mass (Figure 2A and B). Interestingly, the \nrectosigmoid bowel wall was not infiltrated in this case so \nbowel resection was not indicated. Laparoscopy showed \nFigure 1: Pelvic ultrasound (Case 1).\nFigure 2 (A and B): Surgical procedure (Case 1).\nFigure 3: Actual specimen (Case 1).\n\nInternational Journal of Case Reports and Images, Volume 14, Issue 2, 2023; Pages 46–52. ISSN: 0976-3198\nInt J Case Rep Images 2023;14(2):46–52.   \nwww.ijcasereportsandimages.com\nNagy et al. 48\nnormal fallopian tubes suggesting that the patient would \nbe able to get pregnant spontaneously without the need \nfor assisted production techniques.\nHistological examination of excision sample \n(Figure  3) reported recto-vaginal adenomyotic nodule \nand fragmented tissue with features of endometriosis \nwith no evidence of malignancy (Figure 4A and B).\nThe patient became pregnant spontaneously one year \nafter the surgery and delivered a healthy baby at 39 weeks \nby cesarean section.\nCase 2: Rare case of broad ligament ex-\ntrauterine adenomyoma\nA 31-year-old, nulliparous woman [body mass index \n(BMI) of 33.3] with primary infertility for six years \nwas referred with the finding of a large complex and \nhighly vascular right adnexal mass. She presented with \ncomplaints of pelvic pain, dysmenorrhea, and irregular \nmenstruation for the past few months. The patient had \na history of laparoscopic myomectomy in 2016 and three \nfailed in vitro fertilization (IVF). Her blood investigation \nreported an anti-Müllerian hormone level of 7.059 ng/\nmL.\nPelvic ultrasound (Figure 5A–C) showed a bulky \nuterus with features of adenomyosis showing a focal \nadenomyoma at the left anterior uterine wall. Complex \nmixed solid and cystic vascular mass lesion at the right \nadnexal region which appeared to be separable from \nthe right ovary. A right broad ligament adenomyoma \nalong with a small complex right ovarian cyst mostly \nhemorrhagic in nature was suggested. No signs of deep \ninfiltrating endometriosis were seen.\nLaparoscopic extensive adhesiolysis for attached \nbowel and omentum, followed by selective uterine artery \nligation on the right side due to the high vascularity of \nthe tumor was done. The extrauterine adenomyoma was \nseparated from the ovary and the uterus. It was gently \ndissected off the bladder wall. Because of the superficial \ninfiltration of the bladder wall, the bladder was opened \nto identify the extent of involvement before the tumor \nwas completely separated and excised. Both ovaries \nand the rectosigmoid bowel were perfectly normal \n(Video 1: Surgery). The patient was discharged on 2nd \npostoperative day with no complications.\nThe histopathology of the right adnexal mass \nreported features of adenomyoma with cystic changes, \npossibly arising from broad ligament and no evidence of \nmalignancy. Omental biopsy histopathology showed mild \nfeatures of panniculitis.\nThe patient was treated with gonadotropin-releasing \nhormone (GnRH) analogue injections postoperatively for \nthree months. The patient had successful IVF and became \npregnant six months after the surgery. At 38 weeks of \ngestation, a healthy baby was delivered by cesarean \nsection.\nThe patient developed a port site recurrence of \nadenomyoma about one year after the laparoscopic \nexcision.\nFigure 4 (A and B): Histology slide (Case 1).\nFigure 5 (A–C): Pelvic ultrasound (Case 2).\nVideo 1: Laparoscopic approach of a case of extrauterine \nadenomyoma in the right side of the broad ligament attached to \nand infiltrating the bladder.\nVideo 1 URL:  https://www.ijcasereportsandimages.com/\narchive/article-full-text/101409Z01CN2023#video1\n\n\nInternational Journal of Case Reports and Images, Volume 14, Issue 2, 2023; Pages 46–52. ISSN: 0976-3198\nInt J Case Rep Images 2023;14(2):46–52.   \nwww.ijcasereportsandimages.com\nNagy et al. 49\nCase 3: Large extrauterine adenomyoma \nmistaken as an ovarian endometrioma\nA 31-year-old, nulliparous female (weight=74 kg, \nheight=169 cm) was referred with a diagnosis of severe \nendometriosis and large ovarian endometrioma for \na laparoscopic ovarian cystectomy. She had primary \ninfertility for four years. The patient presented with \nsevere dysmenorrhea (10/10), pelvic and abdomen \npain, deep dyspareunia, marked abdominal distention, \ndyspepsia and chronic constipation. She had persistent \nvaginal bleeding for one month preceded by a history of \nheavy irregular menstruation for years.\nPelvic and abdominal ultrasound scan (Figure \n6A–G) showed bulky fibroid uterus with features of \ndiffuse adenomyosis and multiple fibroids, with a large \nright adnexal complex cystic lesion which appeared to \nbe separable from both ovaries with the possibility of \npara-tubal complex cystic mass of unknown etiology or \nhuge extrauterine adenomyoma. No evidence of deep \ninfiltrating endometriosis of the pelvis was seen on \nthe transvaginal ultrasound scan. Magnetic resonance \nimaging (MRI) of the pelvis showed similar findings. \nNo past history of any surgeries or trauma. Blood \ninvestigations showed severe iron deficiency anemia (Hb \n8 g/dL).\nA multidisciplinary team consisting of a colorectal \nsurgeon, vascular surgeon, urologist, and radiology team \ndecided to do laparoscopic exploration and excision of \nthe adnexal mass.\nLaparoscopic exploration showed a huge extrauterine \nadenomyoma with a pedicle attached to the main uterus \ncollectively measured over 20 cm × 20 cm in diameter \nrising above the level of the umbilicus with a cystic \ncomponent full of old blood and the solid component \nattached to the uterus. After the evacuation of the cystic \ncomponent, the mass was removed completely with \npreservation of the right ovarian infundibulopelvic \nligament right ovary and right tube (Video 2: Surgery). \nThe left ovary and tube looked healthy. Hysteroscopy and \nendometrial biopsy were done at the same time.\nHistological examination confirmed extra trying \nadenomyoma with solid component showing smooth \nmuscle bundles separated by well-vascularized connective \ntissue and cystic component also showing the same \nappearance and there was no evidence of malignancy or \natypia. Endometrial biopsy showed hyperplastic glands \nwith no evidence of cytological atypia or malignancy.\nPostoperatively the patient was treated with GnRH \nanalogue monthly injections for three months. The \npatient was not planning for pregnancy.\nFigure 6 (A–G): Abdomen-pelvic ultrasound (Case 3).\nVideo 2: Laparoscopic approach of a case of huge extrauterine \nadenomyoma arising from and connected to the uterus with \nlarge amount of old blood collected inside, resembling large \nendometrioma on the right side.\nVideo 2 URL: https://www.ijcasereportsandimages.com/\narchive/article-full-text/101409Z01CN2023#video2\n\n\nInternational Journal of Case Reports and Images, Volume 14, Issue 2, 2023; Pages 46–52. ISSN: 0976-3198\nInt J Case Rep Images 2023;14(2):46–52.   \nwww.ijcasereportsandimages.com\nNagy et al. 50\nDISCUSSION\nAdenomyosis coexists with other benign disorders, \nsuch as endometriosis (70%), leiomyomas (50%), \nendometrial hyperplasia (35%), and endometrial polyps \n(2%) [9, 10]. Cases 1 and 3 had coexisting endometriosis \nand Case 2 had undergone myomectomy.\nAll three patients had infertility. Recent studies show \nthat adenomyosis negatively affects in vitro fertilization, \npregnancy, and the live birth rate, as well as increases the \nrisk of miscarriage and risk of obstetric complications \n[4].\nPistofidis et al. have described adenomyosis \nclassification based on intraoperative and histopathology \nfindings as diffuse, sclerotic, nodular, and cystic. It \nreported that in the study all cases of cystic and nodular \nadenomyosis were treated by laparoscopic excision of the \nlesion. 89% of patients with sclerotic adenomyosis were \ntreated with wide laparoscopic excision of the abnormal \ntissue and 81% of patients with diffuse adenomyosis were \ntreated with laparoscopic hysterectomy [11].\nIn our cases, Case 1 had large nodular recto-cervical, \nrecto-vaginal extrauterine adenomyoma, which was \nexcised by a multidisciplinary team with a novel operative \ntechnique of combined vaginal and laparoscopic approach. \nOne-year post-surgery the patient had a spontaneous \nconception and delivered a healthy full-term fetus.\nIn Case 2, the patient had a solid-cystic broad ligament \nadenomyoma managed surgically with laparoscopic \nexcision. Selective uterine artery ligation was done before \nexcision of the tumor due to high vascularity. Post-\nsurgery, the patient was treated with GnRH analogue \ninjections. Six months after the procedure patient had a \nsuccessful IVF and became pregnant.\nCase 3 had a large cystic-solid adenomyoma mistaken \nas an ovarian endometrioma. Despite the enormous size \n(20 cm × 20 cm) of adenomyoma, she was successfully \ntreated with laparoscopic excision preserving the uterus.\nThere are many theories about the pathogenesis \nof adenomyosis. One theory suggests that metaplastic \nchanges of intra-myometrial embryonic pluripotent \nMüllerian remnants in the adult uterine wall can possibly \nlead to the establishment of de novo ectopic endometrial \ntissue within the myometrial wall, creating adenomyotic \nlesions [12, 13]. This theory can be applied to Case 3 which \npresented an example of extrauterine adenomyoma that \nis probably arising from metaplastic head and Müllerian \nremnants as there was no antecedent surgery and its logic \nto be explained by the retrograde menstruation surgery.\nCase 2 developed recurrence of adenomyoma one \nyear after the laparoscopic excision. A study by Zhu \net al. concluded that the postoperative drug (GnRH \nagonist with oral contraceptives) use may be beneficial \nto reduce the recurrence of adenomyosis, especially for \nadenomyosis with endometriosis [14].\nSzubert et al. in the review of adenomyosis as a \nrisk factor for myometrial or endometrial neoplasms \nconcluded that adenomyosis may be a potential risk \nfactor for myometrial or endometrial neoplasms [15].\nWe strongly recommend that adenomyosis nodules \nor hysterectomy specimens of the adenomyotic uterus \nshould be removed using in-bag morcellation to avoid \nsignificant morbidity due to risk of dissemination and \nrecurrence as reported by Belmarez et al. [16] and also \nencountered in our Case 2.\nIn Case 1, the finding of large isolated recto-vaginal \nadenomyoma without infiltrating the rectum highlights \nthe utmost importance of accurate preoperative \nradiological evaluation and clinical examination in \nplanning the suitable surgical procedure for the individual \npatient. As in our new pro-forma for ultrasound mapping, \nwe highlighted 3 separate types of recto-vaginal deep \nendometriosis, our case was a clear example of isolated \nrecto-vaginal septum without rectal wall involvement. \nEl-Maadawy et al.  have also highlighted the importance \nof ultrasound mapping to tailor an appropriate surgical \napproach to enhance the patient quality of life and \nfertility, ensuring radical excision of the disease and \nminimizing operative and postoperative complications in \ndeep infiltrating endometriosis [17].\nDonnez et al. suggested that uterocervical adenomyosis \ncould be the cause of deep endometriotic nodules, as \nis also the case for deep anterior endometriosis, called \nbladder adenomyotic nodules [18]. \nWe propose the theory that adenomyosis should be \nregarded as a form of deep endometriosis involving the \nuterus rather than a separate entity, due to the very close \nhistopathological similarity.\nSaunders et al. reported that we may make more \nprogress in developing patient-focused treatments if \nwe stop considering endometriosis as a single “disease” \nwith a diagnosis based solely on the presence of a \nlesion(s) resembling endometrium. The disease model \nis problematic, not only because of the poor correlation \nbetween numbers/location of lesions and pain symptoms, \nbut also because it is estimated that up to 50% of \nasymptomatic fertile women presenting for other surgical \nprocedures may have lesions [19].\nWe believe that the risk of recurrence of deep \nendometriosis depends not only on the nature of the \ndisease but more importantly on the host tissue whether \nit is myometrium, bowel, ovarian, peritoneal, or extra-\npelvic. This concept will significantly facilitate future \nresearch and the reproducibility and accuracy of results \nas we compare type-specific deep endometriosis, i.e., \nbowel, uterine, ovarian, and so on, rather than comparing \nstages that include more than one type of endometriosis \nin the same stage.\nIn the presented case reports multidisciplinary team \nconsisting of an experienced gynecologist, colorectal \nsurgeon, urologist, and radiology specialist decided on \nthe treatment plan resulting in a short hospital stay, \nuneventful recovery, and preservation of the uterus.\n\nInternational Journal of Case Reports and Images, Volume 14, Issue 2, 2023; Pages 46–52. ISSN: 0976-3198\nInt J Case Rep Images 2023;14(2):46–52.   \nwww.ijcasereportsandimages.com\nNagy et al. 51\nCONCLUSION\nWe propose the theory that adenomyoma, which is a \nform of adenomyosis should be regarded as a form of deep \nendometriosis involving the uterus rather than a separate \nentity. Future research needs to focus on studying \nendometriosis behavior and recurrence according to the \ntissue host rather than the staging systems, as we believe \nthat accurate endometriosis typing and comparing \ntissue-specific characteristics of endometriosis is the \nway forward to understand the disease and tailor the \nmanagement according to patient symptoms.\nWe believe that multidisciplinary laparoscopic \ntreatment involving an experienced gynecologist, \ncolorectal surgeon, urologist, and radiology specialist is \nthe way forward for accurate diagnosis and treatment of \nadenomyosis in patients wanting to preserve fertility.\nREFERENCES\n1. Tahlan A, Nanda A, Mohan H. Uterine adenomyoma: \nA clinicopathologic review of 26 cases and a review of \nthe literature. Int J Gynecol Pathol 2006;25(4):361–\n5.\n2. Paul PG, Gulati G, Shintre H, Mannur S, Paul G, \nMehta S. Extrauterine adenomyoma: A review of \nthe literature. Eur J Obstet Gynecol Reprod Biol \n2018;228:130–6.  \n3. Graziano A, Lo Monte G, Piva I, et al. Diagnostic \nfindings in adenomyosis: A pictorial review on \nthe major concerns. Eur Rev Med Pharmacol Sci \n2015;19(7):1146–54.\n4. Szubert M, Koziróg E, Olszak O, Krygier-Kurz \nK, Kazmierczak J, Wilczynski J. Adenomyosis \nand infertility—Review of medical and surgical \napproaches. Int J Environ Res Public Health \n2021;18(3):1235.\n5. Vercellini P, Viganò P, Somigliana E, Daguati R, \nAbbiati A, Fedele L. Adenomyosis: Epidemiological \nfactors. Best Pract Res Clin Obstet Gynaecol \n2006;20(4):465–77.\n6. Harada T, Khine YM, Kaponis A, Nikellis T, \nDecavalas G, Taniguchi F. The impact of adenomyosis \non Women's fertility. Obstet Gynecol Surv \n2016;71(9):557–68.\n7. Dessouky R, Gamil SA, Nada MG, Mousa R, Libda \nY. Management of uterine adenomyosis: Current \ntrends and uterine artery embolization as a potential \nalternative to hysterectomy. Insights Imaging \n2019;10(1):48.\n8. Radzinsky VE, Khamoshina MB, Nosenko EN, et al. \nTreatment strategies for pelvic pain associated with \nadenomyosis. Gynecol Endocrinol 2016;32(sup2):19–\n22.\n9. Benson R C, Sneeden VD. Adenomyosis: A \nreappraisal of symptomatology. Am J Obstet Gynecol \n1958;76(5):1044–57. \n10. Garavaglia E, Audrey S, Annalisa I, et al. Adenomyosis \nand its impact on women fertility. Iran J Reprod Med \n2015;13(6):327–36. \n11. Pistofidis G, Makrakis E, Koukoura O, Bardis \nN, Balinakos P, Anaf V. Distinct types of \nuterine adenomyosis based on laparoscopic and \nhistopathologic criteria. Clin Exp Obstet Gynecol \n2014;41(2):113–8.\n12. Ferenczy A. Pathophysiology of adenomyosis. Hum \nReprod Update 1998;4(4):312–22.\n13. García-Solares J, Donnez J, Donnez O, Dolmans MM. \nPathogenesis of uterine adenomyosis: Invagination or \nmetaplasia? Fertil Steril 2018;109(3):371–9.\n14. Zhu L, Chen S, Che X, Xu P, Huang X, Zhang X. \nComparisons of the efficacy and recurrence of \nadenomyomectomy for severe uterine diffuse \nadenomyosis via laparotomy versus laparoscopy: A \nlong-term result in a single institution. J Pain Res \n2019;12:1917–24.\n15. Szubert M, Kozirog E, Wilczynski J. Adenomyosis \nas a risk factor for myometrial or endometrial \nneoplasms—Review. Int J Environ Res Public Health \n2022;19(4):2294.\n16. Belmarez JA, Latifi HR, Zhang W, Matthews CM. \nSimultaneously occurring disseminated peritoneal \nleiomyomatosis and multiple extrauterine \nadenomyomas following hysterectomy. Proc (Bayl \nUniv Med Cent) 2019;32(1):126–8.\n17. El-Maadawy SM, Alaaeldin N, Nagy CB. Role of \npreoperative ultrasound mapping in the surgical \nmanagement of deep infiltrating endometriosis: A \nprospective observational study. Egypt J Radiol Nucl \nMed 2021;52:159\n18. Donnez J, Dolmans MM, Fellah L. What if deep \nendometriotic nodules and uterine adenomyosis were \nactually two forms of the same disease? Fertil Steril \n2019;111(3):454–6.\n19. Saunders PTK, Horne AW. Endometriosis: Etiology, \npathobiology, and therapeutic prospects. Cell \n2021;184(11):2807–24.\n*********\nAuthor Contributions\nCharles B Nagy – Conception of the work, Design of the \nwork, Acquisition of data, Analysis of data, Interpretation \nof data, Drafting the work, Revising the work critically \nfor important intellectual content, Final approval of the \nversion to be published, Agree to be accountable for all \naspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nSzabolcs Papp – Acquisition of data, Revising the work \ncritically for important intellectual content, Final approval \nof the version to be published, Agree to be accountable for \nall aspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nNesreen Alaa Eldin – Acquisition of data, Interpretation \nof data, Revising the work critically for important \nintellectual content, Final approval of the version to be \npublished, Agree to be accountable for all aspects of the \nwork in ensuring that questions related to the accuracy \n\nInternational Journal of Case Reports and Images, Volume 14, Issue 2, 2023; Pages 46–52. ISSN: 0976-3198\nInt J Case Rep Images 2023;14(2):46–52.   \nwww.ijcasereportsandimages.com\nNagy et al. 52\nor integrity of any part of the work are appropriately \ninvestigated and resolved\nSamar M El-Maadawy – Acquisition of data, \nInterpretation of data, Revising the work critically for \nimportant intellectual content, Final approval of the \nversion to be published, Agree to be accountable for all \naspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are \nappropriately investigated and resolved\nGuarantor of Submission\nThe corresponding author is the guarantor of submission.\nSource of Support\nNone.\nConsent Statement\nWritten informed consent was obtained from the patient \nfor publication of this article.\nConflict of Interest\nAuthors declare no conflict of interest.\nData Availability\nAll relevant data are within the paper and its Supporting \nInformation files.\nCopyright\n© 2023 Charles B Nagy et al. This article is distributed \nunder the terms of Creative Commons Attribution \nLicense which permits unrestricted use, distribution \nand reproduction in any medium provided the original \nauthor(s) and original publisher are properly credited. \nPlease see the copyright policy on the journal website for \nmore information.\nAccess full text article on\nother devices\nAccess PDF of article on\nother devices\n\nSubmit your manuscripts at\nwww.edoriumjournals.com","source_license":"CC0","license_restricted":false}