Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system.A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler  was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion.This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy. Indications for cervical esophageal resection and short-distance reconstruction include limited cervical esophageal cancer, hypopharyngeal cancer invading the cervival esophagus and traumatic injury or dysfunction caused by congenital disorders, corrosive inury, or radiation damage ,2. FurthIn 1907, Carrel first described the technique of an autologous free jejunal graft transplanted into the neck of dogs with microvascular anastomosis to the common carotid artery and internal jugular vein . In the For free cervical jejunal interposition of limited esophageal cancer, a unilateral or bilateral incision medial to the sternocleidomastoid muscle is performed and the platysma is transsected upwards. After retraction of the sternocleidomastoid muscle and division of the omohyoid muscle, lymphadenectomy around the internal jugular vein, the common carotid artery and the vagal nerve can be performed if necessary. The cervical esophagus is dissected posteriorly and mobilized from the hypopharynx down to the upper thoracic aperture. Retaining sutures can be placed and resection is completed. After confirmation of tumor-free resection margins by frozen section, a laparotomy is performed and a jejunal loop with appropriately long vessels is identified by diaphanoscopy. After graft excision, the artery is flushed with heparinized saline. An end-to-end jejuno-jejunostomy is then performed to restore GI continuity in the abdomen. The graft is transferred into the cervical site in isoperistaltic direction and venous and arterial anastomoses are completed using the internal jugular vein and the superior thyroid artery, the thyrocervical trunk or the common carotid trunk . Due to A first stapler-prototype, weighing 3.6 kg and needing approximately 2 hours of assembly time, was introduced in 1908 ,15. ProdWe here describe the case of a patient with a failed gastric conduit after leakage of the cervical anastomosis and development of a tracheal fistula. Three months after discontinuity resection of the anastomosis and formation of a cervical esophagostomy, reconstruction of the continuity with a free jejunal interposition graft was planned. This was difficult due to the location of the remaining gastric conduit deep in the thoracic aperture. Feasibility of a retrograde stapling procedure after endoscopic rendez-vous is described.A 56 year-old caucasian female patient was referred with the diagnosis of esophageal squamous cell carcinoma (ESSC). The patient had a history of smoking (55 pack-years) and moderate alcohol consumption. Work-up including fluoroscopy, thoraco-abdominal CT scan, gastroscopy, bronchoscopy and blood works confirmed the diagnosis of a circular ESSC at 20-25 cm from the incisors Figure A with noAngiography of SMA, IMA, ECA and subclavian arteries showed no pathological findings. Intraoperatively, the proximal stump of the gastric interposition was exposed after cervical incision. Exposition was challenging due to the very deep intrathoracic position of the conduit stump Figure . TherefoWe here describe a modified technique for retrograde stapling of a free jejunal interposition graft for a failed gastric pull-up. The gastric conduit had remained in situ within the right hemi-thorax, its proximal end deep in the thoracic aperture, opening the possibility of limited-length reconstruction by free jejunal interposition. During reconstruction, cervical exposition of the proximal gastric stump was challenging due to its position deep in the thoracic aperture. Preparation for hand-sewn distal anastomosis would have meant a traumatizing access by sternotomy and/or thoracotomy, including a significant risk of surgical damage and yet accepting a high risk of anastomotic leakage. Instead, a laparotomy was performed with subsequent distal gastrostomy and insertion of a gastroscope followed by retrograde gastroscopy of the pull-up gastric interposition. By diaphanoscopy, the proximal stump of the gastric conduit was safely identified and a guide-wire was inserted from the cervival incision site. Then, the anvil of the OrViL circular stapler was introduced via the conduit and the jejuno-gastrostomy was stapled prior to microvascular reconstruction of the graft vessels. Concerning esophagogastric surgery with jejunal interposition, an ongoing controversy exists, whether esophago-jejunal or pharyngo-jejunal anastomoses should preferably be performed as end-to-side circular stapling or be hand-sewn end-to-end ,17. Up uIn our case, revascularisation was performed after the jejuno-gastrostomy, thus enabling adaptation of an ideal vessel-length with the jejunal interpostion already in situ. Vice versa, stapling of the jejunogastrostomy, being a fast and safe procedure, did not necessitate prior microvascular anastomosis of the ischemia-intolerant jejunal flap. Leaving the gastric conduit in situ thus enabled salvage surgery by interposition of a short jejunal segment, offering the benefits of excellent peristalsis, absence of alkaline or acidic reflux and excellent size match of the two conduits .Alternative methods for reconstruction of the cervical esophagus after failure of a gastric conduit are pectoralis major flaps or free tissue transfers such as the radial forearm flap or the anterolateral thigh flap or colonic interposition ,18. The Taken together, we here describe a modified technique of retrograde stapling of a jejunal interposition graft to a gastric conduit that had remained in situ after a leaking esophageal anastomosis. This technique may be of value for a selected group of patients with this unique surgical problem and may help to avoid then unnecessary thoracotomies or colonic pull-ups.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.The authors declare that they have no competing interests.CH drafted, wrote an edited the manuscript and edited the figures. FCP helped to dritically revise the manusript and performed parts of the surgeries. KE and LMD created the figures presented in this manuscript. VB and PR helped drafting and critically revising the manuscript. ML, JD, LP, TK, HJS and MHD were the surgeons performing this new technique of retrograde stapling of a jejunal interposition graft to a gastric conduit. Furthermore, MHD drafted and critically revised the manuscript and HJS critically revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/14/78/prepub


Intravenous leiomyomatosis (IVL) extending to inferior vena cava and heart is one of the most challenging conditions for surgical treatment. We explored the use of computerized tomography angiography (CTA) in preoperative assessment for this disease.A cohort of 31 patients with IVL extending to inferior vena cava and heart were reviewed from the year 2002 to 2014, focusing on the preoperative CTA imaging characteristics and the surgical procedures in clinical treatment.All patients were diagnosed correctly combining the clinical medical history and CTA imaging. Thirteen patients had tumors confined within the inferior vena cava, and 18 patients had tumors intruding into the right heart. Furthermore, 15 tumors were located in the right atrium alone, and 3 tumors involved both the right atrium and the right ventricle. All patients had simple or multiple soft tissue masses from the pelvis, with 22 tumors extending into inferior vena cava through the iliac veins and 9 tumors through the ovarian veins. Three patients had tumors invading into lung and underwent tumor thrombus resection in the pulmonary artery. Patients received either one-stage surgery or two-stage surgery dependent on patient general condition and tumor status. All operations were successfully performed by multidisciplinary cooperation, including gynecology, cardiac surgery, and vascular surgery, without severe surgical-related complications or deaths.CTA imaging can present location, size, and full-scale extension pathway of IVL lesions, and can be used as first-line imaging technique in preoperative assessment, having great significance in making surgical plan and obtaining successful outcome. Intravenous leiomyomatosis (IVL) is an extremely rare form of leiomyoma . IVL, orThe tumor primarily extends through the uterine veins, sometimes reaching the inferior vena cava, the right cardiac chambers, and even the pulmonary artery . CardiacTherefore, early diagnosis and comprehensive preoperative assessment is crucial in clinical management of IVL extending to inferior vena cava and heart. The purpose of our study is to assess the role of computed tomography angiography (CTA) in preoperative evaluation including delineating tumor extent and making surgical plan for this disease.From the year January 2002 to December 2014, 51 patients with IVL were admitted to PUMCH, 31 (60.8 %) patients diagnosed as IVL extending to inferior vena cava and heart. Patients complaining of cardiac symptoms in addition to abdominal/pelvic mass, such as chest tightness, shortness of breath, palpitation, swelling of lower extremities, and even syncope, subsequently underwent CTA if ultrasound or echocardiography indicated space-occupying lesions inside inferior vena cava and heart.CTA was conducted by using a 64-slice multidetector computerized tomography . Image acquisition on the 64-slice scanner was performed with the following parameters: tube voltage 120 kV; effective mAs 450; slice collimation 0.6 mm; pitch 0.625; rotation interval 0.25–0.30 mm; the field of view from pelvic floor to 3 cm above tracheal carnia. Two experienced radiologists retrospectively assessed data sets using a workstation (Philips EBW), which allowed interactive postprocess of imaging data including volume rendering (VR), volume intensity projection (VIP), maximum intensity projection (MIP), multi-planar reconstruction (MPR), and curve-planar reconstruction (CPR). All reconstructed image were excellent.Information on the location, size, morphology, density, blood supply, contrast, extension pathway, and adhesion of the tumor would be offered. After comprehensive preoperative evaluation, patients with IVL extending to inferior vena cava and heart were submitted to one-stage surgery or two-stage surgery. Surgeries were performed by experienced surgeons comprising gynecologists, cardiac surgeons, vascular surgeons, and urinary surgeons. Final diagnoses were confirmed by at least two pathologists based on the postoperative histopathological findings, in combination of imaging demonstration and surgical findings.Our research was approved by the Ethics Committee of Peking Union Medical College Hospital (PUMCH). Written informed consent to use individual clinical data for publication was obtained from each patient.The median age of the entire study population was 31 years (range 24–51 years). The median gravida and para of the patients was 3 (range 0–6) and 1 (range 0–4), respectively. All the patients had history of uterine leiomyoma, and 21/31 (67.7 %) had undergone an operation of uterine leiomyoma, either myomectomy or hysterectomy.Patients who were suspicious of uterine leiomyoma and complained of cardiac symptoms such as chest tightness, shortness of breath, edema of lower extremities were submitted to CTA. Combining the features of CTA imaging and history of uterine leiomyoma, the diagnosis of IVL was considered before surgery. The preoperative diagnostic coincidence rate was 100 % compared with postoperative pathological review.From CTA images, first we could observe simple or multiple space-occupying lesions in the pelvis. The primary tumor lesions of IVL are specifically manifested by augmentation and tortuous clustering of uterine or parametrial vessels. The surface of tumors intruding into venous lumen are covered by smooth inima or endothelium, inadhesive to the venous walls, thus characteristically presented as free mass within the vascular system. In the coronal plane, tumor lesions in the pelvis and in the inferior vena cava are continuous and inhomogeneously enhanced, shaped like “sausages”, and when the right heart are involved, we could observe characteristic “walking stick head” or “snake head” tumor masses. In the cross-sectional plane, the lumen of inferior vena cava presented circular or semicircular change, sometimes with calcification of tumor lesions.A distinct advantage of CTA is directly presenting the full-scale path of extension. Patients with IVL usually had simple or multiple soft tissue masses from the pelvis extending into the inferior vena cava. In our study, 22 patients had tumors extending into inferior vena cava through the iliac veins, and 9 patients through the ovarian veins Fig. . The masAdditionally, among our study population, three patients had tumors invading into lung and underwent tumor thrombus resection in the pulmonary artery. Besides, six patients had renal involvement and defect of renal function, because the pelvic mass compressed the ureter and caused hydronephrosis.It is noteworthy that, in our study, of the 31 patients, 26 patients underwent ultrasonography in multiple regions before submitted to CTA, and the other 5 patients received MRI before performing CTA.The technical requirement for ultrasonography was relatively lower, but the information given by ultrasonography was fragmented compared with CTA. Pelvic ultrasound helped us finding single or multiple solid tumors in the pelvic or even abdominal cavity; from abdominal vascular ultrasound, we could observe “vessel-in-vessel” sign in the inverior vena cava, iliac veins, and renal veins; and ultrasonic cardiogram was able to tell us if there were space-occupying lesions in the right heart, or even the pulmonary artery, in addition to the morphology and structure of the heart. Comprehensive analysis of these fragmented information could help us making diagnosis. However, the continuity and extension pathway of tumors was not available, which was cruicial for making surgical plans.Regarding MRI, its scanning range could be as large as that of CTA, and the post-processing techniques also could provide three-dimensional images. However, the spatial resolution of image was relatively poor containing more artifacts, and the details of intravascular diseases cound not .be presented as clear as compared with CTA. Besides, the time needed for examination was much longer, and patients carrying cardiac pacemaker or metal intrauterine were prohibited from this examination.With the information offered by CTA, surgical plans were subsequently made after multidisciplinary consultation dependent on the tumor extent and patient general condition.Fifteen patients underwent one-stage operations including tumor thrombus resection from the inferior vena cava, pelvic and abdominal mass resection, total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without intracardiac tumor resection Fig. . Of the All operations were successfully performed by multidisciplinary cooperation, including department of gynecology, cardiac surgery, and vascular surgery, without severe surgical-related complications or deaths.Intravenous leiomyomatosis is a special type of uterine myoma which grows in the venous system. The first case of IVL extending to inferior vena cava and heart was reported by Durck in 1907 . If patiConcerning the origination of IVL, there have been two theories: the first is from smooth muscles cells in the venous walls, which proliferate and intrude into venous lumen; the second is from uterine myoma, benign tumor cells invading uterine veins and continuing to grow in the inferior vena cava , 11. MosWhen IVL extends into inferior vena cava and heart, or even pulmonary artery, the life of patients will be threatened fatally, that is the malignant behavior of IVL. Tumor growth in the heart can increase the risk of sudden death attributable to the tricuspid valve orifice or right ventricular outflow tract obstruction, thus early diagnosis and timely operation are of great importance in improving patient outcome . ComprehOptimal diagnostic management of IVL remains a topic of ongoing debate. Typical imaging investigation for IVL encompasses different methods including ultrasonography, magnetic resonance imaging (MRI), and computed tomography (CT). Ultrasonography, especially cardiac ultrasound, is useful in evaluating intravascular and intracardiac lesions when conducted by an experienced operator, but requires highly specialized training. Three-dimensional MRI is playing an increasingly important role in modern imaging diagnosis, but it presented with relatively poor spatial resolution and more artifacts, and is time-consuming and not suitable for patients carrying cardiac pacemaker or metal intrauterine device. The availability of a non-invasive readily available diagnostic technique is therefore desirable.Recent advances in CT have enabled the acquisition of three-dimensional data sets with submillimeter spatial resolution, allowing for detailed image reconstruction which resembles conventional angiography. Besides, multi-slice computed tomography enabled the acquisition of CT angiographic data sets over an extended field of view including abdomen, pelvis, and lower extremities in only a few seconds with a single contrast bolus . In addiCompared with ultrasonography and MRI, a distinct advantage of CTA is directly presenting the full-scale path of tumor extension. The chest & abdomen & pelvis combining scans could clearly display IVL extension pathway. There are two classical pathways: the first is from uterine vein, iliac vein, to inferior vena cava –17; the In the literature, most IVL tumors grow unilaterally, occasionally growing bilaterally. Over 50 % of IVL tumors extend through internal iliac vein, about 25 % extend through ovarian vein, and about 5 % extend through both internal iliac vein and ovarian vein . In our Surgery is the only effective treatment modality for IVL extending to inferior vena cava and heart. Resection includes the uterine tumors, parametrium tumors, ovaries and fallopian tubes, and intravenous and intracardiac tumors. Various surgical approaches have been used for removing the IVL tumor, mainly including one-stage surgery and two-stage surgery. In 1982, Ariza et al reported intracardiac components resection followed by a delayed laparotomy , 21. In The development of cardiopulmonary bypass revolutionized cardiac surgery and contributed immensely to the improvement of patients outcomes . In our Differential diagnosis should be performed between IVL and other diseases that have similar CT imaging that is space-occupying lesions in the venous system or right cardiac and pulmonary system. The differential diagnosis of IVL mainly includes intravenous thrombus, Budd-Chiari syndrome, right atrial myxoma, primary leiomyosarcoma, endometrial stromal sarcoma . First tIn conclusion, CTA can present location, size, and full-scale extension pathway of IVL lesions, and can be used as first-line imaging technique in preoperative assessment, having great significance in making surgical plans and obtaining successful outcome.All the data supporting our findings could be found in this paper.


Steatocystoma simplex is an uncommon skin lesion with a histological pattern that is identical to that of steatocystoma multiplex. We are reporting this case of steatocystoma simplex for its uncommon location in the penile foreskin, and its occurrence in a Wapishana man.A 56-year-old man of Wapishana ethnicity presented with complaints of referred penile discomfort and pain during sexual intercourse for 5 years. A physical examination revealed a mobile, compressible subcutaneous non-tender mass of 4 cm diameter located on the left-side of his penile foreskin. There were no signs of inflammation, no grip on the penile shaft, and no urethral discharge or enlargement of lymph nodes. We found no evidence of other cysts on cutaneous examination. We performed classical excision of the lesion under local anesthesia and confirmed the diagnosis of steatocystoma with the pathological report. As there were no complications, we discharged him the same day.Steatocystoma can be considered a differential diagnosis for cystic lesions on and around the penis. Steatocystoma simplex is a rare skin lesion with a histological pattern that is identical to that of steatocystoma multiplex. Steatocystoma multiplex is a condition with multiple cystic lesions inherited in an autosomal dominant pattern. However, steatocystoma is a non-inheritable solitary lesion. Brownstein, in 1982, was the first to describe steatocystoma simplex [A 56-year-old Indian man of Wapishana ethnicity presented to our Surgery out-patient department (OPD) with complaints of referred penile discomfort and pain during sexual intercourse for 5 years. He was referred to our Urology department as a case of genital tumor. A physical examination revealed a mobile, non-tender, compressible, subcutaneous mass of 4 cm diameter located on the left-side of his penile foreskin Figs.  and 2. HOn histopathological examination, the cyst consisted of numerous folds lined by stratified squamous epithelium. A basal layer, two or three rows of pavement cells, and a well-defined corneal layer that protruded inside the cyst, simulating the beheading of apocrine glands, formed the cyst wall. Sebaceous glands were also found within the cyst wall itself.There was no infection or pain after excision. The patient was discharged from hospital the same day, after surgery.Steatocystoma is a benign adnexal tumor that originates from the pilosebaceous duct. It usually presents with multiple lesions, but Brownstein  reportedSteatocystoma simplex is a benign, solitary, non-heritable counterpart of steatocystoma multiplex that is inherited in an autosomal dominant fashion with multiple lesions ; steatocCystic lesions in and around the penis are uncommon. Cystic lesions that have been reported until now are: mucoid cysts, epidermal cysts, pilonidal cysts, Tyson gland cysts and urethral diverticulum –9. DermoSteatocystoma simplex cysts are non-symptomatic, and the treatment is done usually for cosmetic purposes. The indications for the treatment in the present case were pain and discomfort during sexual intercourse, and cosmetic disfigurement. We performed classical excision of the lesion under local anesthesia. As there were no complications, we discharged our patient the same day. Caution is necessary when treating steatocystoma simplex because aspiration, disruption, or partial excision of the cyst may lead to recurrence. The cyst should be removed intact. Uneventful postoperative recovery without any complication suggests surgery is the best option to manage such tumors. Hence, we recommend resection of such tumors as the best possible management.Steatocystoma can be considered a differential diagnosis for cystic lesions on and around the penis.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Adrenocortical carcinoma is rarely seen in a neonatal period. Adrenocortical carcinoma usually causes virilisation, precocious puberty, Cushingoid syndrome.Describe a case of neonatal adrenocortical carcinoma diagnosed and treated in Vietnam National Hospital of Pediatrics.A case report of neonatal adrenocortical carcinoma with Cushingoid syndrome and persistent hypertension.A boy was admitted to hospital at the age of 23 days because of vomiting, poor feeding and abdominal distension, and edema on both legs. On examination we found the child had Cushingoid syndrome, but not precocious puberty, edema on both legs, and hypertenstion. Blood pressure was 150/90 mmHg, required IV Loxen to maintain BP. Investigation showed cortisol 8AM was high of 4473 nmol/l; cortisol 24AM 3971 nmol/l. Electrolyte, renal function, glucose, urine VMA/HMA were normal. Abdominal ultrasound found a hypo-enhancing mass in the left adrenal area with calcification and dimension of 37x32 mm. Dilated left renal pelvis was also observed. Cardiac ultrasound found ventricular hypertrophy, suspected cardiomyopathy. Neck MRI detected abnormal connection between lymphatic vessels and venous vessels. Abdominal CT showed a heterogeneous mass of 40x41x50 mm with calcification in the left adrenal area. Operation was done to remove the mass. No metastase was noticed during operation. Histology confirmed a diagnosis of adrenocortical carcinoma. Cortical was normal after operation. However, hypertension was still present a week after operation and IV Loxen was indicated to maintain normal BP.Post-operation hypertension was persistent in a neonatal adrenocortical carcinoma patient.Written informed consent was obtained from the patient for publication of this Case report (and any accompanying images). A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Primary mesenchymal chondrosarcoma of the kidney is an extremely rare malignant tumor. To our best knowledge, only 9 such cases have been reported so far.In the current paper, we present the case of a 67 year-old patient with recurrent left lumbar pain, increased fatigability and intermittent macroscopic hematuria. He underwent a surgical resection of the left kidney and left hemicolon.The pathological diagnosis was primary extraskeletal renal mesenchymal chondrosarcoma. Overall survival was 9 months, with pulmonary metastasis and local recurrence at 6 months. The management of the patient is described, from the initial differential diagnosis, after the first clinical examination to the surgical resection, with a special emphasis on the surgical procedures that were carried out.Extraskeletal chondrosarcoma of primary origin in the kidney are extremely rare tumors with a highly malignant potential and very poor prognosis. Because the role of chemotherapy or radiation therapy has not been evaluated properly yet, we underline the importance of surgery in the management of such cases as the main and best approach to achieve clinical remission and long-term survival, provided the patient is referred to a surgical consult in time. Mesenchymal chondrosarcomas (MC) were initially described by Lichtenstein and Bernstein more than 50 years ago as rare tumors that affect the bone tissue , other cIn the current paper, we report description of the surgical management of a renal MC, an extremely rare condition to our knowledge, with only nine other cases having been previously reported –17.In the current paper, we present the case of a 67 year-old patient who was hospitalized with recurrent left lumbar pain, increased fatigability and intermittent macroscopic hematuria. On clinical examination, a large tumor was noticed on the left side. The routine laboratory tests showed that out patient had anemia and hypercalcemia. Ultrasonography revealed a giant, heterogeneous tumor mass of the left retroperitoneum, with a poor vascular signal, as well as multiple hyperechogenous regions. The abdominal computer tomography (CT) Figure  confirmeAs safety and accuracy of percutaneous biopsy was recently reported by Volpe et al , we haveWithin the tumour board of the Cancer Center, the oncologist sustained the idea of neoadjuvant chemotherapy with cisplatin and doxorubicin. Still, the performance status of the patient did not allowed optimal clinical management, as tumour progression was assessed, and surgery was imperative. Soon after the percutaneous biopsy was done, the general condition of the patient began to worsen, as weight loss was noticed along with a diagnosis of sub-occlusive syndrome. The surgical indication was of a left radical nephrectomy and left hemicolectomy, as further described.The first step was to place the patient in a supine position in an extended bed at about 30 degrees below the lumbar space. The operation begun with a bilateral subcostal incision (Chevron incision) completed with a left para-rectal extension and an intercostal branch. The inspection of the abdominal cavity revealed a giant left renal mass of 35 cm in the largest diameter, with a cystic appearance and liquid content, which was highly adherent to the mesocolon. Palpation and detailed inspection of the other intraperitoneal organs did not reveal any noticeable, macroscopic metastases, except the mesocolon, surrounding lymph nodes were not enlarged.Because of its volume, and severely modified loco-regional anatomy, manipulation was difficult and the excision of the tumour in a “non-touch technique”, with the primary ligation of the vascular supply, was virtually impossible. Excision was only possible after the evacuation of the intratumoral content of about 2500 cc of serosanguinous, viscous and gelatinous liquid, using all the available methods to minimize intraperitoneal tumoral spillage .As the colon was very adherent to the medial side of the tumor, the dissection of the mesocolon from the Gerota’s fascia, as initially planned, was virtually impossible. The intraoperative decision was to perform a left hemicolectomy with a termino-terminal anastomosis of the colon. After this step was finished successfully, having the resected colon reflected laterally, the surgeons were able to correctly identify the elements of the renal hilum. First, the renal vein was mobilized completely by ligating and dividing all its tributaries. The next procedure was to identify the renal artery, followed by its ligation and dividing. Similar management was performed for the renal vein and for the ureter. The kidney was mobilized outside the Gerota’s fascia, using both sharp and blunt dissections, together with the ipsilateral adrenal gland and approximately 20 cm of the mesocolon Figure .Figure 3The total time of the surgery was 210 minutes, and the patient had a blood loss of approximately 2000 ml. In postoperative patient received broad spectrum antibiotics and 3 units of blood. After the surgical intervention was finished successfully, the recovery of the patient was slow, but favorable. He was discharged 10 days after surgery. As the patient had a high risk for recurrence due to the positive surgical margins and tumour aggressiveness, the clinical management consisted of an intensified follow-up algorithm, in accordance with the guidelines and radiation regulations , 20. TheAfter the consult of the medical oncologist, it was confirmed that the patient had a stage IV tumor and no salvage chemotherapy was appropriate, taking into considerations his comorbidities and poor performance status. Supportive care and pain management was recommended and pursued until the patient died three more months later, at approximately 9 months after the surgery.The whole specimen was fixed in 10% formalin. After fixation, multiple specimens where paraffin embedded sectioned 4 micrometers thick and coloured with haematoxylin-eosin (H&E). Microscopical examination revealed a pushing biphasic tumor, composed of large sheets of undifferentiated round or slightly spindle-shaped cells arranged in a hemangioperycitomatous pattern, and islands of well differentiated cartilage, with no transition zone between them. The histological picture included foci of osteoid, ossification and calcification, haemorrhage and necrosis. The remaining renal parenchyma showed areas of coagulative necrosis; the tumour did not invade the renal pelvis, but it was extended beyond perinephric tissues into Gerota’s fascia, and paranehric fat, with no evidence of infiltration into renal vein (pT4NxM0V0R1). As tumour spread also involved the paranephric fat, surgeons were not able to obtain completely clean surgical margins (R0). The colon and the adrenal were free of tumour. The concluding diagnosis was extrascheletal MC of the kidney.Extraskeletal chondrosarcomas are rare neoplasms, far less common in comparison with the osseous ones  and pathBecause of their rarity and lack of appropriate studies and clinical trials to assess the best treatment of choice, there are no international accepted guidelines for the management of primary renal MC. Huvos et al. further divided the patients into two groups based on the pathological diagnosis: undifferentiated small cell types and hemangiopericytomatoid type , but hisSystemic chemotherapy or radiation therapies have an unknown role for these cases due to absence of objective evidence . Still, Mesenchymal chondrosarcomas are highly malignant and have a propensity to metastasize especially to the lungs , as was Extraskeletal chondrosarcoma of primary origin in the kidney are extremely rare tumors with a highly malignant potential and very poor prognosis. Because the role of chemotherapy or radiation therapy has not been evaluated properly yet, the main treatment-of-choice is a wide surgical resection with clean margins, after an early and correct diagnosis has been made.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Cutaneous horn is a conical, dense, and hyperkeratotic protrusion that often appears similar to the horn of an animal. Giant cutaneous horns are rare; no incidence or prevalence has been reported. The significance of cutaneous horns is that they occur in association with, or as a response to, a wide variety of underlying benign, premalignant, and malignant cutaneous diseases. A case of giant cutaneous horn of left oral commissure along with carcinoma left buccal mucosa is reported here as an extremely rare oral/perioral pathology. Cutaneous horn is a relatively uncommon lesion, also known by the Latin name “Cornu cutaneum.” It is conical hyperkeratotic projection above the surface of the skin that often resembles the horn of an animal. It may be straight or curved and twisted and vary from a few millimeters to several centimeters in length , 2. The A 45-year-old male presented with complain of a slowly growing conical asymptomatic lesion at the left angle of mouth. The lesion had been present for the past 2 years and was gradually increasing in size despite the patient having cut off its tip several times. Patient also complained of a lesion over left buccal mucosa which was present for the past two months and was gradually progressive. History of cigarette smoking for the past 30 years was present. Past medical history was insignificant. On examination, a hard, grey coloured, conical keratinized lesion measuring 3 × 1 cm was present over the left angle of mouth .Oral examination showed a 4 × 1 cm velvety proliferative growth over the left buccal mucosa extending posteriorly from the left oral commissure Figures .Neck examination was suggestive of levels I and II cervical lymphadenopathy on the left side. Preoperative work-up included routine blood investigations and X-ray chest which were within normal limits. FNAC from neck node was inconclusive. Punch biopsy of the mucosal lesion was suspicious for verrucous carcinoma. Under general anaesthesia and nasotracheal intubation patient underwent wide local excision of the buccal mucosa growth taking 1 cm margin along with excision of the conical cutaneous lesion with supraomohyoid neck dissection of the left cervical nodes. Primary closure of the defect was done in 3 layers. Postoperative period was uneventful and patient was discharged on postoperative day 5.Histopathological examination of the surgical specimen showed features consistent with verrucous carcinoma of buccal mucosa with hyperkeratosis underlying the horn Figures  and 4. AThe term “cutaneous horn” is a morphologic designation referring to unusually cohesive keratinized material and it is not a true pathologic diagnosis. Cutaneous horns though grossly similar to horns in animals are histologically quite different from them. The animal horns are composed of superficial hyperkeratotic epidermis, dermis, and centrally positioned bone. No such axially positioned well-formed bone is observed in the gigantic human horns. On the other hand, no cystic structures lined by trichilemmal type epithelium are seen in those of the true animal horns . MajoritThough cutaneous horn can be removed by simple detachment and cauterization of the base, a full thickness wide local excision with an adequate margin should be obtained for histopathological analysis, keeping in mind the frequent association of malignant/premalignant changes at the base. Cryosurgery is not advocated for the treatment of giant cutaneous horns as it does not ensure full thickness excision of the tumor and also it is not appropriate for the treatment of squamous cell carcinomas.Cutaneous horns are predominantly benign lesions; however possibility of nearly one third of them harboring malignant or premalignant skin lesions should be kept in mind. Full thickness excision with margin should be the treatment of choice to enable detailed pathological examination of the underlying tissue.


Osteoblastoma is a rare and benign osteoid-producing primary bone tumor that affects mainly the long bones. 36% of these tumors are observed around the spine and the vast majority arises around the posterior.This report describes a case of C3-4 osteoblastoma occurring in a 5-year-and-8-month-old Han Chinese child. The pathophysiology of symptom development, evaluations, and management are presented. Because of the close proximity of the osteoblastoma to the vertebral artery canal, the artery suffered a minor laceration intraoperatively. Hemostatic gelatin sponges were used to compress the bleeding site instantly and a tricortical iliac crest fixed with a screw was also used to add pressure to the gelatin sponges. Fusion on the other side was also used to stabilize the spine. To the best of our knowledge, this is the first report of a case of osteoblastoma at C3-4 with artery injury intraoperatively.This case delineates the difficulties in diagnosing this tumor, the challenges and problems encountered during its surgical management, and the favorable prognosis after adequate treatment.The online version of this article (doi:10.1186/1471-2474-15-313) contains supplementary material, which is available to authorized users. Osteoblastoma is a rare and benign osteoid-producing primary bone tumor that affects mainly the long bones. Thirty-six percent of these tumors are observed around the spine and the vast majority arises around the posterior , 2. The A Han Chinese boy aged 5 years and 8 months was admitted to the hospital for evaluation of neck and right shoulder and arm pain persisting for more than 6 months. The intensity of the pain had gradually increased during the course of the illness. However, there was no pain during sleep.On physical examination, the patient tended to keep his neck slightly bent and twisted to the right side, and the pain aggravated severely with motion. The strength of the muscle groups of his right hand was Grade 4/5, while the strength of the other muscle groups was normal. His right-side Hoffmann’s sign and the Babinski’s sign for both sides were positive. All deep tendon reflexes were also exaggerated. No sensory changes were noted on physical examination.Plain radiographic studies showed an oval radiolucent lesion located on the pedicle and facet of C3-4 vertebrae on the right side in the anteroposterior Figure A and latAfter anesthesia, the patient was placed carefully in the prone position with a Mayfield 3-point head holder. Fluoroscopy confirmed that no iatrogenic subluxation or dislocation was caused by this position Figure A. DuringA diagnostic delay is common in cases of cervical osteoblastoma. Symptoms of patients afflicted with osteoblastoma of the spine usually include dull, localized, and gradually increasing pain. However, these symptoms were non-specific and usually neglected by physicians, which may have been the cause of the 6-month diagnosis delay in the present case. The patient was eventually diagnosed correctly because of his severe neurological deficit and was managed surgically. Neurologic deficits are occasionally reported in the literature. In our case, the patient presented with muscle weakness, sensory disturbance, and hyperreflexia.In some cases, the vertebral artery canal was eroded by the osteoblastoma, and the use of preoperative angiography and embolization was useful to reduce intraoperative blood loss . HoweverThere should be always an attempt to achieve diagnostics by biopsy before surgery, which has become a necessary prelude to successful management of suspected spinal tumors. In this case, the differential diagnosis with osteosarcoma and osteoma osteoid is quite unlikely before operation. In addition, biopsy is generally preferred for a variety of reasons, including lower morbidity, cost effectiveness and shorter procedure time and patient length of stay. However, we didn’t perform pre-operative biopsy in this case for the following reasons: (1) According to the literature, sclerotic lesions showed a low diagnostic accuracy rate by biopsy . SpecimeThis tumor was classified as benign lesion, locally aggressive, the treatment of which is ideally performed by a marginal resection. However, the surgical resection was planned to be intra-lesional resection because of the proximity of the noble anatomic structures.On the 12-month follow-up CT, a considerable narrowing of the vertebral canal was observed, which was probably caused by insufficient tumor removal. Although a complete excision of the lesion was not achieved because of vertebral artery injury, the gross and microscopic tumor, as well as a circumferential margin of normal bony tissue was removed. At the 12-month follow-up, the patient presented without neurologic deficit, and disease progression or recurrence was not observed because of the insufficient removal.Blindness after spinal surgery has been described as a rare but serious, irreversible, and incurable complication. Previously reports have described the delayed onset of cortical blindness secondary to vertebral artery injury following cervical spine trauma . The visWhether spinal fusion is necessary after tumor resection remains controversial. Fusion for cervical stabilization substantially decreases the mobility of the cervical spine and predisposes the discs above and below the fusion to degeneration. However, stabilization of the cervical spine is critical to prevent progressive kyphotic deformity. Several previous reports have described kyphotic deformity following intralesional excision of osteoblastoma –13. ChilIn conclusion, this case delineates the difficulties in diagnosing this tumor, the challenges and issues encountered during the surgical management, and also the favorable prognosis after adequate treatment.Written informed consent was obtained from the parents of the young patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. The human subjects Institutional Review Board of Sichuan University approved this study prospectively.


We report a rare case of combined hepatocellular carcinoma and fibrolamellar carcinoma arising in a noncirrhotic liver, in a 14-year-old boy who underwent right hepatectomy. We discuss the clinicopathological and immunohistochemical features and the clinical outcome in this unusual tumor. Hepatocellular carcinoma of adult type (HCC) and fibrolamellar carcinoma (FLC) are two distinct entities unique in their clinical, histological, and biological aspects . There hA 14-year-old boy presented with history of right sided abdominal pain for 2 months. On examination there was an irregular, firm, swelling palpable in the liver extending up to 7 cm below the right costal margin. Computed tomography (CT) of the abdomen showed a large 9.6 × 10.2 × 10.5 cm well-defined, heterogeneously enhancing mass in the right lobe of liver in segments 6 and 5 and another lobulated 9.8 × 6.7 cm mass with homogenous enhancement in segments 8 and 7 suggestive of malignant liver masses with intrahepatic metastases. Investigations showed no elevation of serum alphafetoprotein (AFP), beta human chorionic gonadotrophin, or carcinoembryonic antigen. Hepatitis B surface antigen, hepatitis C antibody, and human immunodeficiency virus antibody were negative. Liver function tests at the time of admission showed total serum bilirubin level of 0.4 mg/dL, direct 0.2 mg/dL, total protein 8.2 g/dL, albumin 3.8 g/dL, aspartate aminotransferase (AST) 289 U/L, alanine aminotransferase (ALT) 99 U/L and alkaline phosphatase (ALP) 143 U/L, and INR of 0.96. There was no history of parasitic infestation or known exposure to environmental toxins. A wedge biopsy from the liver mass revealed a moderately differentiated hepatocellular carcinoma following which the patient underwent right hepatectomy.Histopathological findings: grossly, the right lobe of the liver weighed 1000 g. The external surface was focally nodular and on sectioning revealed a circumscribed tumor measuring 10 × 8 × 12 cm with solid brown cut surface almost reaching the capsular surface. Adjoining this tumor was another nodular lesion measuring 8 × 9 × 9 cm with lobulated grey white cut surface . Also seMicroscopic examination of the larger brown tumor and the small nodules showed large polygonal cells arranged in pseudoglandular and trabecular pattern  separateImmunohistochemistry revealed tumor cells of HCC with diffuse positivity for Hep Par1  and focaThe patient was given chemotherapy which included cisplatin, carboplatin, and adriamycin, which he tolerated well, completed the course, and was on followup. Four months after surgery, S. bilirubin, total was 0.5 mg/dL, S. protein 7.5 g/dL, S. albumin 4.4 g/dL, AST 22 U/L, ALT 11 U/L and ALP 290 U/L.Two years after surgery, new lesions were detected in the liver, on ultrasonography. Subsequent CT scan showed a heterogeneous mass in the porta, between the hepatic artery and inferior vena cava, fairly well-defined measuring approximately 9.7 × 4.6 × 4.6 cm with a lobulated contour and calcification on its inferior aspect, likely to represent a nodal mass. Considering disease recurrence and inoperability, the patient was put on Sorafenib treatment from March 2012. Presently, till the writing of this paper, he has survived and is on palliative care.FLC is an uncommon tumor which occurs in adolescents and young adults and is rare in the Asian population . It is qThere are occasional reports of FLC coexistent with or admixed with HCC , 4, 5. TWe report the first case of synchronous FLC and HCC, presenting as 2 adjacent, but separate, well-defined gross and microscopic lesions in a 14-year-old boy from India. Typical HCC with fibrous stroma can resemble FLC but these cases should not be mistaken for mixed HCC and FLC. Immunohistochemistry is useful in resolving these cases. The tumor cells of FLC show strong positivity for CK7, which is focal in HCC, as seen in our case. A recent study has shown strong positivity for CD68 in FLC with 96% sensitivity and 80% specificity, with 98% negative predictive value . These aMutations in the beta catenin gene have been reported in all categories of hepatocellular neoplasm but not in FLC and there was no nuclear staining for beta catenin by immunohistochemistry . We did Most of the earlier case reports –4, 8, 9 The presence of CK7 and/or CK19 has been suggested to represent evidence of hepatic progenitor cell origin . The celAFP levels are typically normal in FLC . So raisThe occurrence of two morphologically distinct types of liver tumor in the same patient raises the possibility that they could have arisen from prehepatocytic cancer stem cell. This may be worth investigating further in the future.


Giant inguinoscrotal hernias are extremely rare nowadays, but they may still be encountered after years or even decades of neglect. Such hernias containing both bowel loops and urinary bladder have not been reported in the medical literature to date, to the best of our knowledge.We report a case of a 65-year-old Moroccan man who presented with giant right-sided and long-standing inguinoscrotal hernia with compromised quality of life due to walking difficulties and sexual discomfort. Computed tomography revealed a voluminous hernia sac containing small and large bowel loops, greater omentum, and urinary bladder. Surgical repair was done through the classical inguinal incision using the Lichtenstein tension-free hernioplasty technique. No debulking or abdominal enlargement procedure had to be performed, apart from a partial omentectomy.Giant inguinoscrotal hernia containing intestinal segments and urinary bladder is a challenging surgical disease. A Lichtenstein tension-free technique seems to be the best surgical procedure for both the patient and the operating surgeon. It should be used whenever possible in such cases. Although inguinal hernia is one of the most common surgical disease states encountered in medical practice, its treatment has evolved and has become easily accessible, especially in high-income countries. Thus, giant inguinal hernia has become extremely rare and appears only after years of neglect or lack of an accessible surgical facility. It is defined as an inguinal hernia that extends below the midpoint of the inner thigh in standing position . BecauseIn this report, we describe an unusual case of a giant inguinoscrotal hernia containing bowel loops and urinary bladder, which we managed through the classical inguinal incision using the Lichtenstein tension-free hernioplasty technique. We also highlight different problems relative to the management of this uncommon disease.A 65-year-old Moroccan man presented with a longer than 12-year history of a right-sided inguinoscrotal hernia, for which he had previously refused any surgical treatment. He reported a large inguinoscrotal swelling that was gradually getting bigger and recently reached below the level of his mid-thigh. He also described episodic abdominal pain and increasingly difficult urination. This development significantly affected his quality of life, with difficulties in walking and sexual activity, prompting him to finally accept surgical management. He had no history of chronic cough, constipation, or previous surgery. Clinical examination revealed a very large, irreducible, no cough impulse, and non-tender right inguinoscrotal hernia. The hernia mass was about 30 cm in size and extended to the midpoint of the inner thigh. The scrotal skin was thickened, but there were no signs of inflammation, excoriation, or ulceration Fig.  and 5. TIn high-income countries, the diagnosis of inguinal hernia is usually made early, when the patient notices the development of swelling or groin pain. Given the potential hernia strangulation, surgical correction is often carried out without delay. Consequently, giant inguinoscrotal hernias have become extremely rare and are currently seen in clinical practice only after years or even decades of self-neglect , 3. In aRepair of a giant inguinal hernia is a real challenge, even for experienced surgeons. Abrupt and forced reduction of massive contents of the hernia sac into the limited space of the peritoneal cavity leads to a sudden increase of intraabdominal and intrathoracic pressures. This can cause abdominal compartment syndrome, resulting in compromised respiratory and cardiac function due to splinting of the diaphragm and reduction of venous return . This sySurgical options for combating this loss of domain may be divided into either distending the abdominal wall to increase the abdominal space or debulking the abdominal contents. The enlargement of the peritoneal cavity by progressive preoperative pneumoperitoneum has been highly recommended in the past , 9, but In our patient, none of these techniques were mandatory. Therefore, in spite of massive and specific content, we performed a forced reduction through only an enlarged deep inguinal ring. No debulking or abdominal enlargement procedure had to be performed, apart from a partial omentectomy. Operative repair was achieved through a standard inguinal incision with polypropylene mesh using the Lichtenstein tension-free technique. The mesh, positioned over the posterior wall of the inguinal canal, helps to strengthen the weakened abdominal wall, thus affording significant reduction of the risk of hernia recurrence. According to recent medical literature, current guidelines suggest the Lichtenstein technique as the preferred surgical option for repair of giant inguinal hernias , 15. MorGiant inguinal hernias are uncommonly encountered in modern surgical practice. However, surgical repair is challenging because of the potentially fatal complications related to increased intraabdominal pressure and the risk for recurrence, which is much higher than in other inguinal hernias. Therefore, adequate preoperative preparation, combined with intensive postoperative monitoring, is essential to obtaining good outcomes. The Lichtenstein tension-free technique seems to be the best surgical procedure for both the patient and the operating surgeon. It should be used whenever possible. Informed consent from the patient is needed to cover all possible surgical options, because the final decision regarding surgery is generally made intraoperatively.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Moreover, the left altered lung lobe, corresponding to the mobile structure detected by ultrasound, was removed. Based on cytological, histopathological, and immunohistochemical examinations, an invasive epithelioid pleural malignant mesothelioma was diagnosed.A 7-year-old Dachshund was clinically examined because of a 10-day history of lameness in the left hind limb. On the basis of radiological and cytological findings, an osteosarcoma of the left acetabular region was suspected. The dog underwent a hemipelvectomy and osteosarcoma was diagnosed by subsequent histopathological examination. An immovable subcutaneous mass was noted on the left chest wall during the physical examination and non-septic neutrophilic inflammation was diagnosed by cytology. Forty days later, the dog showed signs of respiratory distress with an in-diameter increase of the subcutaneous mass up to 4 cm. Thoracic radiography and ultrasonography revealed pleural effusion and a lytic process in the fourth left rib. Furthermore, ultrasound examination revealed a mixed echogenic mobile structure with a diameter of around 2 cm floating within the pleural fluid of the left hemithorax close to the pericardium. The dog underwent surgery for an  Malignant mesothelioma is an uncommon tumor arising mostly from the serosal surface of the pleural or peritoneal cavity . In mostThe simultaneous occurrence of a mesothelioma along with other primary malignancies has been reported repeatedly in humans, whereas no such cases have been reported in dogs . PleuralThe present case represents the first report of a diffuse pleural mesothelioma directly invading the thoracic wall in a dog having a concurrent osteosarcoma.A 7-year-old male Dachshund weighing 7.6 kg was admitted to the Veterinary Teaching Hospital, University of Teramo, Italy, with a 10-day history of lameness in the left hind limb. During physical examination, the dog showed a grade 4 lameness on a 1–4 scale and strong pain upon palpation of the proximal portion of the left hind limb. Furthermore, an immovable subcutaneous mass measuring around 1.5 cm in diameter was noted on the left chest wall. The complete blood count, serum chemistry profile, urinalysis, and hemostatic profile were unremarkable.A radiographic examination of the pelvis and hind limbs showed osteolytic lesions in the left ischiatic bone of the acetabular region and subtle thickening of the cortices of the caudal acetabular rim.A fine needle aspirate (FNA) cytology of the acetabular lesions was done and showed moderate cellularity with a mixture of individual and multinucleated cells. The individual cells were round to oval and had variably shaped nuclei, prominent and multiple nucleoli, and dark blue vacuolated cytoplasma containing fine pink granules. The multinucleated cells were regarded as being osteoclasts. Furthermore, a pink intercellular matrix was found. Based on these findings, an osteosarcoma was diagnosed. A FNA cytology of the subcutaneous mass on the thoracic wall showed several neutrophils in a debris but without visible microorganisms consistent with a non-septic neutrophilic inflammation. A bacteriological examination was done but bacteria were not cultured. Thoracic radiography and abdominal ultrasound were unremarkable for metastatic lesions.The dog underwent a hemipelvectomy and a histopathological examination of the excised tissue was performed. Microscopically, a neoplastic lesion consisting primarily of polyhedral cells with moderate nuclear pleomorphism was observed. The mitotic index, expressed as the mean value of mitoses/10 high power fields , was 1.1. The neoplasm was infiltrative and gave rise to a small amount of osteoid matrix. The findings were consistent with a productive osteoblastic osteosarcoma. The owner declined any further treatment.Forty days after this, the dog showed signs of respiratory distress. The subcutaneous mass on the thoracic wall had increased in diameter up to 4 cm. A thoracic radiography revealed small to moderate amounts of pleural effusion in the left hemithorax. A pleural reflection was visible on the right side between the medial and caudal lobes. Furthermore, the fourth left rib showed an expanded contour with thinning of the cortices, bone destruction, and an interrupted periosteal reaction. A mild periosteal reaction was noted on the fifth left rib. Soft tissue swelling was remarkable superficially between the third and sixth rib of the left hemithorax Fig. .Fig. 1RaAn ultrasound examination of the subcutaneous mass showed a hypoechoic cavitating lesion of 3 cm in diameter with a corpuscular content adherent to the fourth rib. Furthermore, the margins of the fourth rib appeared irregularly thickened with hypoechoic areas being consistent with a lytic process Fig. . An ultrThe FNA cytology of the subcutaneous mass was repeated. The cytological pattern was similar to the previous FNA cytology, whereas cytology of the bone aspirate of the fourth rib was non-diagnostic.3 cells/µl, and the protein concentration was 5.2 g/dl. Direct smears showed large clumps of cells with “mesothelial slits”, anisocytosis, aniso-macrokaryosis, multinucleation, and single to multiple prominent and variably shaped nucleoli. Several cells presented cytoplasmic vacuoli and the formation of a thick brush border. A moderate number of neutrophils was also present. The cytological pattern suggested a mesothelioma . Microscopically, a neoplastic lesion was observed. The tumor infiltrated all thoracic wall layers including the bone cortex and the rib periosteum, and showed a multifocal pattern in the lung tissue. The neoplasm consisted primarily of epithelioid cells that were arranged as cords or nests or showed a “gland-like” tubular pattern. Neoplastic cells contained abundant eosinophilic, occasionally vacuolated, cytoplasm and were interspersed within abundant connective tissue Fig. . MitoticThe dog died from complications arising after surgery. The owner declined a necropsy.Though mesothelioma is the most common primary tumor of serosal membranes, it is a rare neoplasm both in humans and dogs , 5. MostMesotheliomas are considered malignant due to their ability to spread by implantation, but they rarely metastasize in dogs , 8. MaliMetastases are rare and generally spread via the lymphatic system . NeverthBone destruction, in particular rib erosion, has not been reported in dogs with diffuse or solitary mesotheliomas. The differential diagnosis of lytic rib lesions includes primary or metastatic neoplasia, inflammatory and metabolic disease, and trauma. Primary tumors of the ribs mainly consist of osteosarcomas, chondrosarcomas, hemangiosarcomas, and fibrosarcomas, but osteosarcomas and hemangiosarcomas have been reported to develop bone metastasis as well . In the The co-existence of mesothelioma and other malignancies appears relatively frequent in humans, and most of these tumors are carcinomas and adenocarcinomas , 15. ExpThe simultaneous occurrence of mesothelioma and other primary tumors has not been described in dogs previously. The contribution of asbestos to canine mesothelioma remains unknown, although it is considered a risk factor , 19. OthThis case represents the first report of a diffuse pleural mesothelioma directly invading the thoracic wall in a dog with a concurrent osteosarcoma. Malignant mesotheliomas need to be considered a potentially locally invasive tumor in dogs and, therefore, should be included in the differential diagnosis when investigating a subcutaneous mass in the thoracic wall, especially in dogs with pleural effusion. Malignant mesotheliomas should be considered in the diagnostic workup of patients with lytic rib lesions.


Fibroepithelial polyps (FEPs) are rarely seen lesions of the lower female genital tract with polypoid proliferations of stroma. These tumors usually present in the vulvovaginal region of the reproductive aged women. In this presentation, we report a case of a psoriatic woman who developed unusual multiple polypoid lesions approximately 15 cm in size arising from both left and right labia minora and unique connection of FEPs with psoriasis disease. Fibroepithelial polyps (FEPs) are rarely seen lesions of the lower female genital tract with polypoid proliferations of stroma , 2. ThesIn this presentation, we report a case of a psoriatic woman who developed unusual multiple polypoid lesions approximately 15 cm in size arising from both left and right labia minora and unique connection of FEPs with psoriasis disease. Written informed consent was obtained from the patient according to the tenets of the Declaration of Helsinki. After surgical resection, histopathological investigation confirmed the diagnosis of FEP.A 28-year-old nulligravid woman with a history of psoriasis disease admitted to our gynecologic clinics complaining of bilateral painless vulvar masses which were first noticed five years ago. Until then, the patient did not seek any treatment for these slow-growing masses due to some personal reasons. But, over the course of 12 months, the labial masses have grown gradually and she decided to seek treatment because of a sudden increase in the size of labial masses. Her medical history was not remarkable for any other diseases rather than psoriasis which she has had since she was born. Gynecological examination revealed two separate pedunculated, nontender polypoid lesions approximately 15 × 10 cm and 13 × 6 cm in sizes arising from both left and right labia minora  accompanSome lesions were found as moderately hypercellular. The surface of the polypoid lesion showed the fern-like papillary appearance covered by intact epidermis. In addition, chronic inflammation was detected in the pathological specimen. Immunohistochemical staining was negative for S100, CD-34, and cytokeratins, and the involved areas seemed to be immunoreactive for desmin.Psoriasis is a chronic inflammatory skin disease involving hyperproliferation of the keratinocytes in the epidermis. The typical clinical presentation of the disease is itchy, erythematous lesions covered with silvery scales on patients skin as a result of an increased epidermal cell turnover rate . 29–40% FEPs are extremely rare, benign, and locally infiltrative tumors with pedunculated polypoid appearances originating from pelvic soft tissues . They moFEPs are prone to circumscribed lesions with central fibrovascular cores in them and they mostly occur in the superficial subepithelial stroma containing stellate and multinucleated stromal cells . ImmunohAlthough the pathogenesis of FEPs is not completely enlightened, the reactive hyperplastic process in subepithelial mesenchymal tissues in the genital region is considered to play an important role in the pathogenesis of FEP . In the FEPs typically present as single lesions in general, but they have the propensity of being multiple during pregnancies . In currBased on the knowledge that the patient's denial of experiencing conditions which might cause vulvar FEPs such as the history of being pregnant, using tamoxifen or hormonal therapy, and being exposed to repeated or long-standing trauma and the patient's approval for the period when FEP occurred and grown rapidly which coincided with the time in which psoriasis worsened and became uncontrolled, we regard that this young woman developed multiple vulvar FEPs caused by an uncontrolled psoriasis disease.In conclusion, this case presentation is the second reported case with respect to the psoriatic patient with FEP, but it differs from the first one in presenting the rarely seen bilateral multiple FEPs in the lower female genital tract. It is hoped that this work will make significant contribution to literature on FEP development in psoriatic patients.


Malignant granular cell tumors are rare, intensely aggressive entities. This paper presents a case of a large rapidly recurrent malignant granular cell tumor with regional and distal metastases on the back of a 54-year-old Cuban man. The primary tumor recurred within six months of the original wide local excision and with satellite lesions apparent at twelve months, and the mass was diagnosed using the histological criteria established by Fanburg-Smith et al. for malignant granular cell tumors. By fifteen months, right axillary lymphadenopathy, multiple satellite lesions, pulmonary nodules, and distant metastasis in the right thigh were present. At sixteen months, wide local excision of recurrent mass and local satellite masses along with right axillary dissection and placement of Integra with subsequent split-thickness skin graft were performed by surgical oncology and plastic surgery teams. The surgical specimen measured 32.0 × 13.5 × 5.5 cm, containing multiple homogeneous masses with the largest mass 22.0 × 9.0 × 4.6 cm. Following surgery, patient was started on Pazopanib 800 mg/day based on phase III randomized trial data in the treatment of soft tissue sarcomas showing this as a potential novel therapy for malignant granular cell tumors.  Granular cell tumors, first described by Abrikossoff in 1926 as myoblastomas .Granular cell tumors represent 0.5% of all soft tissue tumors , and theWhile there are multiple case reports presently in the literature, representing a variety of presentations, this case involves a large rapidly recurrent malignant granular cell tumor of the skin and subcutaneous tissue of the back with regional and distant metastases, which demonstrates the capacity of these tumors to recur and to metastasize within a very limited amount of time. This case further details the surgical management for local disease control in this case and potential novel therapy for MGCT.This patient is a 54-year-old Cuban man with past medical history of emphysema, 105 pack-year smoking history, and family medical history of lung cancer who presented to Jackson Memorial Hospital with recurrent MGCT. The primary lesion first appeared on his right upper back in October 2011 and was excised in Cuba, and by April of 2012, the mass recurred at the original site with multiple satellite lesions in right axilla as well as right axillary lymphadenopathy . The PatIn February 2013, the patient was admitted back to the hospital as the mass on his back was extremely painful and was oozing serosanguinous fluid. Subsequently, he underwent a palliative resection of the recurrent primary tumor and satellite lesions on the upper right back as well as of the large matted right axillary nodal mass . PlasticFinal surgical pathology indicated that the specimen on the right upper back was 32.0 × 13.5 × 5.5 cm, containing multiple homogeneous masses ranging from 2.0 × 2.0 × 2.0 cm to 22.0 × 9.0 × 4.6 cm. The large right axillary mass measured 10.0 × 8.0 × 4.3 cm. One out of five enlarged lymph nodes were positive for tumor. The deep margin was free of tumor.The postoperative course was uncomplicated, with development of clean granulation tissue under the Integra. The patient was brought back 3 weeks later when he underwent a split-thickness skin graft from the left upper thigh to the right upper back by the plastic surgery team. The graft take was 100% and the final result upon postoperative follow-up was satisfactory . A monthLocal recurrence and metastasis are relatively common in malignant granular cell tumors, with 32% rate of recurrence and 50% metastasis in the Fanburg-Smith analysis. Poor prognostic factors associated with MGCT include large tumor size, older patient age, increased mitotic activity, and Ki-67 greater than 10% . FurtherIn this case, the patient's primary tumor recurred within six months following first the tumor excision in Cuba. By one year, not only had the tumor recurred, but multiple satellite lesions were also evident. At fifteen months, imaging confirmed the recurrence and right axillary mass along with lymphadenopathy and asymptomatic metastases to the right upper thigh and lung. At the time of surgery at Jackson Memorial Hospital, sixteen months after the original resection, the recurrent tumor had grown to large proportions, with pathology noting the largest lesion, among several on the right upper back, was 22.0 × 9.0 × 4.6 cm, and the skin was ulcerating overlying the masses.In addition to the incidence of recurrence and metastasis and the rapidity of tumor growth, other challenges exist in treating the malignant granular cell tumor. Currently, surgical resection remains the best possible option as no chemotherapy or radiation has been reported effective. Wide local resection is generally the treatment of choice; however, Mohs micrographic surgery has been utilized for malignant and benign granular cell tumors –26. Alth


Osteolipoma affecting oral cavity is indeed rare. We hereby report a case of osteolipoma affecting buccal mucosa. A review of literature of osteolipoma of oral cavity, particularly on radiographic/imaging findings was done. Only 16 cases of Osteolipoma of oral cavity are reported in the literature. The radiographic findings of our case, i.e. multiple dense homogenous radio-opaque structures was reported earlier only in one case [out of 16] of osteolipoma of oral cavity. Key words:Lipoma, osteolipoma, panoramic radiography, radio-opaque, radiography.  Lipoma is a benign tumor composed of mature fat tissue arranged in lobules that are separated by fibrous septa surrounded by their fibrous capsule. Lipoma can affect any part of the body, with only 1-4% of them affecting oral cavity. Buccal mucosa, floor of the mouth, tongue and lip are the most common sites affected .On reviewing the English literature, only 16 cases of osteolipoma affecting oral cavity were reported. Osteolipoma affecting para-oral structures like parotid gland, submandibular space, parapharyngeal space etc. were excluded and only cases affecting the oral cavity were included for reviewing the radiographic/imaging findings, particularly. Out of them, only seven cases have described the radiographic/imaging findings of Osteolipoma affecting oral cavity. Moreover, none of the cases had radiographic features which were similar to our case, except for one case, which includes the presence of multiple homogenous dense radio-opaque structures. The site of the occurrence of the present lesion, which is retro-commissural area, is also unique and not been reported earlier.We hereby report a case of osteolipoma of the left retro-commissural area with a unique radiographic presentation.A 38 year old female patient presented with a chief complaint of painless swelling in her left inner cheek region since 28 years, which first appeared as a small nodule and gradually increased to attain the present size. On intra-oral examination, a solitary swelling located at the left retro-commisural area, measuring approx. 2x2x3 cms, the surface of which exhibited a small white discoloration which is perhaps secondary to surface trauma Fig. . On palpPanoramic radiograph Fig. A revealeBased on clinico-radiological and histopathological correlation, a final diagnosis of Osteolipoma was considered.Lipomas containing osseous tissue are either intra-osseous or parosteal variety . However pure soft tissue osteolipomas are rare. To our knowledge only 16 cases of intra-oral osteolipomas are reported. The age/sex, site, clini-cal presentation, duration of the lesion and radiographic presentation of these cases are described in On reviewing the literature the age of oral osteolipoma patients ranged from ‘at birth’ to 81 yrs, with equal distribution of cases between males and females. The most common site affected was buccal mucosa followed by buccal vestibule/sulcus, palate, floor of the mouth and tongue. Clinical presentation in most of the cases was an asymptomatic swelling and rest of them presented with facial asymmetry, except for one case which had an accompanying feature of congenital cleft palate. Our case was a 38 yr old female patient with a painless swelling in buccal mucosa.Most of the cases of osteolipoma of oral cavity presented as painless, well circumscribed, nodular masses with soft-hard in consistency . In our Different theories are proposed for the osseous changes in lipomas. Some believe that osteolipoma is a benign mesenchymoma and that both adipose and osseous tissue could originate from multipotent undifferentiated mesenchymal cells. Others believe that neoplastic changes could occur in the fat cells and bone is then formed by metaplasia of fibroblasts to osteoblasts . OsteoinLocal factors such as chronic micro-trauma and compromised blood supply could act as osseous-metaplasia-inducing factors in lipoma. Since the present lesion was located in buccal mucosa, in line of occlusion, we believe that chronic trauma to the lesion from the masticatory forces could be the triggering factor for calcification/ossification process. Moreover, ossification is known to be associated with lipomas of longer duration. The duration of oral osteolipoma ranged from 2 months to 40 years as per the literature review. The present case had a history of 28 yrs duration of lesion in the oral cavity.et al. (Out of the 16 cases of osteolipomas of oral cavity reported in the literature, only 8 case reports documented the radiographic/imaging findings . Only onet al. , patchy et al. . MultiplHistologically, adipose tissue is often mixed with trabeculae of bone in osteolipoma, which was clearly evident in the present case.Treatment of oral osteolipoma is complete surgical excision, which shows no recurrences and prognosis is similar to that of the other lipomas . SurgicaIn conclusion, oral osteolipoma is a rare entity, wherein we report a case affecting retro-commissural area. Osteolipoma should be considered as a radiographic differential diagnosis for multiple calcified dense radio-opaque structures involving oral soft tissues.


Since abdominal radical hysterectomy was first described by Clark and Reis in 1895, it has been commonly used in the primary surgical treatment of carcinoma of the cervix. We report the case of a 45-year-old woman who was diagnosed with a small bowel obstruction due to jejunal torsion to her right ureter mimicking postoperative adhesion ileus.A 45-year-old Turkish woman was admitted to our emergency department with complaints of abdominal pain, constipation, nausea and vomiting. She had undergone an abdominal radical hysterectomy for cervical carcinoma three years earlier. Computed tomography scans revealed intestinal dilatation, a large amount of free fluid in the abdominal cavity and an area suspicious for jejunal perforation. Because of these radiological findings suggestive of obstruction and bowel ischemia, our patient underwent emergency surgery. Operative findings that showed a jejunal segment was turned around her right ureter so that it was mimicking a fibrous band.In this current case, we present the first determined complication of radical hysterectomy. According to our case report, surgical oncologists should be aware of this complication and review the surgical technique. It is considered that readaptation of the dorsolateral peritoneal layer after extended pelvic lymph node dissection resulted in fewer complications. Carcinoma of the uterine cervix is the most common gynecologic malignant neoplasm worldwide ,2. The mSince Clark and Reis described abdominal radical hysterectomy (ARH) for the first time in 1895, it has been commonly used in the primary surgical treatment of carcinoma of the cervix. ARH was then detailed, widely described and performed by Wertheim more than 100 years ago . RadicalIn this case report, we present the case of a patient admitted to our emergency department with a mechanic bowel obstruction because of jejunal torsion around her right ureter as a late complication of ARH.3. An abdominal ultrasonography (US) scan was performed, followed by a computed tomography (CT) scan of her abdomen/pelvis. The abdominal US scan detected a swollen and immobile small bowel. The CT scan was performed for a better evaluation of our patient’s symptoms and confirmed the suspicion of mechanic bowel obstruction. The CT scan revealed intestinal dilatation, a large amount of free fluid in the abdominal cavity and an area suspicious for jejunal perforation. Moreover, the CT scan showed a group of poorly enhanced and thickened bowel walls : 289mg/L, blood urea nitrogen (BUN): 56mg/dL, creatinine (Cr): 2.36mg/dL, sodium (Na):112mmol/L, potassium (K):2.7mmol/L. The arterial blood gas analysis revealed a lactic metabolic acidosis with a pH value of 6.99 and lactate level of 6.7mmol/L. In the historical examination, she had not been able to pass either gas or stool for three days. In her medical history, she had been admitted to the emergency room (ER) with a complaint of lower left abdominal quadrant pain but she had been discharged with a urinary tract infection diagnosis based on a urinalysis, which revealed pyuria with 56 leucocytes per mmAn aggressive fluid-electrolyte resuscitation 20ml/kg/hr) and antibiotics (ceftriaxone 2 gr/ 24h and metronidazole 500mg/6h intravenous) administration was started immediately in the intensive care unit. Because these radiological findings were suggestive for obstruction and bowel ischemia, our patient underwent emergency surgery six hours after admission.The prior midline incision was used to inspect the abdomen. The small intestines were dilated and there was a large amount of an exudative fluid in the abdomen. A jejunal segment was turned around a fibrous band and the surgeons realized that the ‘band’ was the right ureter . An abdominal CT scan was performed and a small amount of free fluid collection was detected between the small intestine loops. The fluid was aspirated at the interventional radiology unit. The fluid was clear and no microorganisms could be isolated in the fluid. She was discharged on the tenth postoperative day with normal oral feeding and excellent mobilization.Radical hysterectomy and pelvic lymph node dissection have been considered as the standard surgical treatment for cervical cancer for more than 100 years . In 1905Peritoneal adhesions may develop after pelvic and abdominal surgery or their combination . AdditioA urinary tract infection is a common diagnosis in ERs. However, pyuria is one of the important findings, for urinary tract infections may cause a misdiagnosis if the other causes are ignored. Retrocecal appendicitis or other closed organ infections may cause pyuria . As repoMany gynecologists advocate that closure of the posterior peritoneum is not necessary after an ARH, however, it may help to prevent retroperitoneal complications . Janscheet al. reported their results for frequent problems following extended pelvic lymph node dissection (PLND) and cystectomy with or without reperitonealization. Extensive adhesions between small bowel loops and the abdominal and pelvic walls or the iliac vessels are often found in patients who have to undergo a reoperation following PLND [Roth ing PLND . Small bRadical hysterectomy with lymphadenectomy still remains an important modality for gynecologic oncology procedures, keeping in mind both common and rare complications of the procedure may decrease delays in treatment and increase success in managing the complications. According to our case report, surgical oncologists should be aware of this complication and review the surgical technique. Closing the dorsolateral peritoneal layer after extended PLND is considered to result in fewer complications.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.ARH: abdominal radical hysterectomy; CT: computed tomography; ER: emergency room; PLND: pelvic lymph node dissection; US: ultrasonography.The authors declare that they have no competing interests.HYB and BK took care of our patient and wrote the initial draft. HYB, BK, AD and UO operated on our patient. BK edited the manuscript and performed the literature review. All authors read and approved the final manuscript.


A 64-year-old woman with dizziness and blurry vision underwent an evaluation for a possible stroke with a head-neck CT scan and a transthoracic echocardiogram. The head-neck CT scan was unremarkable, but the echocardiogram was notable for a 2.0 × 2.3 cm heterogeneous echodensity attached to the mitral valve. After a transesophageal echocardiogram and chest CT scan, the mass was determined to be a caseous mitral annular calcification, CMAC. This entity is a rare variant of MAC with an estimated prevalence of 0.068%. Echocardiographic techniques can distinguish CMAC from other intracardiac masses such as tumor, cyst, or abscess. CMAC is associated with cerebrovascular accidents; however, optimal treatment is controversial given the rarity of this clinical finding. Management strategies should be tailored based on the patient's presentation, risk factors, and overall clinical circumstances. Mitral annular calcification (MAC) describes a condition in which the annulus of the mitral valve becomes calcified –3. In ra2 score of 3, the patient was started on rivaroxaban, a factor Xa inhibitor for stroke management. She was followed closely with a repeat TTE 6 months later revealing no changes in the size or appearance of the mass.A 64-year-old woman was admitted to the hospital after experiencing acute visual deficits. Her symptoms resolved within 24 hours and were consistent with a transient ischemic attack (TIA). The patient's past medical history was significant for paroxysmal atrial fibrillation, migraines, and hypertension. Prior medical records indicated that she was taking 325 mg of aspirin once a day for paroxysmal atrial fibrillation. The patient did not take any additional medications. Her family and social history were unremarkable. On physical exam, her blood pressure was 170/116 mmHg and heart rate was 88 bpm with a respiratory rate of 20 and oxygen saturation of 98%. The patient had an irregularly irregular heart rate and rhythm with a soft midpeaking systolic murmur best appreciated at the right upper sternal border. No carotid bruits were appreciated. An electrocardiogram showed atrial fibrillation with a ventricular rate of 88 bpm and no significant ST or T wave changes. Remarkable lab values included a prothrombin time of 11.4 s, 0.5 mg/dL creatinine, 71 mg/dL HDL, 105 mg/dL LDL, and 103 mg/dL triglycerides. CT angiography of the head and neck was unremarkable except for mild carotid bulb calcifications. Brain MRI revealed old ischemic changes in the periventricular and subcortical white matter consistent with possible old strokes. A transthoracic echocardiogram (TTE) noted a round echodense mass measuring 20 × 23 mm attached to the mitral valve annulus, along the atrioventricular groove and adjacent to the posterior mitral leaflet . The masCaseous mitral annular calcification is a rare medical condition that involves the mitral annulus and, in some instances, extends into the mitral valve. Deluca et al.  found thThe risk factors for developing CMAC are similar to those for developing atherosclerosis . Since aCardiac masses are uncommon findings that can involve thrombus, malignant or benign tumors, metastases, and vegetations. Nonmalignant tumors such as myxomas can have a characteristic stalk attaching the mass to the interatrial septum . CMAC prThere does not appear to be a consensus as to what constitutes the best management for patients diagnosed with CMAC. Some studies have shown that patients with CMAC have an increased risk of developing atrial fibrillation when compared to patients without CMAC after controlling all other cerebral and cardiovascular risk factors . Harpaz This rare clinical case illustrates how echocardiography and allied imaging modalities can help differentiate CMAC from other intracardiac masses. Making the correct diagnosis of CMAC can facilitate the implementation of appropriate treatment strategies that may help reduce the risk of future cerebrovascular accidents.


Schwannoma is a tumor which has neuroectoderm origins, is hard, well-circumscribed, encapsulated, and slow growing benign cranial tumor, and may autonomously grow out of the nerve sheath of peripheral nerves. It is mostly seen in the head and neck region. In the paranasal sinus and nose areas, it is seen at a rate of 4%. The diagnosis is mostly made after histopathological examination. In this paper, a Schwannoma case observed in the nasopharyngeal region was presented in a 20-year-old female who had complaints of sleeping with open mouth, snoring, foreign body feeling in throat, and swallowing difficulties. The tumor was extracted via transoral approach. No recurrence was observed during follow-up over the next year. This case presentation is presented for the first time in the literature in English. Schwannoma is a tumor which arises from the motor and sensitive peripheral nerve sheath. It consists of Schwann cells and is neuroectodermal in origin, benign encapsulated, and with perineural invasion . HistoloApproximately 30–40% of Schwannomas are observed in the head and neck region. Most frequently being the Nervous Vagus, they may particularly root in the last fourth cranial nerves and more rarely in autonomous nerves. Schwannomas are also observed in the nasal region at a rate of 4% . This caA 20-year-old female presented with complaints of sleeping with an open mouth, snoring, a foreign body feeling in the throat, and difficulty in swallowing, which have occurred for 1 year. During her oropharynx and nasal endoscopic examination, a medium hard, semimobile, painless when pressed, and well-circumscribed mass, with 2 × 1 cm dimensions, was observed, originating from the nasopharynx and stretching downwards from the back of the soft palate .Magnetic resonance (MR) examination revealed a vascular lesion with no high flow which starts from the nasopharynx and completely fills the choana . In compApart from these, no pathology was observed in the ear-nose-throat and cranial nerve examinations. The mass was excised transorally under general anesthesia. The mass was well-circumscribed and could be easily distinguished from peripheral tissues.In histopathological examination, S100 (+) hyalinizing spindle cell mesenchymal tumor, Antoni A, Antoni B, and Verocay corpuscles were identified . The patSchwannoma is a benign tumor arising from the nerve sheath or from Schwann cells which do not have a neural element. Although rare, benign Schwannomas might show malign transformation, so it is important to follow up closely . In the In planning diagnosis and treatment, magnetic resonance (MR) is a good choice. In T1 and T2 weighted images, high signal density is remarkable and, unlike paragangliomas, no vascular flow is observed in Schwannomas. Computed tomography (CT) has importance in terms of presenting the lesion's anatomic localization and its relationship with peripheral structures . In MR aSince nasal and paranasal sinus Schwannomas grow slowly, they cannot be recognized by nonspecific complaints such as nasal congestion, nasal discharge, nasal bleeding, and swelling of the face . In someIn our case, due to the Schwannoma arising from the nasopharyngeal region, the patient had complaints of sleeping with open mouth, snoring, foreign body feeling in the throat, and swallowing difficulties, which had increased during the last year.Since the lesion is considered vascular in origin for tumors located around the parapharyngeal region, biopsy is accepted as a relative contraindication . TherefoThe gold standard in therapy is that the neural structure of the tumor roots is protected as much as possible and that the tumor is totally excised . In nasaIn conclusion, Schwannoma should also be considered in the differential prognosis of patients who have sharp and outlined borders with heterogeneous density. In this paper, a Schwannoma case in the nasopharyngeal region is presented for the first time in the literature.


Adrenocortical neoplasms (ACNs) are rare and poorly characterized in infants. The true incidence of ACNs is not well known and it appears to vary substantially across different geographical areas. ACNs are more common in females and two peaks of incidence have been identified: The first year of life and between the age of nine and 16 years. Due to the heterogeneity and rarity of ACNs, their pathological and prognostic classification is challenging. The current study describes the case of a seven-year-old male, who presented to the Department of Pediatric Surgery, University of Siena  with a feminization syndrome and increased somatic growth that was associated with a unilateral adrenal mass, which was diagnosed by magnetic resonance imaging. Surgical excision of the mass was performed and histological analysis determined that it was an ACN, with a low risk of malignity; however, the pathological classification of the tumor was challenging. At present, the future behavior of ACNs is unpredictable. Therefore, increasing the knowledge surrounding this type of tumor may aid in its diagnosis, treatment and prognosis. Due to the rarity of pediatric ACNs, no single pediatric oncology center has acquired extensive experience treating this type of tumor. Thus, the initiation of an international tumor registry may aid with the management of patients presenting with ACNs. Adrenocortical neoplasms (ACNs) arise from the adrenal cortex and are classically considered to be epithelial tumors (carcinoma or adenoma) . This clIn September 2012, a seven-year-old male was admitted to the Department of Pediatric Surgery, University of Siena  with a feminization syndrome, which presented as bilateral gynecomastia. Increased somatic growth was observed (bone age was advanced by more than two years) and a unilateral adrenal mass was diagnosed by ultrasound (USS). The symptoms had begun approximately eight months prior to admission, however, the patient had received treatment for an endocrinological disease. The patient’s plasma testosterone was lower than normal  and the androstenedione level was within the normal range . The plasma estradiol level  was greater than normal. The presence of the mass was confirmed by magnetic resonance imaging (MRI), which revealed a unilateral lesion of the adrenal gland, measuring ~3.8×2.7×3.2 mm. The lesion was well-defined and no additional abdominal abnormalities were present. Furthermore, no lymphadenopathies were observed. The results for metanephrines and catecholamines obtained from a 24-h urine test were negative. In addition, a computed tomography scan revealed that there was no involvement of the chest. Surgical excision of the mass was performed via an open anterior transperitoneal approach and the entire adrenal gland was removed . A biopsThe adrenocortical neoplasm (ACN) is a rare type of pediatric tumor and represents <0.5% of all childhood neoplasms and 6% of all pediatric adrenal tumors ,3–5. Theet al ; the duration of symptoms ; age of the infant (<3 years indicates improved prognosis); and histological features . The surIn conclusion, the current report may be beneficial in increasing the knowledge of ACNs. The present case of ACN in an infant male was managed according to the TREP guidelines; however, an international tumor registry is proposed as it may aid with the consistent management of these types of patient worldwide. Furthermore, the present report aimed to highlight the important role of pediatric surgeons, who are required within the team that manages the pathological analysis of ACNs in infants. Additionally, we described the marginal role that pathologists have had in previous cases, which explains the challenges experienced by the pathologist involved in the present case in diagnosing this type of tumor.