Burkitt's lymphoma is a form of non-Hodgkin's B-cell lymphoma with more than one identifiable variant. The sporadic form most commonly presents with abdominal lymph node involvement.We herein report on three patients from our experience that presented with either endobronchial or colonic Burkitt's lymphoma. Their clinical presentation mimicked that of other syndromes. After confirmatory pathological diagnosis, the patients had complete remission through the use of an optimal treatment protocol.Our review of the cases and comparable reports warrants careful workup of such presentations to ensure early diagnosis and therapeutic planning of this highly aggressive disease. MYC oncogene are believed to highlight the hallmark of the disease [Burkitt's lymphoma is an aggressive form of non-Hodgkin's B-cell lymphoma that is usually diagnosed in children and young adults, and to a lesser extent in middle-aged adults. Endemic, sporadic (non-endemic) and immunodeficient variants have been recognized . Burkitt disease . However disease . This va disease . In comp disease . EBV inv disease . The imm disease . We hereB adenocarcinoma. Computed tomography (CT) scan of the chest showed a large mediastinal mass 5 × 3.5 cm in dimension invading the superior vena cava, right pulmonary artery, and the right main bronchus, with multiple lung nodularity. Bronchoscopic examination revealed a fungating mass intruding into the orifice of the right main bronchus causing partial obstruction. Pathologic examination of the biopsy sample revealed high-grade, non-Hodgkin, B-cell lymphoma. Immunohistochemical testing was positive for CD45, CD20, CD10, and BCL-6, and negative for CD3, TdT, and BCL-2; which was consistent with Burkitt's lymphoma. Cerebrospinal fluid (CSF) studies were always negative for lymphoma. No evidence of lymphoma was noted in the bone marrow. Chemo-immunotherapy with hyper-CVAD  plus rituximab were given according to the Thomas et al. protocol [Patient 1 is a 62-year-old woman who presented with a few days history of right facial swelling and dyspnea. The patient underwent left radical mastectomy twenty years prior to presentation for a moderately differentiated stage IIprotocol  for 8 cyPatient 2 is a 16-year-old boy who presented with signs and symptoms of acute appendicitis. Appendectomy was performed on an emergent basis and the tissue was sent to pathology. Diffuse lymphoreticular infiltration of the mucosa of the appendix penetrating the muscularis of the cecal end and extending to the adjacent fatty tissue was noted. High-grade, non-Hodgkin, B-cell lymphoma was described. Immunohistochemical testing was positive for CD45, CD20, CD10, and BCL-6, and negative for CD3, TdT, and BCL-2; which was consistent with Burkitt's lymphoma. CSF and bone marrow studies were negative. The patient received hyper-CVAD plus rituximab according to the Thomas et al. protocol  for 8 cyPatient 3 is a 37-year-old male patient who presented with right lower quadrant pain, that is colicky in nature and radiating to the whole abdomen. Rectal bleeding was also reported. CT scan of the abdomen showed a 4.4 × 4.1 cm cecal mass with small adjacent lymph nodes, the largest measuring 1.4 × 0.6 cm. Colonoscopy revealed a large ileocecal mass. Biopsy results showed a diffuse lamina propria lymphoid infiltrate with intermediate size cells that are mildly pleomorphic with prominent central basophilic nucleoli and brisk mitotic activity. Immunohistochemically, high-grade non-Hodgkin B-cell lymphoma that is CD45, CD20, CD10, and BCL-6 positive was noted. The cells were negative for CD3, CD 5, BCL-2. KI-67 proliferation index was positive in all tumor cells. The diagnosis of Burkitt's lymphoma was entertained. CSF and bone marrow studies were negative. The patient received hyper-CVAD plus rituximab according to the Thomas et al. protocol  for 8 cySporadic Burkitt's lymphoma accounts for 1%–2% of lymphoma in adults and up to 40% of lymphoma in children in the United States and western Europe . Lymph nThe endobronchial involvement in our first patient, with simultaneous mediastinal extension, resulted in what is known as superior vena cava syndrome (SVC syndrome), which is a complication of many mediastinal disease resulting in the obstruction of the superior vena cava with various subsequent signs and symptoms. Malignancy is the etiology in 60% of the cases, with bronchogenic carcinoma having the highest frequency. Small-cell and non-small cell lung cancer account for 22% and 24% of the cases, respectively. Lymphomas involvement is noted in 8% of the cases . EndobroAbdominal symptoms are a frequent initial complaint in Burkitt's lymphoma. However, an acute surgical abdomen is a rare presentation. Our second patient and the patient reported by Dunning et al.  presenteBurkitt's lymphoma is an extremely rapidly growing tumor with a high sensitivity to chemotherapy but in which drug resistance can develop quickly. These dynamic features make prompt diagnosis and initiation of appropriate therapy essential for optimal outcome. Our report and review highlighted some unusual presentations of this tumor that should be kept in mind when compiling a differential diagnosis for similar presentations. Pathologic and immunohistochemical testing remain the only definitive methods of diagnosis. The choice between surgical, chemotherapeutic and chemo-immunotherapeutic treatment should be individualized.Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.KMM designed the study, compiled the different sections of the report, and helped in writing the manuscript. AIS and ATT drafted the manuscript, revised it critically for important intellectual content and helped in preparing the tables. All authors read and approved the final manuscript.


Small bowel volvulus is a rare occurrence in the Western world and its occurrence after ileo-anal ouch formation is even rarer.We report a case of a 26 year old lady who presented with small bowel volvulus and subsequent ischaemia and necrosis of her ileo-anal pouch created 5 years previously.This case illustrates a rare but potentially devastating complication of ileo-anal pouch formation and as such the diagnosis should be borne in mind when a patient with a pouch presents with an acute abdomen. Small bowel volvulus (SBV) as a cause of intestinal obstruction is an uncommon surgical emergency. It is a recognised entity in neonates associated with abnormal midgut rotation,2, but iA 26-year old Afro-Caribbean lady presented acutely with a 24-hour history of colicky abdominal pain, fever and vomiting. She was known to have sickle cell trait and a history of ulcerative colitis, for which she had undergone a total colectomy with ileo-anal pouch formation 5 years earlier. On examination she had a distended abdomen, generalised abdominal tenderness and features suggestive of small bowel obstruction. The clinical diagnosis was confirmed on plain and contrast radiography Figure , 2. An aSBV is a rare cause of small bowel obstruction in the West with a reported incidence of 1.7–5.7 cases per 100,000 habitants. Primaryet al reported the presence of increased discrete clustered contractions after small bowel anastomosis to the anal sphincter, possibly as a consequence of functional obstruction[Changes in gut motility and tone have also been implicated in the formation of primary volvulus. Chaussade struction. Alteratstruction,9.Secondary SBV is more commonly seen in the West and can develop as a result of twisting of the small bowel around a fixed point that may have arisen due to adhesions, internaIleo-anal pouch formation is a commonly performed procedure for patients with ulcerative colitis to maintain faecal continence following colectomy. Complications of the procedure include the development of cuff abscess, pouch leak, strictures, fistulation, stenosis, and pouchitis. Small bThe patient concerned has given her full informed consent for the use of all radiology and pictures and the case history in the production of this paperThe authors declare that they have no competing interests.SP drafted and edited the manuscriptGS drafted part of the manuscriptSG edited the manuscriptJH edited the manuscriptIA performed the surgeryBA performed the surgery


The case of a 64 year old female who was known to have gallstones is presented. She was admitted tothe Hospital following an attack of acute cholecystitis. Ten days after vigorous conservative treatmentcholecystectomy was performed. The histological examination showed the presence of the gallbladderleiomyosarcoma. Primary sarcomas of the gallbladder are rare, leiomyosarcoma being the most infrequenttype, their preoperative diagnosis almost impossible and their prognosis poor.


Eccrine porocarcinoma is a rare cutaneous neoplasm that mainly affects elderly people and grows slowly over a long period of time but often experiences an accelerated growth phase. Eccrine porocarcinoma may arise de novo or evolve from a pre-existing benign eccrine poroma. We reported a 86-year-old Japanese woman presenting with two reddish-colored pendulated lesions on a keratotic light brown plaque on the right thigh. Dermoscopic examination of the light-brown plaque demonstrated many whitish globular structures in a light-brown background. At the two reddish-colored pendulated lesions, polymorphous and prominent vessel proliferation was observed together with irregularly shaped whitish negative network. Immunohistochemical study demonstrated a positive CEA staining at ductal structures and atypical clear cells of reddish nodules. A diagnosis of eccrine porocarcinoma arising in a pigmented hidroacanthoma simplex was eventually established, and the dermoscopic features of eccrine porocarcinoma from hidroacanthoma simplex was described for the first time. A 86-year-old Japanese woman presented at Hiratsuka City Hospital with a cutaneous tumor on her right thigh. Examination revealed two reddish-colored pendulated lesions at the peripheries of a keratotic light brown plaque of 27×17 mm , which hHistopathologic examination of the flat pigmented plaque disclosed many well-defined nests within the epidermis . The nesSince the entire tumors were continuous, we made a final diagnosis of eccrine porocarcinoma and eccrine porocarcinoma in situ arising from pre-existing lightly pigmented hidroacanthoma simplex. The patient had been doing well after the operation. However, 8 months later, a right inguinal lymph node metastasis was found. After the inguinal lymph node dissection was performed, lung and para-aortic lymph node metastases were confirmed on the CT. The patient's general condition deteriorated and died 16 months after the surgery.Hidroacanthoma simplex (HAS) is a benign eccrine tumor that is also known as intraepidermal poroma. Eccrine porocarcinoma (EPC) is a rare cutaneous neoplasm that grows slowly over a long period of time but often experiences an accelerated growth phase . EPC mayDermoscopy improves the clinical diagnosis of many pigmented and nonpigmented skin tumors including eccrine poroma. We described additional dermoscopic features for eccrine porocarcinoma and hidroacanthoma simplex. Only a few studies were published about the dermoscopic features of eccrine poroma. Altamura et al. published a case of nonpigmented eccrine poroma of the pubic region that simulated amelanotic melanoma, both clinically and dermoscopically. They described pink to reddish, irregularly shaped and sized structures reminiscent of milky-red areas, red lacunes, and linear irregular vessels . NicolinThe combination of atypical vascular pattern and milky-red globules is especially specific for the diagnosis of eccrine porocarcinoma. The former is also observed in other lesions, such as amelanotic melanoma, actinic keratosis, Bowen's disease, and basal cell carcinoma and squamous cell carcinoma.In this paper, we have shown characteristic dermoscopic features of a lot of whitish globular structures in the light brown back ground. Each whitish round structure would correspond to a nest of cellular proliferation of hidroacanthoma simplex in the epidermis. Since the nests of poroma cells are entirely in the epidemis, hidroacanthoma simplex would only show whitish globular structures without vessels. There are comedo-like, well-circumscribed dark brown structures, which would correspond to keratotic pluggings in the surface. In the two reddish-colored lesions, polymorphous and prominent vessel proliferation is observed together with irregular whitish negative network. Vessels included dotted, linear-irregular, glomerular, and hairpin. Vessels were more conspicuous and irregular in the EPC. The present case is composed of EPC and EPC in situ on the plaque of HAS, and the obvious difference in vessels on dermoscopy could be a helpful clue for an estimation of the grade of malignancy.Although it would be difficult to differentiate amelanotic melanoma from EPC on dermoscopy alone, the peripheral findings suggesting HAS, such as whitish globular structures on the homogeneous brown area, might be helpful for a diagnosis of EPC.In this case, although the three portions of the tumor were continuous, the pathological difference well explained the difference in dermoscopic features. Evaluations of various skin lesions using dermoscopy would be indispensable in the daily dermatology practice.


We present the contrast-enhanced spiral CT findings in a case of acute celiac artery occlusion with gastric perforation and total splenic infarction. Spiral CT depicted thrombus in the celiac axis and its branches, stenosis of the superior mesenteric artery, splenic infarction and lack of enhancement of the gastric wall with a large necrotic gap. Spiral CT enabled prompt diagnosis and therapy in this rare condition in a patient with suspicion of acute mesenteric ischemia. Acute celiac axis occlusion is an infrequent event. Acute or chronic mesenteric ischemia occurs more commonly from superior mesenteric artery (SMA) occlusion and may result in small bowel necrosis. It may be assessed with contrast-enhanced spiral CT, and the use of multi-detector row CT scanners increases diagnostic accuracy . We repoAn 80-year-old woman was admitted to our hospital with two days' history of dyspnea and deteriorating left sided abdominal pain. Past medical history was notable for diabetes mellitus, hypertension and coronary artery disease. She had been on digitalis, gliclazide, felodipine and isosorbide mononitrate for years. On physical examination, she was overweight, in poor general condition, with overt dyspnea, tachypnea, pallor, and dry skin. Abdomen was distended with absent bowel sounds, muscular rigidity and deep tenderness on palpation, worse on the left upper and lower quadrants. Chest examination revealed adequate left lower lung excursion but diminished breath sounds. Both legs were oedematous with normal peripheral arterial pulses.2 51 mmHg, pCO2 33.9 mmHg, PH 7.51, SO2 88.9%.Admission laboratory tests on were remarkable for: WBC 18600 (83.6% granulocytes), glucose 321 mg/dL , LDH 556 u/L , Na 130 mmol/L, K 3.1 mmol/L. ECG showed atrial fibrillation and signs of chronic digitalis therapy. Blood gases were: pOA CT scan of the abdomen was performed on a single-detector-row spiral scanner  after oral contrast administration  and intravenous injection of 150 ml of 300 mgI/ml non-ionic contrast medium , administered with a power injector and followed by 50 ml of normal saline flush. Contrast enhanced scans were obtained during the hepatic portal dominant phase in the upper abdomen and venous phase in the pelvis with beam collimation of 5 mm, table increment of 10 mm, and reconstruction interval of 4 mm. Spiral CT showed necrosis of the stomach wall with absence of enhancement and presence of a large gap at the left lateral surface with leakage of contrast medium into the peritoneal cavity Figure , and extth postoperative day.Following initial resuscitation, the patient underwent midline laparotomy in the operating room. Free bile-stained peritoneal fluid and a 7 cm perforation of the gastric fundus were found, the spleen was infarcted and dark coloured, while the remaining viscera were normal. The stomach was repaired using running absorbable suture in two layers, after trimming the edges of the perforation and splenectomy was performed. The patient had good immediate postoperative recovery but died of cardiopulmonary complications on the 4Acute celiac artery obstruction occurs as a result of atherosclerosis, aneurysm, dissection, embolisation of intracardiac thrombi in atrial fibrillation, coagulation disorders caused by HIV infection, external arterial compression by the median arcuate ligament -4, or asIschemic necrosis occurs more frequently in organs supplied by end arteries. Gastric ischemia is uncommon as the stomach has a rich blood supply from branches of the celiac axis, as well as from SMA collaterals. A recent prospective study reported two cases of combined celiac and inferior artery obstruction with acute mesenteric ischemia without, however, signs of gastric ischemia . The perIn splenic infarction occurring in various clinical conditions , pain usCaution should be exercised when interpreting focal stomach wall discontinuity on CT studies, as it may also be encountered in perforated gastric ulcers ; in our In conclusion, contrast enhanced spiral CT may accurately depict acute celiac artery occlusion and its sequelae. Accompanying gastric ischemia is very uncommon, radiologists should, however, be aware of its possibility and imaging findings, and evaluate carefully stomach wall enhancement in patients scanned with suspicion of acute mesenteric ischemia.CT: computed tomography; EBC: erythrocyte blood cell count; ECG: electrocardiogram; LDH: lactic dehydrogenase; SMA: superior mesenteric artery; WBC: white blood cell count.Consent for publication was not gained before the patient died. The patient's family gave their oral consent for publication. We believe that the patient cannot be identified from this case, and that there is no reason to think that the patient or their family would have objected to publication.The authors declare that they have no competing interests.NLK made substantial contributions to analysis and interpretation of data and was a major contributor in writing the manuscript. EA made substantial contributions to conception and design and was a major contributor in writing the manuscript. DL made substantial contributions to acquisition, analysis and interpretation of data, as well as literature search. RM made substantial contributions to acquisition, analysis and interpretation of data. GT made substantial contributions to acquisition, analysis and interpretation of data. IF revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.


We present a previously undescribed entity: trigger finger secondary to a leiomyoma. This is the first time such a case has been reported and highlights the fact that common conditions can sometimes present secondary to rare diseases.A 39-year-old Caucasian man presented with a fairly typical presentation of trigger finger. During surgical treatment, the lesion was excised and sent for histology, which showed tissue consistent with a leiomyoma. The patient made an uneventful recovery.Trigger finger is a common condition that is usually easily diagnosed and managed. However, it is important to appreciate that uncommon conditions, such as leiomyoma, can present with what is sometimes considered trivial disease, and one should always consider the differential diagnoses even when faced with relatively benign conditions. Trigger finger is a common condition, first described by Notta in 1850, characterised by painful clicking and locking of a digit. The underlying cause is a failure of normal tendon gliding in the A1 pulley region of the tendon sheath. This is usually associated with a proliferation of chondrocytes (stenosing tensosynovitis). We present a case of trigger finger secondary to a leiomyoma; a previously unreported condition.A 39-year-old, right-handed Caucasian male office worker presented with a three-month history of painful locking and clicking of his right ring finger. There was no history of trauma and he was otherwise fit and well. On examination, he had a tender mass on the volar aspect of the metacarpophalangeal joint as he actively flexed and extended the ring finger, and there was a small, palpable lump overlying the fourth metacarpophalangeal joint.A diagnosis of trigger finger was made; however, the palpable lump was significantly larger than usually found with a Notta's nodule. An X-ray of the right hand was unremarkable and an ultrasound scan revealed an elliptical soft tissue mass associated with the flexor tendons and A1 pulley.At surgical exploration under general anaesthesia, a circumscribed soft tissue mass, 1.5 cm in diameter, was found infiltrating the A1 pulley and flexor digitorum superficialis (FDS)  on immunohistochemical analysis. These findings were consistent with a leiomyoma.Trigger finger, also known as stenosing tenosynovitis, is seen in healthy middle-aged women and younger patients with occupations that involve repetitive and prolonged gripping and grasping. It is also associated with other conditions such as rheumatoid arthritis, gout, amyloidosis and diabetes; in these cases it is referred to as secondary trigger finger.Rarely, trigger finger is caused by space occupying lesions or anatomical abnormalities which compromise tendon gliding. Previously described examples include: phalangeal exostosis ; anomaloAlthough the exact aetiology of trigger finger is commonly unknown, the majority of cases are related to a fusiform swelling of the flexor tendon at the level of the A1 pulley in the region of the metacarpophalangeal joint. The swelling in the tendon is often due to repetitive trauma which leads to inflammation, fibrosis and thickening of the tendon; or it can be due to the healing process after direct trauma or laceration. This nodule compromises the normal gliding of the tendon thorough its sheath, thus leading to the symptoms of snapping, triggering or locking. In our patient, a leiomyoma was found to be compromising tendon gliding in the region of the A1 pulley.Benign tumours are common in the hand, but leiomyoma is uncommon: in a series by Butler et al of 437 hand tumours only one was a leiomyoma . LeiomyoAs we demonstrate with this case, uncommon pathology may present in a relatively common condition. We advise careful and methodical assessment of patients presenting with trigger finger, because although the majority of cases will be routine and uncomplicated, there are rare occasions when an underlying tumour is the cause of symptoms. If there are any doubts about the possible aetiology, then further investigations such as ultrasonography or magnetic resonance imaging should be utilised.Written informed consent was received from the patient for this publication. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.ZH and QB wrote and revised the manuscript. DR was involved in the operative management and overall care of the patient, and provided guidance throughout the preparation of the manuscript.


Primary or idiopathic hypertrophy of the pyloric muscle (IHPM) is a rare entity with uncertain pathogenesis which both clinically and pathologically mimics gastric cancer. We present a rare late-occurring case of IHPM in a 71-year-old Caucasian man with no apparent predisposing factor. Imaging studies demonstrated gastric distension with air fluid levels and no evidence of extrinsic compression. At upper endoscopy, massive gastric distension and no evidence of any ulcer or other mucosal defects were observed. Microscopically, marked hypertrophy of muscularis mucosa with smooth muscle cells arranged in whorls and fascicles was present which gradually transitioned to normal areas. The muscle fibers stained with smooth muscle actin and trichrome stain highlighted fibrosis between the muscle fibers. Although uncommon, IHPM can clinically and histologically mimic other proliferations in the gastric wall, such as gastrointestinal stromal tumor or a spindle cell neoplasm. The recent advances in understanding the pathogenesis of IHPM are discussed. Primary or idiopathic hypertrophy of the pyloric muscle (IHPM) in adults is a relatively rare, yet well-established entity , 2. The We report a case in an older male with no prior history of gastrointestinal symptoms and no apparent precipitating factor.A 71-year-old Caucasian man had been experiencing abdominal distension, nausea, and vomiting for three months. His symptoms worsened progressively over the previous two weeks when he was referred to our institution for further evaluation. The abdominal distention and vomiting appeared to be mostly postprandial, and the vomitus consisted of mainly undigested food and no bile. His symptoms were independent of the type and consistency of the type of the food ingested. His past medical history was significant for cardiovascular diseases, end stage renal disease, and diabetes mellitus with no history of gastrointestinal problems.Abdominal films obtained before admission showed massive gastric distension. Physical exam revealed a soft, mildly distended abdomen. No tenderness, mass, and/or hernia were discovered. The remainder of the examination was unremarkable except for his dialysis fistula in right upper extremity. He was admitted with diagnosis of gastric outlet obstruction. Abdominal films following admission again demonstrated gastric distension with air fluid levels. A CT scan did not show any evidence of extrinsic compression.An upper endoscopy (EGD) demonstrated massive gastric distension with a large collection of partly digested food. There was no evidence of an ulcer or other mucosal defect in the pyloric channel, but the channel did not appear to relax and dilate . The endThe patient did not improve, and surgical exploration was recommended. At exploratory laparotomy, a massively dilated stomach was encountered. During this procedure, a minigastrotomy was made on the greater curvature of the stomach, and greater than 3 liters of foul-smelling particulate matter gastric contents were removed, consistent with longstanding food retention. The origin of this retention appeared to be due to pyloric stenosis with an associated thickened gastric wall. An antrectomy with Roux-en-Y gastrojejunostomy was performed, and a Witzel feeding jejunostomy tube was placed.The specimen consisted of a segment of stomach, antrum and pylorus measuring 9 × 6 × 4 cm. The wall of the stomach was uniformly thickened over the proximal portion of the specimen involving the entire circumference of the gastric wall. A very prominent gastric fold measuring 1.5 cm in thickness and located at 1 cm from the distal margin was observed at the pylorus. There were focal areas of congestion in the mucosa, but no masses or ulcerations were seen. Microscopically, marked muscularis propria hypertrophy with smooth muscle cells arranged in whorls and fascicles were seen in the pylorus, while the remaining stomach also showed a thickened muscularis propria Figures . TransitImmunohistochemistry staining for smooth muscle actin  confirmed the thick layer of smooth muscle . TrichroAdult IHPM has been previously described in literature –15. PatiRadiology examination can be normal in many cases , 15, andMicroscopic examination demonstrates marked hypertrophy of pylorus muscles which may be associated with reactive mucosal gastropathy. However, no other significant pathologic process such as inflammation or neoplasm should be seen in the muscularis propria. The transition of the hypertrophied section is usually gradual from the normal areas , 12. TheThe exact etiology of adult IHPM is unclear. The most widely accepted etiologic classification includes a primary type with no apparent underlying disease and a secondary type. The secondary type can have many causes including exuberant healing of a previous gastric or duodenal ulcer, carcinoma, gastrointestinal stromal tumor, extrinsic postoperative adhesions, bezoars, and vagal hyperactivity leading to muscular hypertrophy , 14, 16.Differential diagnosis includes the more common neoplastic processes and diabetic gastropathy both can have the similar clinical presentation. Though recognizing carcinoma is often straightforward, the spindle cell neoplasms such as gastrointestinal stromal tumor might be more difficult to differentiate from IHPM. Diabetic gastropathy shows the characteristic hydropic neural degeneration with severe reduction in the density of unmyelinated axons, vasculopathy with thickening of the vessel walls, and smooth muscle degeneration and fibrosis, with eosinophilic inclusion bodies (M-bodies) which appear to be unique to this condition. The preferred treatment is surgery with gastric resection and Billroth I anastomosis , as was We present this relative unusual presentation of gastric outlet obstruction to raise the awareness of the existence of this lesion and not confuse the histologic findings with other proliferations in the gastric wall such as a gastrointestinal stromal tumor or other spindle cell neoplasms. Attention to the clinical and histologic features should allow a correct interpretation and prevent misinterpretation of a neoplasm, especially at the time of frozen section.


We present the unusual occurrence of two distinct neoplasms in a 42-year-old woman with an operated pituitary adenoma 18 years ago.Clinical history, magnetic resonance imaging studies and histopathological findings were utilized for our diagnostic considerations.Concomitant presence of a cerebellar medulloblastoma secondary disseminated within the spinal canal and a pituitary macroadenoma, was identified.To the best of our knowledge, this is the first reported case in which these two neoplasms are simultaneously occurred in the same individual. A short review of the literature is performed. Medulloblastomas are posterior fossa tumors preferentially manifested in children less than 15 years and rarely occurring in adults  with somPituitary tumors constitute about 10–15% of all intracranial tumors . PituitaSimultaneous occurrence of two different tumors in a patient, including cases which concern the central nervous system (CNS), has been previously described in the literature -9. This In this context, we report the case of a 42-year-old woman suffering simultaneously from a cerebellar medulloblastoma, secondary disseminated within the spinal canal, and a pituitary macroadenoma. The patient had been operated 18 years before due to a pituitary adenoma. Taking into account the published data, for the first time a medulloblastoma coexists with a pituitary tumor.A 42-year-old woman was admitted to the Hellenic Red Cross Hospital with diminished function of her right leg as well as sensory disturbances of one week duration. Neurological examination revealed paresis of the right leg, and increased tendinous reflexes in both legs. The abdominal reflexes were all abrogated. During hospitalization the patient showed deterioration of neurological symptoms with severe paresis of both legs as well as urinary incontinence.The specific details of patient's history were as follows: Occupation: housewife; Ethnicity: Ukranian; Weight: 65 Kgr; Height: 180 cm; Medical history: previous surgery 18 years ago due to a pituitary adenoma-no data available regarding the completeness of the resection and the administration or not of irradiation therapy; Family history: unremarkable; Pregnancies: no; Smoking: no; Drinking alcohol: no; Current medications: no.Magnetic resonance imaging (MRI) of the brain demonstrated an inhomogeneously contrast-enhancing, multilobulated tumor of the posterior cranial fossa, measuring 3 × 3 × 2,3 cm Fig. . The masThe imaging studies, additionally, showed a recurrent macroadenoma of the pituitary gland with greatest diameter 2,8 cm Fig. . The masMRI of the spinal cord, also, showed multiple intradural-extramedullary masses with obstructive effects especially in the upper level of thoracic spinal cord as well as small-size tumors in the entire length of the spinal cord. More specifically, the contrast-enhancing masses of the upper thoracic cord had greatest diameter from <10 mm to 3,2 cm and were isointense in T1 and T2-weighted images relative to spinal cord [Fig. A non-circumscribed, soft, friable, partly necrotic mass, measuring 3 × 1,5 × 0,5 cm, from the biggest mass in the thoracic spinal cord, was excised, fixed in formalin 10% and embedded in paraffin. The histological and immunohistochemical profile of multiple tissue sections was analyzed using the conventional stain with hematoxylin/eosin and the Bond-maX system  according to the manufacturer's instructions. The Primo Star upright microscope and the Axio Cam IC camera  were also utilized for assessing and capturing of images.Specifically, a small cell malignant tumor with ill-defined rosettes was identified Fig. . ImmunohThese histopathological results along with the MRI findings of the brain's examination were consistent with a diagnosis of a central PNET (medulloblastoma) of the cerebellum with secondary dissemination through the CSF.The mass of the cerebellum was not excised as it did not demonstrate serious compressive results and it was necessary to avoid any further aggravation of the general medical status of the patient. The patient received CNS irradiation in another medical center but chemotherapy was not administered since the patient refused any further medical treatment. Unfortunately, the patient died one year after the initial diagnosis.We described the case of a medulloblastoma primary localized in the cerebellum of a 42-year-old woman with secondary dissemination through the CSF pathway. However, our case was further complicated as it was detected a mass in the sellar region with an imaging appearance fully consistent with a pituitary macroadenoma. To the best of our knowledge, this is the first report in the literature of a medulloblastoma coexisting with a pituitary tumor, in the same individual.Regarding differential diagnosis, a pituitary carcinoma, developed in the ground of the adenoma and exhibited metastatic lesions in the CNS, including the cerebellum as well as the spinal cord, was the main entity under consideration. The histological features, however, as well as the immunohistochemical profile (chromogranin A negative and vimentin positive) of the lesion of the spinal cord excluded this diagnosis. Furthermore, there was not noted any evidence of metastatic disease elsewhere, a finding usually observed in pituitary carcinomas . Thus, aAs a matter of fact, the occurrence of two distinct tumors within CNS has been previously described in the literature. Interestingly, Gironimi et al. in 1981 reported the case of a primary Burkitt-type lymphoma of the CNS, developed in an 11-year-old boy 6 months after extirpation of an astrocytoma, stressing the notion of collision tumors and their differential diagnosis , metastaFurthermore, Curto et al. recently presented the concurrent presence of pituitary adenoma, intracranial meningioma and cerebral aneurysm highlighting the suggestion that growth hormone or other growth factors could play a role in appearance or in growth of meningioma . PreviouAttempting to explain the emergence of the medulloblastoma in our patient, two hypotheses could be considered. The first one is related to a possible histogenetic or clinical (as far as a specific syndrome is concerned) interconnection between medulloblastomas or cPNETs and pituitary adenomas. However, there is no bibliographical evidence for this kind of association and thus the above mentioned theory must be excluded.On the other hand, according to the second assumption, the medulloblastoma could be developed as a result of the previous therapeutic manipulations for the pituitary tumor. Specifically, the patient most probably received irradiation for the initially presented pituitary adenoma, 18 years ago. Therefore, given that the occurrence of a second intracerebral neoplasm after craniospinal radiotherapy is well recognized ,15, it cIndeed, the estimated risk for the aforementioned second tumors is thought to be as high as 1–2%, occurring with a latency of 8–15 years ,15.In summary, regardless of the various explanations which can be given, we reported the peculiar concomitant presence of a disseminated medulloblastoma and a pituitary macroadenoma. The former tumor most probably progressed in the context of a previous irradiation therapy for the initial pituitary adenoma, 18 years ago.The major reason for which we consider irradiation as the most likely causative factor for the expansion of the new tumor is that radiotherapy accounts for the growth of a second tumor in many other instances . It shouWritten informed consent was obtained from the patient, at the time of initial diagnosis and prior surgery, 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.The authors declare that they have no competing interests.VS: Writing of manuscript, histological diagnosis. ES: Writing of manuscript, acquisition of clinical data. IS: Conception and design of case report. PK: Analysis of imaging findings. CA: Analysis and interpretation of clinical data. MA: Analysis and interpretation of clinical data. VV: Revising of manuscript. CB: Revising and editing of manuscript, histological diagnosis. All authors read and approved the final manuscript.


Splenic rupture is a rare complication of colonoscopy. For this reason the diagnosis could be delayed and the outcome dismal. Fifty-four cases of splenic rupture after colonoscopy have been described in the literature. The majority of the cases required emergent or delayed splenectomy, 13 of these cases were treated conservatively. The main feature that stands out from the review of the literature is the "surprise" of this unexpected complication. This factor explains the elevated mortality (2 out of 54 cases), likely due to the delay in diagnosis. The case here described is probably among the most complex published in the literature; in fact the presence of dense intra-abdominal adhesions not only contributed to the complication itself, but also explain the confinement of the hemoperitoneum to the left supra-mesocolic space and the delayed presentation (13 days from the time of the trauma). Colonoscopy is a very popular diagnostic and therapeutic procedure, and it is usually very well tolerated by the patient. Besides the complications due to the bowel preparation  and theFinally, acute appendicitis and splenic rupture are extremely rare complications. Only nine cases of acute appendicitis after colonoscopy have been reported. The pathophysiologic mechanism seems to be due to the luminal occlusion by a fecalith during the endoscopic maneuvers .The first case of splenic rupture after colonoscopy was published in 1975 by Wherry and Zehner . At the In rare cases the diagnosis is made after 48–72 hours. Our case of a two-stage splenic rupture after 13 days seems exceedingly rareThe patient is a 50-year old woman admitted at our Department of General and Breast Surgery of the University of Catania.The patient had an extensive past surgical history that included a cholecystectomy in 1984, a right upper quadrantectomy with lymphoadenectomy in 1997, a left quadrantectomy in 1998, and a radical total abdominal hysterectomy in 2003 for large fibromas.Eleven days prior to the admission to our unit, the patient underwent colonoscopy for a history of rectorrhagia. The exam was conducted under light sedation and without difficulties. The exam was unremarkable to the cecum except for the presence of several diminutive polyps (3 mm) in the rectum, which were biopsied for histological evaluation. At the end of the procedure the patient developed left sided chest pain and a syncopal episode that she did not report to her family or to her physician.The following day the patient had a mild fever, but she was otherwise stable.On post-procedure day 4 the patient went to her family physician, who obtained a chest and abdominal radiographic series and some routine blood work. The chest roentegram revealed an obliteration of the left costophrenic angle, whereas the abdominal radiograph was within normal limits. The laboratory analysis revealed a normal hemoglobin level (14 g/dl) and a mild leukocytosis (17.4). The patient denied any spontaneous or induced abdominal pain, the bowel function was within normal limits, but she had a persistent modest temperature elevation (38 degrees).The patient was then treated with antibiotics and analgesics. A second chest roentegram appeared unchanged.Because of her persistent and reproducible left sided chest pain and fever and her history a previous mastectomy for cancer, she was referred to us because of a suspected pleuro-parenchymal lesion.After confirming her modest leukocytosis and normal hemoglobin level, she underwent a computed tomography of the chest and abdomen, which showed some atelectasis at the left lung base with hemi-diaphragmatic elevation and hypodense convex areas within the spleen, indicative of subcapsular hematoma Figure . In lighAfter performing a Medline search using the keyword colonoscopy, splenic rupture, splenic injury, splenic trauma, we found 49 citations, 43 of which in English language, for a total of 54 cases of splenic rupture after colonoscopy. Overall there is a female sex preponderance (sex ratio of 3.8/1) and an average age of 62 years (range 29–85). In 13 cases the patient has a previous history of intra-abdominal operations. Twenty-one of the colonoscopies were simply diagnostic, one was done in conjunction with an upper endoscopy, 3 included biopsies and 15 had concurrent polypectomies. Only three cases were described as modestly difficult.Only one patient was on oral anticoagulation therapy with Warfarin.The onset of symptoms was usually immediate (within 24 hours from the exam), but in some cases was delayed by several days ,36-38,46Although the diagnosis of the first reported case was made by angiography, the Computed Tomography (CT scan) is the main test utilized now days. In previous series (before 1991) the most common diagnostic modality was exploratory laparotomy (10 cases), followed by ultrasonography and CT scan (2 cases), diagnostic peritoneal lavage (1 case) and post-mortem (1 case). The treatment was by emergent laparotomy in the majority of the cases, whereas 12 cases where treated non-operatively. In one case the treatment was by percutaneous embolization of the splenic artery. One reported case of a patient with a history of Crohn's disease had a combined splenic and liver laceration found on exploratory laparotomy. One patient died in spite of emergent splenectomy.The reason for splenic rupture after a colonoscopic examination seems to be associated with the alteration of the peritoneal attachments that support the spleen in the left upper quadrant .Any kind of traction on these ligaments could determine a capsular rupture, which then disrupts a portion of the parenchyma densely adherent to it.The rupture can be immediate because of damage to the hilum or entire organ disintegration, or delayed. In the first case the clinical presentation is with hypovolemic shock. In the latter the timing of manifestation of the shock varies and it could be gradual and delayed by few hours from the trauma depending upon degree of the parenchymal and capsular lesions. The mechanism is related to the formation of a subcapsular or intra-parenchymal hematoma, that then, instead of organizing itself into a pseudocyst, increases in size until determines the rupture of the capsule (delayed splenic rupture).Although the exact reasons of development of a subcapsular or intra-parenchymal hematoma after a colonoscopy are not entirely clear, three mechanisms have been postulated:The first one is related to the sudden trauma when the endoscope traverses the splenic flexure .The second one is related to the avulsion of the splenic capsule caused by the excessive traction on the spleno-colic ligament during the endoscopic examination .The third theory implies the traction on the adhesions between the spleen and the colon determined by previous surgical interventions or inflammatory processes .In any case there are several risk factors that could predict the rupture of the spleen after colonoscopy: coagulopathies, infectious or hematological splenomegalies, specific pharmacological treatments (such as Hematopoyetic Growth Factors), intestinal or pancreatic inflammatory processes and previous intra-abdominal operations -9,11-13.Other authors blame this complication to the endoscopic manoeuvres utilized to navigate through the splenic flexure (in particular hooking and reduction) or to therapeutic interventions such as polypectomies and biopsies ,15.In our case the colonoscopic exam was easily conducted and there was no therapeutic intervention except for a biopsy of small rectal polyps.Differently from the cases published in the literature, in which the clinical manifestation appeared between 2 hours and 10 days ,29, our In most of the cases the patients report left upper quadrant abdominal pain which can be referred to the left shoulder (Kehr sign). The latter sign is not specific and could also be present after uncomplicated colonoscopies. Only one of the reported cases presented with complete lack of pain . In moreIn other cases the clinical presentation is more subtle. This usually occurs in cases of delayed rupture or in the presence of dense adhesions. The adhesions, in fact, not only can limit the extent of the hematoma, but can also prevent the onset of signs of peritoneal irritation from the hemoperitoneum.In our case the dense adhesions, result of the previous extensive surgical history, determined the unusual and delayed clinical presentation. We can speculate, in fact, that following the trauma or stretching of the splenic ligaments (physiologic or post-operative), the dense adhesions determined a sort of hemostasis and delayed the splenic rupture with signs of hemodynamic instability only13 days after the event.The atypical chest pain reported by the patient with the associated fever, leukocytosis and left pleural effusion was initially interpreted as a non specific pleuro-parenchymal lesion due to her previous history of bilateral breast cancer. Since the most common complication after colonoscopy are related to perforation and hemorrhage, the absence of intra-abdominal findings with negative abdominal plain x-rays, led to the exclusion of a complication related to the colonoscopy. It is then possible that a number of self-limited splenic ruptures goes undiagnosed because of lack of important symptomatology. On the other hand it is possible that other cases with an even longer lag of time between the endoscopic procedure and the splenic rupture were interpreted as a consequence of a more recent traumatic event and as such not published in the literature. It is then important to rule out a splenic rupture by U/S or CT scan in every case of abdominal or thoracic pain associated with anemia and lack of rectorrhagia ,2,13,24.Since both the plain abdominal x-ray and the U/S give indirect signs of splenic rupture, the CT scan is the diagnostic exam of choice, especially for those patients candidate for non-operative treatment. In the literature 9 patients underwent successful conservative treatment with transfusions and close monitoring ,33,46,48There are only 54 cases of splenic rupture following colonoscopy published in the literature. Some authors postulate that there are other less severe cases that are not published. The rarity of this complication and the potential delay in its clinical presentation (like in the case here reported), could lead to dismal results. The presence of abdominal or thoracic pain associated with anemia and/or hypotension after a colonoscopic exam, should follow a strict diagnostic protocol in order to rule out a splenic rupture. In fact although rare this is the most insidious complication of colonoscopy. For this reason the consensus conference of the Italian Society of Surgery on "Safety in Surgery" describes the splenic rupture as a rare but severe complication and ranks it the third complication of colonoscopy after hemorrhage and colonic perforation .CT – Computed tomographyU/S – UltrasoundThe authors declare that they have no competing interests.AC, MDV, AZ, GA attended the patient, conceived the study and drafted the manuscript. AC and GP contributed to the study and participated in drafting the manuscript. ELM revised critically the manuscript for important intellectual content. All Authors read and approved the final manuscript.


We report the case of a patient with intraosseous ganglion in the lateral femoral condyle. An 11-year-old girl presented with right knee pain following a twisting injury. Plain radiographs of the knee showed a small circumscribed radiolucency with a thin sclerotic margin in the subchondral region of the lateral femoral condyle. Although the image findings and location are not typical, the lesion was tentatively diagnosed as osteochodritis dissecans. Six months after the conservative treatment with a break from vigorous sports activities, the size of the bony lesion had not decreased. Thus, we performed arthroscopy to make a definitive diagnosis. Arthroscopic examination revealed an area with dimple and surface irregularity at the lateral femoral condyle. On excision of the overlying tissue, the lesion was cystic containing brown mucous fluid. No association between the cyst and the articular structures was observed. Histologic examination of the resected cyst wall showed dense fibrous tissue with spotty areas of calcification. Base on these findings, we made a diagnosis of intraosseous ganglion. At the nine-month postoperative follow-up, the radiographic examination showed healing of the lesion. We speculate that the lesion in this case might have occurred as a result of repetitive overstress or microtrauma. Intraosseous ganglion is a benign non-neoplastic lesion of unknown etiology. The femoral head and the tibia have been shown to be relatively commonly affected . HoweverAn 11-year-old girl was evaluated for right knee pain following a twisting injury. She belonged to a volleyball club and practiced almost every day. However, no history of antecedent trauma and no relevant medical history were noted. She had suffered mild knee pain in activities of daily living for three days before the injury and been managed by her primary care physician. Radiographic examination was performed by the initial doctor, and she was referred to our clinic for investigation of an abnormal lesion found in the radiograph.Physical examination on initial presentation at our clinic showed full range of motion of the affected knee without limping, and effusion, swelling, local heat, instability or tenderness were not detected. Plain radiographs of the knee showed a small circumscribed radiolucency with a thin sclerotic margin in the subchondral region of the lateral femoral condyle. The lesion was located near the contact area at maximum knee extension Fig . The sizOn arthroscopic examination, an area with a dimple and irregularity was seen at the weight bearing region of the lateral femoral condyle, where it contacted the tibial articular surface at full extension Fig . The remThe postoperative course was uneventful and the patient was permitted to resume sports activity at 4 months. At the nine-month postoperative follow-up, she remained asymptomatic and the radiographic examination showed the bony lesion was barely identifiable with apparent healing Fig .Our patient presented with an intraosseous ganglion in the subchondral region of the femoral condyle. The occurrence of a ganglion in this location and age group is rare. The youngest patient previously reported with this type of ganglion was a 6-year-old boy . His pasThe cause of the intrasseous ganglion is unknown. Kambolis reported that ganglionic cysts of the bone developed by invasion of the ganglion-like connective tissue into the bone from the local soft parts . SchajowIn the present case, extension of the ganglion into the joint cavity was not seen and the lesion was located in the subchondral region of the lateral femoral condyle. The location of the cyst was in the area of contact where repetitive mechanical stress may be applied at full extension. Since the patient was a volleyball player, we speculated the lesion in this case might have occurred as a result of repetitive overstress or microtrauma. Histological findings of the cyst wall seem to be coincident with our speculation. Arthroscopic examination of the articular surface of the lesion showed a dimple and thinning of the overlying cartilage. There may have been a subtle communication between the cyst and the intraarticular space. The presence of communication between the cyst and the joint has been observed in previously reported cases, and Schajowicz et al. suggested the possibility of subsequent obliteration of the connecting channel . The dimManagement of the intraosseous ganglion in previous reports was usually simple curettage with or without bone graft, and the prognosis generally good without recurrence. Only curettage was performed in our case because the lesion was small and left open. Subsequent healing was observed in the following few months. However, continued follow-up is necessary to guard against the possibility of recurrence of the lesion.The authors declare that they have no competing interests.All authors co-wrote the paper and discussed the results and commented on the manuscript. All authors read and approve the final manuscript.


Desmoplastic fibroma (DF) is a rare, benign but locally aggressive, intraosseous lesion with a high tendency of local recurrence. In this report the actual literature is reviewed regarding epidemiological data, pathology, clinical diagnostic criterias, therapy and prognosis. Moreover, a report of an interesting case is included localized in the mandibular corpus. Desmoplastic fibroma (DF) is a benign but locally aggressive neoplasm of the bones ,2 and itFor reviewing the international literature a systematic search in the PupMed database of the National Library of Medicine was performed using the key words "desmoplastic fibroma", "mandible" and "jaw". This search revealed that only 76 cases (from 1968 to 2009) of desmoplastic fibroma in the jaw area have been published to date, which reconfirms the infrequency of these tumours and the low incidence.Intraosseous desmoplastic fibromas (DF) are very rare myofibroblastic tumours  ,44 and tIn this report we present the clinical course and therapy of a patient with the first diagnosis of a desmoplastic fibroma in the left mandibular corpus, after resection of an extensive but low-grade myofibroblastic sarcoma in the right ramus 8 years before. Regarding the mental nerve we decided on a gentle resection and an observing follow-up strategy after the final diagnosis had been confirmed. Ten months after resection, clinical and radiographical controls of our patient showed no recurrence of the DF, but a periodic follow-up over at least 3 years is recommended A 23-year-old Caucasian male patient consulted the Department for Cranio- and Maxillofacial Surgery for analysing an intraosseus, rounded tumour in the left mandibular corpus, which was initially diagnosed by an MRI scan 12 months ago in a different institute  is a rare, benign but locally aggressive, intraosseous lesion with a high tendency of local recurrence. With respect of the patient's post-operative well-being and if periodic follow-ups are guaranteed, the tumor should be carefully resected with only narrow safety margins.All authors disclaim any financial or non-financial interests or commercial associations that might pose or create a conflict of interest with information presented in this manuscript.MS, AZ, RD, CN and JH made substantial contribution to the conception and design of the manuscript. RE carried out the pathological investigations and participated in creating this part of the manuscript.All authors were involved in revising the manuscript critically and have given final approval of the version to be published.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


Paraplegia due to a spinal cord epidural mass is an extremely rare presentation of undiagnosed leukemia. We are reporting a case of 14-year-old girl, who presented with paraplegia due to thoracic epidural mass, as the initial presenting manifestation of acute myeloid leukemia. Granulocytic sarcoma or chloroma should be considered in the differential diagnosis of an epidural mass in patients with or with out leukemia granulocytic sarcoma, which are rare extramedullary tumor-like proliferation of myelogenous precursor cells that may de novo precede acute leukemia or coincide with the first manifestation or relapse of acute myeloid leukemia. Paraplegia due to chloroma is an extremely rare presenting neurological manifestation in myeloid leukemia. ChloromaA 14-year-old schoolgirl presented with progressive weakness of both lower limbs of two weeks duration associated with numbness of both lower limbs, which ascended up to lower chest region. She was having back pain for the last one month for which she consulted local hospital. Later, she developed bladder symptoms as hesitancy, and urgency for the last one week. No upper limb weakness or cranial nerve symptoms. No h/o fever, significant weight loss, or contact with tuberculosis was diagnosed.On examination, she was thin built and vitals were normal. Cranial nerve examinations including fundus were normal. Upper limb powers were normal while in lower limbs she had grade 1 power in both lower limbs. Tendon reflexes were absent in lower limbs with bilateral extensor plantar response. She had a sensory level at D4 with spinal tenderness at mid thoracic region. Other system examinations were normal.Investigations done showed hemoglobin 13 gm%, total count 8,400, polymorph 60%, and lymph 40%, with high erythrocyte sedimentation rate (ESR) of 130. Chest x-ray was normal. Lumbar Cerebrospinal fluid (CSF) study showed: Total count of 104 cells/mm with 90% lymph, protein 802 mg/dl, and glucose 56 mg/dl. Gram stain, AFB stain, cultures, and cytology for malignant cells were negative. Magnetic resonance imaging (MRI) showed extensive epidural lesion extending from D3 to D11, hypointense in T1 , hyperinParaplegia, as the initial presenting feature of acute myeloid leukemia, is very rare. Chloroma should be considered in the differential diagnosis of any epidural mass in patients with or without leukemia. Granulocytic sarcoma occurs in 3 to 9% of AML cases. Rarely cIn our patient, paraplegia due to chloroma as the initial presenting feature of AML, is very rare. MRI usually shows epidural mass lesion compressing the cord, isointense with cord in T1, and hyperintense in T2-weighted images. The differential diagnosis includes epidural abscess, metastasis, and lymphoma deposits. Lymphoma usually shows epidural extension of tumor directly from vertebral body and inhomogeneous hyperintense signals in T2 images of vertebral body due to marrow infiltration, which is not seen in chloroma. CSF cytology for malignant cells will be negative in extradural compressive myelopathy due to chloroma as in our case.Granulocytic sarcomas are usually radiosensitive and are often treated with local radiotherapy and chemotherapy.7 Newly d7


Torsion of gallbladder is an uncommon cause of acute abdomen. Volvulus occurs along the long axis of the gallbladder mesentery, and according to the degree of rotation symptoms, and signs may vary.A 79-year-old woman presented with a one-day history of acute onset of right upper abdominal pain. The patient underwent laparotomy with a preoperative diagnosis of acalculous cholecystitis with possible gangrene. At laparotomy, the gallbladder was distended, and multiple necrotic areas were observed. It was rotated more than 180 degrees clockwise around the mesentery, and cholecystectomy was performed.Cholecystectomy is the treatment of gallbladder torsion. Clinical signs and radiographic studies may be helpful to diagnose gallbladder torsion. Early diagnosis and surgical treatment lower the mortality of disease. Torsion of the gallbladder is an uncomon condition, which can cause acute surgical abdomen. It was first described by Wendell in 1898. Since then approximately 300 cases have been reported in the literature . We repoA 79-year-old woman presented with a one-day history of acute onset of right upper abdominal pain. Nausea, and vomiting were also present. The vital signs were normal. Examination revealed a very tender mass in the right upper quadrant of abdomen. Laboratory investigations, including complete blood cell count, and liver function tests were within normal limits.Abdominal ultrasound (US) examination showed a distended gallbladder, thickened gallbladder wall and fluid collection around the gallbladder. Ultrasonographic Murphy's sign was positive.No stones were detected by US. Computed tomography (CT) of the abdomen showed that the gallbladder was not within the normal anatomical liver fossa. The wall was thickened, and at one point the integrity of the wall was lost. Fluid collection all around the gallbladder indicated a "floating gallbladder" and well-enhanced curvilinear structure on the right side of the gallbladder indicating cystic duct were also identified. Diffuse edematous smooth thickening of the gastric antral wall was observed which was compatible with secondary inflammation Figure  and 1b. The patient underwent laparotomy with a preoperative diagnosis of acalculous cholecystitis with possible gangrene. At laparotomy, the gallbladder was distended, and multiple necrotic areas were observed. It was rotated more than 180 degrees clockwise around its mesentery, and there were no gallstone in gallbladder Figure . CholecyAcute torsion of the gallbladder is an uncommon condition, characterized by rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. It is more frequent in elderly patients, The female-to-male ratio is reported to be 3:1 in adults and 1:4 in the pediatric age group ,3.The etiology of gallbladder torsion is not well known however, the long gallbladder mesentery, and minimal attachment of the gallbladder to the liver facilitate rotation. The loss of visceral fat, and elasticity, liver atrophy, spinal deformities and weigth loss are predisposing factors that accelerate volvulus of gallbladder ,4. In thTwo types of gallbladder torsion have been described: incomplete (rotation less than 180 degrees), and complete (rotation more than 180 degrees) . PresentPreoperative diagnosis of gallbladder torsion is difficult. Clinical presentations are common to other intraabdominal conditions . The diagnosis is usually confirmed at laparotomy. The reported findings of gallbladder torsion at US include a floating gallbladder, and thickened gallbladder wall . HoweverCholecystectomy is the treatment of gallbladder torsion. Both open and laparoscopic techniques are available for the cholecystectomy. Laparoscopic detorsion and cholecystectomy offers advantages of the minimally invasive surgery . ClinicaUS: Ultrasound; CT: Computed tomography.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.I declare that I have no competing interests.KC performed surgery and writer of manuscript. AP performed surgery and interpreted the patient data. ZK performed and interpreted radiological examinations. TZN reviewer of manuscript.


A 42-year-old female who had her right index finger amputated 13 months back now presented to the department of gastroenterology with symptoms of abdominal pain and bleeding per rectum. On examination the patient had iron deficiency anemia and features of cachexia. Upper gastrointestinal (GI) endoscopy and colonoscopy were done but did not reveal any lesion. The patient underwent computed tomography (CT) scan on a Siemens 64-slice CT scanner, which showed multiple rounded, markedly enhancing, small gut  lesions, along with an enteroenteric intussusception [Figures What is the probable close differential diagnosis?What is the appropriate diagnostic modality in such patients?What treatment should be offered to this patient?Malignant melanoma metastasis to jejunum leading to intussusception.CT enterography.Palliative resection (enterectomy with end-to-end anastomosis), along with chemotherapy and immunotherapy, is the procedure of choice in patients with this condition.Cutaneous melanoma is a malignancy characterized by a high mortality rate. It can metastasize to all organs, though the GI tract is an unusual metastatic localization. In fact, in 50% of cutaneous melanomas, metastases in the GI tract are diagnosed upon autopsy; in only 5% of cases are they diagnosed clinically.2 The sma5Our case had abdominal pain with mild bleeding per rectum, which is extremely rare with metastasis to the intestine.13 We sug


A 33-year-old woman sought medical attention for a painful swelling of the leftankle. Plain radiographs revealed an osteolytic lesion involving the left distal tibia.An excisional biopsy provided the diagnosis of leiomyosarcoma in the tibia. Astaging work-up was performed and an abdominal CT showed 4 liver hypodenselesions in both lobes with peripheral contrast enhancement. A liver biopsyconfirmed the diagnosis of epithelioid hemangioendothelioma of the liver. Noassociation between these two entities has been described before. This caseintroduces the importance of the pathological confirmation of apparent metastaticlesions in low grade sarcomas and provides a review of the literature of bothtumours. Primary leiomyosarcoma of the tibia and epithelioid hemangioendotheliomaof the liver are rare soft tissue sarcomas with few cases reported. No association between these two clinical entities has been described before. This case introduces the importance of the pathological confirmation of apparent metastatic lesions.A 33-year-old woman sought medical attention for a two-month progressivepainful swelling of the left ankle. Plain radiographs revealed a 5 cmosteolytic lesion involving the left distal tibia metadiaphysis with cortical destruction and no periosteal reaction . An exciThe woman sought medical attention at our hospital. Due to the atypicalclinical presentation and course, a liver biopsy was performed. Macroscopically there was a white, firm lesion. Histologically the tumor was composed of a fibrous stroma, with myxohyaline areas, as well as epithelioid and dendritic cells containing intracellular vacuoles. Immunohistochemistry revealed positive staining for endothelial markers CD31 and CD34, cytokeratin (AE1 and AE3), and vimentin. Smooth muscle actin (HHF and 1A4), desmin, and S-100 protein staining were negative. The pathological diagnosis was consistent with epithelioid hemangioendothelioma. Both pathological samples were compared by two different pathologists confirming the coexistence of two distinct pathological entities. Chemotherapy was no longer continued, and a watch and wait policy was assumed. The patient is four years later under close follow-up with no evidence of progression of the epithelioid hemangioendothelioma of the liver and no signs of recurrence of the leiomyosarcoma in the tibia.Primary leiomyosarcoma of the bone is a very rare tumor first reported by Evans and Sanerkin . Many caEpithelioid hemangioendothelioma is an infrequent soft tissue tumor of vascular origin. It was first described in the lung by Dail and Liebow . Initial


Colorectal cancer is extremely rare in children. We report a case of a 12-year-old boy who presented with a five-month history of weight loss and anorexia, associated with vomiting episodes, dizziness, fatigue, and dyspnea. On physical examination, a palpable abdominal mass was noticed on the right hypochondrium and flank. An imaging study was performed, which showed a solid mass on the right colon. The patient underwent incisional surgical biopsy, and subsequent histopathologic analysis revealed a colon mucinous adenocarcinoma. Pediatric colon adenocarcinoma represents less than 1% of all neoplasms in the first two decades of life . HistoloA 12-year-old boy presented with a five-month history of significant weight loss (5 kg in one month) and anorexia, associated with vomiting, dizziness, weakness, and dyspnea. On physical examination, a palpable abdominal mass was noticed on the right hypochondrium and flank. The patient was also slightly pale, and a systolic murmur was observed by cardiac auscultation. Blood tests showed microcytic and hypochromic anemia and eosinophilia as the only abnormalities. The patient was negative for both acid-alcohol resistant bacillus and human immunodeficiency virus.An abdominal X-ray showed a soft-tissue mass with no calcification, on the right flank and mesogastrium, with inferior deviation of the bowel A. Based Based on the imaging findings, computed tomography (CT) was performed on the abdomen. The scan confirmed the presence of an infiltrating tumor, with slight enhancement from the contrast media, located on the right colon wall, extending from the cecum to the hepatic flexure. The adjacent meso and abdominal wall were also involved. Mesenteric hypodense masses that might correspond to neoplastic implants were observed C. Chest The patient underwent a right hemicolectomy, with an end-to-end anastomosis between the ileum and the transverse colon . During Colon adenocarcinoma is a rare tumor in pediatric patients, with an incidence of one in one million , 2. ThisHistologically, mucinous adenocarcinoma is the most common histotype in pediatric colon cancer , 3–5. ThBarium enema studies suggest that colon carcinomas in adults are generally small polypoid masses (early carcinoma), irregular annular lesions with abrupt margins, or large intraluminal masses –9. By USIn this case, disease was at advanced stage at diagnosis, with CT and US exams showing a large mass in the right colon wall, causing significant reduction and irregularity of the lumen, and infiltrating the mesenterium and adjacent abdominal wall, consistent with the literature. Enlarged lymph nodes were also identified.Prognosis in colorectal cancer is usually determined by the degree of intestinal wall invasion, lymph node involvement, and hematogenous metastases. For this reason, early detection increases the chance of cure. Therefore, the rarity, low level of suspicion, and aggressive histological type normally seen in children can lead, in most cases, to late diagnosis and poor prognosis.In our case, imaging revealed extensive metastatic disease, disseminated throughout the peritoneal cavity, reflecting the delay in diagnosis that is described in the literature in similar cases. These findings were confirmed during surgery, which determined the impossibility of curative resection, and led to a poor prognosis, despite adjuvant therapy.


Composite tumors of the adrenal medulla or paraganglia are extremely rare and present a diagnostic dilemma. These tumors consist of a neuroendocrine component mixed with a neural component.We describe the imaging characteristics together with the corresponding pathological findings of a composite tumor. Apart from any component-specific imaging findings, the hallmark of this entity is the presence of histologically distinguishable components.A 61-year-old Caucasian man was referred to our hospital due to a suspect lesion found on chest computed tomography carried out for unclear thoracic pain. An abdominal computed tomography scan and ultrasound examination detected a retroperitoneal tumor comprising two different tumor components. Twenty-four-hour urine revealed high levels of normetanephrine, characteristic of a neuroendocrine tumor. An octreoscan prior to surgical procedures revealed multiple osseous and intra-hepatic metastases. The final histopathological workup revealed a composite paraganglioma with neuroblastoma. Our patient died ten months after the initial diagnosis from tumor-associated complications.Composite paragangliomas with neuroblastoma are rare tumors of the retroperitoneum. Such tumors should be considered in the differential diagnosis of retroperitoneal masses. Composite tumors of the adrenal medulla or paraganglia are extremely rare. Pheochromocytomas arising from outside the adrenal glands are called paragangliomas. Paragangliomas are more common in the head and neck region than in the retroperitoneum. The synonym mixed neuroendocrine-neural tumor implies that these tumors consist of a neuroendocrine component (paraganglioma or pheochromocytoma) mixed with a neural component  .We present the ultrasound and computed tomography (CT) findings of a metastatic composite paraganglioma with neuroblastoma presenting as a retroperitoneal mass in correlation with the macroscopic and microscopic pathological findings.A 61-year-old Caucasian man underwent a chest CT due to unclear right-sided thoracic pain. In addition our patient complained of abdominal cramps. Examination suggested a retroperitoneal mass seen on the most caudal CT slices. He was referred to our hospital for abdominal ultrasound, showing a 11 cm large retroperitoneal tumor located right and ventral to the abdominal aorta  in a 24-hour urine test, clinically proving a neuroendocrine tumor of the pheochromocytoma/paraganglioma family. Unaware of this differential diagnosis, an endosonographic-guided transduodenal fine needle aspiration was performed confirming the diagnosis. Fortunately no hypertensive crisis occurred.In addition, intra-hepatic metastases were seen on the initial CT scan and a subsequent octreoscan also revealed the presence of intra-osseous metastases. On contrast-enhanced CT the liver metastases had a slight early arterial enhancement with a reduced wash-out during the venous phase. On ultrasound the liver metastases were not well delineated, but appeared slightly hypo-echogenic compared with the surrounding liver tissue. Contrast-enhanced ultrasound was not performed. The CT findings, in particular, would be consistent with metastases from a neuroendocrine tumor.The presence of metastatic disease precluded a curative resection. However, local resection of the tumor was undertaken for symptomatic relief.Macroscopically the partially resected tumor Figure  reflecteMicroscopically, the encapsulated paraganglioma showed the typical Zellballen growth pattern, an elevated mitotic activity (Ki-67) of up to 50%, necrosis and vascular invasion. The small blue round cells of the neuroblastoma component displayed a highly proliferative (around 90%) and broadly infiltrative growth pattern and lymphovascular invasion was seen Figure . ImmunohThere was no evidence for an amplification of the prognostic oncogene N-myc. Tumor metastasis of the neuroblastoma component was histologically confirmed by lymph node and skin biopsies.Subsequently, our patient was treated with palliative chemotherapy and radiotherapy beginning with three cycles of carboplatin aqueous solution and etoposide phosphate. On tumor progression palliative radiotherapy with 10 × 3 Gray at multiple locations followed. Subsequently chemotherapy with CHOP  was started and finally (after two months) changed to a weekly dose of docetaxel with prednisone. Ten months after the initial diagnosis our patient died of cancer-related pulmonary embolism and pneumonia.The paraganglia are widely dispersed collections of specialized crest cells that lie adjacent to the sympathetic ganglia and plexuses throughout the body . Tumors Pheochromocytomas or paragangliomas can occur sporadically or in association with inherited conditions . Sporadic forms are usually diagnosed at age 40 to 50, whereas hereditary forms are diagnosed earlier ,4.The clinical manifestations of pheochromocytoma result from the known physiologic effects of catecholamine release. The classic triad of headache, palpitation, and excessive sweating is seen during the paroxysmal hypertensive crisis. Urinary normetanephrine or vanillylmandelic acid levels are elevated in over 90% of patients from whom 24-hour urine collections are obtained . Recent If laboratory test results indicate a pheochromocytoma, CT imaging of the adrenal gland as well as of the organ of Zuckerkandl, to encompass all chromaffin cell-bearing tissue along the lower abdominal aorta from the origin of the inferior mesenteric artery to the aortic bifurcation and into the iliac vessels, is often helpful to locate the tumor. On CT, both pheochromocytomas and paragangliomas usually measure 3 cm or larger, demonstrate areas of necrosis or hemorrhage, and may even contain fluid. Due to the danger of a hypertensive crisis, suspected paragangliomas/pheochromocytomas should not be biopsied prior to surgery.Generally, paragangliomas have a more aggressive course than their adrenal counterparts. Dissemination occurs via both the lymphatic and hematogenous routes, with the most common sites of metastasis being the regional lymph nodes, bone, liver, and lung . With thNeuroblastomas are malignant tumors that consist of primitive neuroblasts and may arise anywhere within the sympathetic plexus or adrenal medulla. Two-thirds of neuroblastomas are located in the abdomen, and approximately two-thirds of these abdominal lesions arise in the adrenal gland . NeuroblIn composite paragangliomas, a less-differentiated neuronal component seems to be the leading prognostic feature since metastases occur more often from this component. Accordingly, in our case the metastases were of neuroblastoma-type. Both, the neuroendocrine and the neuronal component are thought to be derived from common chromaffin precursor cells by aberrant differentiation. A deletion of the succinate dehydrogenase subunit B gene has recently been associated with composite paraganglioma with neuroblastoma .On CT, the appearance of the paraganglioma was characterized by relatively sharp outlines and intratumoral heterogeneity with anechogenic lesions, hypoechogenic components, small calcifications and hypervascularization corresponding to the blood-filled cysts and necrotic debris in the macroscopic section. The neuroblastoma was irregularly shaped, lobulated, and not encapsulated.Having said this, the different possible components of composite paragangliomas clearly imply that these tumors cannot be defined by a single specific imaging pattern but rather by the existence of such different components which subsequently can be correlated to certain morphologic tumor subtypes. As in our case, laboratory data could be of great differential diagnostic help.Little information is available about the outcome of composite paragangliomas because of their rarity. Some reports have described indolent behavior . HoweverThe treatment of these patients includes surgery and chemotherapy according to the most aggressive tumor component as well as prolonged follow-up due to possible late metastases.Composite paragangliomas with neuroblastoma are rare tumors of the retroperitoneum. However, such tumors should be considered in the differential diagnosis of retroperitoneal masses. Imaging does not allow a differentiation between benign and malignant tumors, but may assist in pre-operative planning. As these tumors are very rare, there is only limited knowledge about treatment and outcome. In the absence of metastases a resection should be considered.The authors declare that they have no competing interests.TF and SK analyzed the clinical and radiological data. FRF and PKB analyzed and interpreted the pathological data. TF and FRF wrote the main parts of the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's next of kin for the 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.


Although GIST generally occurs in the digestive tract, such as the stomach, and small and small intestine primarily, Omental GIST tumours are very rare.A 63-year-old male patient, who recognized an abdominal tumor 1 year before admission, had a slight expansion of the tumor, reduction of the body and malaise, was consulted to our hospital. Abdominal CT and MRI revealed a cystic lesion of 26 cm in diameter with a clear boundary from immediately below the interseptum to the pelvic cavity, and imaged the septum and cystic wall. We considered that the patient had a cystic tumor in the abdomen, of which the primary lesion was unknown, and scheduled surgery. The patient unfortunately deteriorated with shock and sudden pain in the abdomen. Wediagnosed tumor rapture, and emergency surgery was performed. The tumor, weighing 3,600 g, was mostly cystic, and filled with sanguinous fluid and clot. Histologically, the tumor was composed of spindle cells, and was positive for c-KIT (CD117), slightly positive for alpha-smooth muscle actin (SMA), and S-100 protein positive. Based on these findings, the tumor was diagnosed as GIST primarily occurring in the greater omentum.We experienced a rare case of GIST which originated from the greater omentum. Recently, the prognosis of GIST has been improved since the treatment with Imatinib.It is necessary to consider the diagnosis of GIST on encountering a mass in the greater omentum. Tumours occurring in the greater omentum are rare, and diagnosis of such lesions is difficult. Tumours with the immunohistochemical characteristics of gastrointestinal stromal tumor (GIST), of which the primary lesion is in the greater omentum, have recently been reported. Generally, GIST occurs in the digestive tract, and the incidence of primary GIST lesions in the greater omentum has been reported to be less than 1%. We describe a patient with massive GIST occurring primarily in the greater omentum, which subsequently ruptured spontaneously during the observation period, necessitating emergency surgery.A 63-year-old male, who recognized an abdominal mass 1 year before this admission, presented with a slight expansion of the tumor, weight loss of 5 kg in 3 months, and malaise. A massive non-tender abdominal tumor was palpated. Haematological examination found anaemia and high levels of CRP and LDH, while the levels of CEA, CA19-9, and AFP were within the normal ranges.Abdominal ultrasonography found microcyst clumps and some solid areas in the periphery of the lesion. Fig.  AbdominaHematological examination showed no aggravation of anemia.We considered that the cystic tumor had ruptured, and performed emergency surgery on the day. There was about 2,000 ml of sanguinous ascites in the abdominal cavity, and a rupture about 4.5-cm long was observed on the right side of the tumor. Fig.  Based onGenerally, GIST occurs primarily in the digestive tract, such as the stomach, and small and large intestine, and the incidence of the primary GIST lesion in the greater omentum is very unusual. Among mIt has been reported that GIST in the mesentery and greater omentum, structures which lack ICCs, are derived from mesenchymal cells that are less differentiated than ICCs, ICC preA single patient with spontaneous rupture of GIST in the greater omentum during the observation period has been reported by Shingu et al . They coThe authors declare that they have no competing interests.NY Documented and prepared the draft. HO: Contributed towards revising the manuscript critically and has given final approval for the version to be published, KM Literature search and edited part of the manuscript. TB Edited part of the manuscript and interpreted the radiological images. HS Literature search and edited part of the manuscript. IN Revision of bibliography and edited part of the manuscript. HK Examined the surgical specimen and provided the histological photographic slides. TA Contributed towards conception, design, analysis and interpretation of data. TN Contributed towards conception, acquisition of data and preparation of the draft. TJ Contributed towards revising the final manuscript critically. All authors read and approved the final manuscript.


A 52 year-old woman presented with an incidentally detected retroperitoneal angiosarcoma and multiple hepatic metastases. After chemotherapy with weekly paclitaxel and doxorubicin, angiosarcoma had progressed rapidly. Because few chemotherapeutic options were available for her, sunitinib  as a salvage regimen was administered. Although sunitinib was interrupted after two weeks due to hematologic abnormalities, some metastatic nodules were regressed. Therefore, sunitinib was recommenced at a reduced dose . Serial computed tomography scans showed variable response in each tumor, however, sunitinib at least delayed tumor progression, compared to previous chemotherapy. With this case report, we suggest sunitinib may be effective against angiosarcomas. When sunitinib is administered to patients with angiosarcomas, hematologic abnormalities should be monitored frequently as severe hematologic toxicity may be caused either by sunitinib per se or angiosarcoma. Angiosarcomas are rare subtypes of soft tissue sarcomas originating from the vascular endothelium, and commonly occur in skin and soft tissues . The cliA 52 year-old woman presented with an incidentally detected retroperitoneal mass and multiple liver nodules. Her initial computed tomography (CT) and positron emission tomography (PET) scans showed a huge retroperitoneal mass with direct invasion into the spleen, pancreas tail, and stomach, and three metastatic hepatic nodules. The size of the retroperitoneal mass was 12.5 × 10 cm and the dimensions of the hepatic metastases were 4.4 × 4.1 cm in segment IV, and 2.5 × 1.9 cm and 1.2 × 1.1 cm in the right posterior segment. Percutaneous needle biopsy of a hepatic nodule was performed. In histology, irregular and sinusoidal vascular proliferation, atypical endothelial lining, and undifferentiated tumor cells were noted. These findings were consistent with angiosarcoma. This is supported by immunohistochemical study that shown tumor cells were positive for CD 31 and CD34.2, on days 1, 8, 15, and 22, every 6 weeks) was administered as first-line chemotherapy. Our patient tolerated this regime well; no significant toxicities were observed. After one cycle of paclitaxel, a CT scan . In a follow-up CT scan  as a salvage regimen. After 2 weeks of sunitinib, the patient presented to the clinic with severe asthenia, and chemotherapy was interrupted. A laboratory investigation revealed grade 4 thrombocytopenia, grade 3 anemia, fragmented RBCs in the peripheral blood smear, and decreased levels of both serum haptoglobin and fibrinogen. Prothombin time was within normal limits. These data supported a diagnosis of microangiopathic hemolytic anemia (MAHA). The hematologic abnormalities were suggestive of the Kasabach-Merritt phenomenon (KMP), except that coagulopathy was absent. One month later, the thrombocytopenia and anemia had regressed. At that time, a CT scan yielded interesting findings. Some of the numerous scattered hepatic nodules had disappeared, whereas others showed no change in size, and the size of the retroperitoneal mass had also decreased, with evidence of internal necrosis, although two hepatic masses in the right posterior segment had progressed slightly. When we considered the prolonged interruption to treatment caused by toxicity, and the rapid rate of progression prior to the introduction of sunitinib, we formed the view that sunitinib was active against our patient's tumors. Therefore, we recommenced sunitinib treatment, but at a reduced dose . Although grade 2 thrombocytopenia and MAHA reoccurred, these toxicities were less severe than before. On monthly CT scans, some hepatic metastases and the retroperitoneal mass responded to sunitinib. However, two hepatic metastases of the right posterior segment further progressed; it was thus difficult to interpret any overall chemotherapeutic effect of sunitinib. To evaluate any antitumor activity on the two hepatic masses, gross tumor volume was measured on serial CT scans  and the After an additional 3 months of sunitinib therapy, recurrent hematologic toxicities associated with MAHA/KMP and concomitant deterioration of the patient's general condition caused chemotherapy to be interrupted. Two months later, the patient died of tumor invasion to her heart and inferior vena cava, about 11 months after initial diagnosis.Angiosarcomas are derived from vascular endothelial cells and account for less than 2% of soft tissue sarcomas . The medRecently, tyrosine kinase inhibitors (TKIs) have emerged as novel agents in the treatment of soft tissue sarcomas . There aDuring treatment with sunitinib, our patient suffered from severe thrombocytopenia and MAHA. Although sunitinib suppresses bone marrow function, and a single case report of sunitinib-induced thrombotic thrombocytopenia purpura has appeared , it is dIn this case report, our patient had advanced angiosarcoma and her clinical features suggested the worst possible outcome . The tumIn conclusion, this is the first case report indicating that sunitinib may be effective against angiosarcomas. When sunitinib is administered to patients with angiosarcomas, hematologic abnormalities should be monitored frequently as severe hematologic toxicity may be caused either by sunitinib per se or angiosarcoma. Further studies are needed to explore sunitinib efficacy in angiosarcoma treatment.


Most bladder tumors are derived from the urothelium. Benign mesenchymal tumors are rare. Leiomyoma of the bladder is the most common benign neoplasm. We present a case of leiomyoma of the bladder presenting with acute urinary retention in a female patient and report on the post-operative change in urodynamic findings. To our knowledge, few cases of this kind have been reported.A 56-year-old woman presented with acute urinary retention. Evaluations including ultrasound, magnetic resonance imaging, cystoscopy, and urodynamics contributed to a diagnosis of leiomyoma of the bladder. Various medications were ineffective for solving her lower urinary tract symptoms; therefore, a transurethral resection was performed. The final pathological report was leiomyoma. After the operation, her symptoms resolved; this improvement was confirmed by an urodynamic analysis. The postoperative urodynamics demonstrated a lower frequency of detrusor overactivity during filling cystometry and an increase in the uroflow rate, with reduced detrusor pressure in a pressure flow study.Leiomyoma of the bladder can cause female outlet obstruction. A review of the literature and disease management is discussed. Most bladder tumors are derived from the urothelium. Benign mesenchymal tumors are rare and comprise 1 to 5% of all bladder neoplasms . ApproxiA 56-year-old woman presented at our hospital with an episode of acute urinary retention. She also complained of urinary frequency and urgency for the past 4 months. A physical examination did not reveal any particular findings, including pelvic organ prolapse. The results of a laboratory evaluation were within the normal limits. The urinary cytology was class II. In our cytology system, a scale of 1 - 5 was used. An ultrasonography detected a round mass in the bladder and no signs of hydronephrosis. A cystoscopy revealed a smooth surface and an intact mucosa tumor at the bladder neck. Magnetic resonance imaging (MRI) demonstrated a homogenous mass measuring 2.7 cm in diameter occupying the space between the bladder neck and the anterior vaginal wall. The tumor was homogenously enhanced after the injection of gadolinium  indicated female bladder outlet obstruction (BOO), but the post-operative PFS did not  urodynamic studies (UDS) in this patient. The number of involuntary detrusor contractions decreased from 3 to 1 during a filling cystometry, and the values of first desire to void volume and maximum desire to void volume increased. Preoperatively, she voided with a QMesenchymal tumors of the bladder, especially leiomyomas, are a relatively rare and heterogenous group of neoplasms arising from the mesenchymal tissues normally found in the bladder and constitute 1 to 5% of all bladder neoplasms .About 250 cases of leiomyoma of the bladder have been previously reported in the English language scientific literature . The incLeiomyoma of the bladder can be totally asymptomatic or can present in a varied manner depending on the location of the tumor with obstructive symptoms (49%), irritative symptoms (38%), hematuria (11%), and flank pain (13%) . NineteeUltrasonography, MRI and cystoscopy are valuable diagnostic tools that can depict the morphology and anatomic location of leiomyomas. MRI is especially useful. Non-degenerative leiomyomas are usually visualized on MRI as low-intensity masses both on T1 and T2 weighted sequences with a smooth surface, while degenerative leiomyomas have a heterogenous signal intensity . A variaGenerally, the treatment for leiomyoma of the bladder involves a simple excision of the tumor. These lesions are sometimes resected transurethrally or transvaginally, but open surgery  has also been reported. There are only a few reported recurrences and none of malignant degeneration . therefodet is still relatively high. The high PdetQmax after TUR is difficult to explain. At our institute, the normal PdetQmax (average ± SD) value for healthy women is 26 ± 8 cmH2O. We generally perform a PFS twice and compare the non-tubed uroflowmetry results for each patient. Therefore, this high PdetQmax value was reproducible. We speculate that the existence of an anatomical or functional urethral stricture may explain the high PdetQmax value. We did not feel any resistance during the insertion of a 22-Fr cystoscope; therefore, an anatomical urethral stricture is unlikely. Thus, a functional urethral stricture might have caused the high PdetQmax value, although we did not perform a video-urodynamics study to confirm the presence of a functional urethral stricture.Recent literature on BOO in women suggest that this condition might be more common than previously thought . LeiomyoLeiomyoma of the bladder can cause female outlet obstruction. Preoperative urodynamic assessments of this condition should permit a greater understanding of this unusual clinical entity.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.TUR: transurethral resection; LUTS: lower urinary tract symptom; MRI: Magnetic resonance imaging; UDS: urodynamic studies; PFS: pressure flow study; BOO: bladder outlet obstructionThe authors declare that they have no competing interests.MM drafted the first manuscript. MM, HA and HS cared for the patient. HY helped to draft the manuscript. All authors reviewed the report and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2490/10/13/prepub


Pilomatrixomas are uncommon in children and are frequently misdiagnosed preoperatively. We report a two-year-old female patient with an unusual localization in the earlobe. The lesion was treated by simple enucleation and in two years of follow-up there has been no evidence of recurrence. The case is being reported in view of its rarity and unusual location. Pilomatrixomas are uncommon tumors which are frequently misdiagnosed preoperatively. The tumor usually appears in the first two decades of life and is commonly located in the head and neck region.2 Few casA two-year-old girl presented with a firm swelling in the earlobe of eight months duration. There was history of trauma to the area. Initially, the swelling was red and painful; hence, patient was thought to have an abscess and treated with systemic antibiotics but in vain. Lesion gradually increased in size and there was spontaneous resolution of redness.Examination of the left earlobe revealed a non-tender, firm, well-circumscribed, freely mobile nodule located below the right ear nodule . The ovePilomatrixoma is a relatively rare, benign skin tumor arising from the hair follicle. Pilomatrixoma occurs at any age, but is most common in children under the age of ten. Women2]2] and WhAlthough pilomatrixoma is common in the head and neck region,2 it can 5Pilomatrixoma develops from an abnormal formation of cells that are similar to hair cells, which become hardened or calcified. The etiology is not completely understood, though the role of activating mutation in the b-catenin gene mapped to Chromosome 3p22-21.3 has been reported.8 Pilomat12Biopsy is the gold standard for diagnosis of this condition; fine neeThe treatment of choice is local excision.2 Recurre10Physicians, otolaryngology's, dermatologists and surgeons should be familiar with this entity of pilomatrixoma and consider it in the differential diagnosis of superficial or calcified subcutaneous masses in the auricular region.