An increased risk of posttransplant malignancy has been consistently reported following various solid organ transplants. The malignancies most commonly encountered are non-melanoma skin cancers, carcinomas of lung or breast and posttransplant lymphoproliferative disorders. Angiosarcoma, an uncommon vascular mesenchymal neoplasm, is rare in the posttransplant setting. This report describes two patients who developed high-grade angiosarcoma following a solid organ transplant. Notably, in both patients, the diagnosis of angiosarcoma was preceded by diagnosis of a lymphoproliferative disorder with monoclonal immunoglobulin heavy chain rearrangement. An increased risk of developing malignancy has been observed following solid organ transplantation, with rates and malignancy type closely related to the transplanted organ. The most common neoplasms encountered are non-melanoma skin cancers (NMSC). Significant increases in incidence of other common malignancies such as lung, breast, and renal cell carcinomas are consistently reported as well. While p62-year-old man with alcoholic cirrhosis initially treated with chemoembolization for hepatocellular carcinoma. He underwent orthotopic liver transplant in January 2006. Following transplant, he was maintained on the immunosuppressant tacrolimus. A routine surveillance MRI performed two years later (April 2008) revealed a 3.5 cm left adrenal mass. Systemic imaging, including PET/CT, reported an adrenal mass, splenomegaly 18 cm) and FDG-avid mesenteric and para-aortic lymphadenopathy. Biopsy of the left adrenal mass showed a post-transplant lymphoproliferative disorder (PTLD), consistent with an Epstein-Barr virus (EBV) negative, monomorphic, diffuse large B-cell lymphoma. Spinal fluid and bone marrow were both unremarkable. EBV DNA was undetectable by PCR. The tacrolimus dose was decreased by half, and the patient was started on CHOP chemotherapy  with rituximab. Interim evaluation with a PET/CT showed disease progression and treatment was switched to the ICE regimen  with rituximab. Autologous stem cells were harvested and stored after his ICE chemotherapy. Upon completion of chemotherapy, PET/CT demonstrated disease remission and bone marrow biopsy remained negative for lymphoma. Five months later, the patient developed a firm swelling of his upper lip. A biopsy revealed monophasic diffuse large-B-cell lymphoma with clonal heavy chain rearrangement. A PET/CT showed FDG avidity in the upper lip and sub-mandibular lymph node. Due to concern for significant local morbidity, he was treated with dexamethasone and a palliative course of radiation. In view of limited improvement, the radiation was discontinued after only four fractions. He then received 2 additional cycles of ICE with rituximab. In April 2009, the patient was admitted for autologous stem cell transplant, following etoposide, carboplatin and thiotepa conditioning. He tolerated the autologous transplant well, but a subsequent PET/CT showed continued FDG avidity in the upper lip. Local radiation therapy was resumed. Following stem cell transplant, he was maintained on rituximab every three months, the last of which was given in November 2010.In February 2011, he presented with dyspnea on minimal exertion, abdominal dissension, malignant ascites, and disseminated intravascular coagulation. Imaging revealed a cirrhotic liver, portal hypertension, and a new 23 cm hepatic mass with hemoperitoneum. Biopsy of the liver mass revealed highly atypical cells with hyperchromasia and markedly pleomorphic nuclei with prominent nucleoli and markedly increased mitotic activity including atypical mitotic figures . Following the transplant, she was maintained on rapamycin for immunosuppression. EBV DNA copies were not detected prior to transplant but quickly rose to 3,500 copies following transplant and upon initiation of immune suppression. Her viral level became undetectable on anti-viral therapy.In September 2012, she had a colostomy surgery due to abdominal distention and colonic dysmotility. At the same time, an enlarged left cervical node was noted, and a biopsy was performed. Pathology review of the specimen showed a focal increase in large B cell population, found to be distributed in loose nodules concerning for PTLD. Flow cytometry was attempted but failed due to the low cellularity of the specimen. However, a clonal immunoglobulin heavy chain gene rearrangement was detected by PCR, further supporting the possibility of PTLD. In November 2012, the patient noted rapidly increasing abdominal girth. CT imaging demonstrated ascites and a 4.8cm ill-defined soft tissue density in the left suprarenal area. In January 2013, she underwent resection of the left adrenal mass, a mass around the splenic bed, and of an abdominal deposit. Pathology of these areas showed high-grade angiosarcoma with positive surgical margins  developed de novo tumors, one of them being angiosarcoma. The majIn summary, the few reported patients with angiosarcoma and PTLD vary in type of transplanted organ, immunosuppression therapy and in seropositivity for a possible oncogenic virus. While the possible association of the rare post-transplant angiosarcomas with PTLD may suggest the presence of underlying host variables predisposing the recipients to develop post-transplant malignancies, these are yet to be defined. Assessment of genetic abnormalities in these tumors in the future may inform the possible susceptibility conferring host variables.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.


A 45 year old female presented to the Department of Dentistry and Faciomaxillary Surgery complaining of difficulty in swallowing and tongue movements. General health examination revealed that the patient was conscious, oriented, a febrile and vitals were stable. Occlusion stable. Mouth opening was of three finger breadth. Lateral temporomandibular joint movements were satisfactory. On intra oral clinical examination, a pedunculated mass was observed palatally in relation to left maxillary molar teeth region, where a root stump was evident. Patient stated that the swelling has started as a pinpoint lesion before 1 year and progressed to the size of 5cm x 3cm as seen during clinical examination. The colour of the mass was of coral pink, smooth, nodular in some areas and symptomatic during contact between maxillary and mandibular teeth. Radiological investigations such as orthopantomograph and maxillary occlusal views revealed absence of bony involvement. To differentiate the clinical mimicking situation of intra oral fibroma and pyogenic granuloma, surgical excision was done followed by histopathological examination reporting as intra oral fibroma. Fibroma is of smooth surfaced painless solid mass, occasionally nodular, with collagen and connective tissue histopathologically. Whereas, pyogenic granuloma present as painless and smooth mass which bleeds on palpation clinically with histopathological picture of chronic inflammatory infiltrate, endothelial cell proliferation and hyperplastic granulation tissue. Postoperative review was after 1 month with good prognosis thereby facilitating efficient swallowing and tongue movements.


Conclusion. To our knowledge, this is the first reported case for endometriotic cysts (endometriomas) located in a huge cystic degenerated leiomyoma. PubMed search revealed no report concerning endometriotic implantation in the leiomyomas.Uterine leiomyomas are the most common pelvic tumor in women. Leiomyoma can show atypical locations and degenerations and may not be easily differentiated from adnexal masses. Uterine leiomyoma can undergo cystic degeneration and is said to be found in 4% of all types of degenerations. The commonest type of degeneration is hyaline seen in 60% of patients. Usually uterine leiomyoma does not present as clinical and radiological diagnostic challenge. However, when leiomyoma undergoes massive cystic degeneration they may become clinical and radiological diagnostic dilemmas. The MRI showed a huge cystic mass protruding up to the pelvis not differentiated from bilateral endometriomas and accompanying subserous myomas. Surgery revealed that the mass is not bilateral endometriomas but a huge pedunculated leiomyoma with cystic degeneration and cystic endometriosis. Endometriosis is a troubling gynecologic condition occurring in 10% to 15% of women of reproductive age and is associated with fertility problems. As a peritoneal disease, the locations of endometriotic lesions are predominantly the ovaries (96.4%), followed by the soft tissue (2.8%), gastrointestinal tract (0.3%), and urinary tract (0.2%) and other rare locations. The presented case is multiple sized cystic endometriosis (endometriomas) located in a huge pedunculated subserous leiomyoma in an infertile woman having a history of laparoscopic bilateral endometrioma surgery. Leiomyoma is the most common benign gynecological tumor seen in women , 2.Leiomyomas are classified as submucous, intramural, and subserous according to their origin and the symptoms and signs differ according to the location , 2. LeioEndometriosis is a common gynecologic disease affecting 10% to 15% of reproductive age women and is associated with various degrees of fertility problems . EndometEndometriosis is a common, benign, chronic, estrogen-dependent disorder. It can be associated with many distressing and debilitating symptoms, such as pelvic pain, severe dysmenorrhea, dyspareunia, and infertility, or it may be asymptomatic and incidentally discovered at laparoscopy or exploratory surgery.These ectopic endometrial implants are usually located in the pelvis but can occur nearly anywhere in the body. The common locations of endometriosis are the ovaries, fallopian tubes, pelvic peritoneum, and uterosacral ligaments , while the atypical sites of endometriosis include the gastrointestinal tract, urinary tract, soft tissues, and chest, nose, and incisional sites  . EndometEndometriosis at locations outside the pelvis is explained by dissemination of endometrial cells or tissue through lymphatics and blood vessels.The coelomic metaplasia theory proposes that the coelomic  cavity contains undifferentiated cells or cells capable of dedifferentiating into endometrial tissue. This theory is based upon embryologic studies demonstrating that all pelvic organs, including the endometrium, are derived from cells lining the coelomic cavity.One hypothesis is that secretion of various cytokines by endometriosis implants and inflammatory cells into the peritoneal cavity leads to proliferation of implants, recruitment of capillaries , and chemoattraction of leukocytes to these foci of peritoneal inflammation . OxidatiEndometriotic implantation either by aspiration needle inoculation or by hypothetical invagination of endometriomas into the degenerated leiomyoma is an extreme rarity.46-year-old woman with 8 years of primary infertility was admitted to Clinart International Hospital for bilateral multicystic complex adnexal masses diagnosed 4 years ago as bilateral endometriomas. She had 7 IVF attempts and only in 3 cycles; embryo could be transferred with no clinical outcomes. She had a history of laparoscopic endometrioma surgery 8 years ago and endometriomas on both ovaries were aspirated and their capsules were excised together with the laparoscopic excision of a subserous myoma. Ca 12-5 and Ca 19-9 values had been high before the laparoscopic surgery. She had no other medical or surgical history and all biochemical serological and hormonal parameters were normal other than high Ca 12-5 and Ca 19-9 which supported the diagnosis of endometrioma.MRI investigation was carried out 2 years ago and bilateral endometriomas were reported without any radiological signs of malignancy. Patient was informed about the possible risks of malignant transformation of the adnexal masses at all times; she was admitted for fertility reasons but surgical intervention was rejected. All attempts for fertility were failed due to either the absence or diminished ovarian response to ovarian hyperstimulation by gonadotropins. Some cycles were monitored naturally with no collected oocytes. It was not easy to differentiate the follicular response by ultrasound and all oocytes retrieved from the follicles were aspirated through the endometriomas and endometriotic fluid was seen in the aspiration tubes. Oocyte retrieval (OR) by bypassing the endometriomas was not possible technically because the masses on both sides were huge and multilobulated and ovaries could not be discriminated easily. In two cycles the endometriomas were aspirated to reduce the size of the mass and to obtain oocytes easily under the suppressive antibiotherapy.She decided to have the surgical operation and admitted for surgery at 31.03.2015. Pelvic MRI , Ca 12-5The mass was well vascularised and adherent and a very thick vascularised adhesion was separated by electrocautery and sutured. Then the mass was taken out and it was a great surprise for all the team that the huge mass was originating from the anterior surface of the uterus just below the right corn and was evaluated as pedunculated degenerated leiomyoma with a thick pedicle.Thorough search of the uterus and ovaries revealed 4 subserous leiomyomas of different sizes and both ovaries were free from any endometriotic lesions and left fallopian tube was adherent to the posterior of the uterus. Left ovary was found atrophic and right ovary was found smaller than normal. No endometriomas or endometriotic lesions were seen on the ovaries, tubes, and the uterus. Multiple leiomyomas at different size were seen on the surface of the uterus and uterus myomatosis was diagnosed intraoperatively.She was supposed to have bilateral endometriomas for long time and the mass was misinterpreted as endometrioma both clinically and radiologically. The reason why the mass was interpreted as multilobulated bilateral endometrioma was due to the chocolate coloured aspiration materials seen in oocyte pick up procedures and also high Ca 12-5 and Ca 19-9 values. The mass was excised from the uterus by sharp dissection and the uterus was sutured with 1/0 Vicryl. Macroscopical evaluation of the mass at the operating theatre revealed multiple small nodules and a small leiomyoma seen on the surface close to the pedicle of the mass. Intraoperative evaluation showed multiple blue discolorations on the mass and no solid component was seen within the excised mass. The other leiomyomas were excised and sutured and the adherent left side tube was released from the uterus by sharp dissection and following hemostasis, irrigation, and aspiration, abdominal wall was closed layer by layer. Total amount of blood loss was 150 mL and the duration of operation was one and a half hours and no surgical and anesthesiological complications were observed. The pathology lab was informed verbally about the case and detailed information was given and aspirated fluid and the extirpated leiomyomas were sent to the pathology laboratory for cytological and pathological evaluation.Intraoperative and postoperative macroscopic figures are shown in Figures No malignant cells were elucidated from the peritoneal aspiration fluid.A mass weighed 1285 grams and 18 × 18 × 8 cm in size with smooth surface was evaluated and 10 × 7 cm surgical excision site was visualised together with nodular leiomyomas (one separated from the mass and another in size of 4 cm). The mass was excised sagittally and first impression of the mass was cystic degenerated leiomyoma with mucoid melting plus multiloculated cystic mass (12 × 8 × 7 cm in size) filled with sticky dark brown liquefied bloody fluid (chocolate cyst) .Endometrial glandular epithelial linings were found in the wall of blood filled wide cystic structures in the dissections of degenerated leiomyoma and multiple foci of endometriosis and wide range of old blood (hemosiderophages) were found in the leiomyoma Figures  and 8.Cystic endometriosis in degenerated leiomyoma  but may arise in nearly any anatomic site. In addition, unusual growth patterns may be seen, including benign metastasizing leiomyoma, disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis, parasitic leiomyoma, and retroperitoneal growth. However, some extrauterine leiomyomas may mimic malignancies, and serious diagnostic errors may result. The most useful modalities for detecting extrauterine leiomyomas are ultrasonography, computed tomography, and magnetic resonance (MR) imaging. The superb contrast resolution and multiplanar capabilities of MR imaging make it particularly valuable for characterizing these tumors, which usually show low signal intensity similar to that of smooth muscle on T2-weighted images. The radiologist's recognition of this and other characteristic features may help steer the clinician toward timely, appropriate management and away from unnecessary, potentially harmful treatment .Pedunculated cystic leiomyomas should be considered in the differential diagnosis of multiloculated cystic adnexal masses since sonographic and CT findings cannot differentiate these tumors from ovarian malignancy . TypicalHowever, cases that are extremely difficult to differentiate from other conditions are occasionally encountered. To understand the wide spectrum of MR imaging findings, such unusual appearances can be classified into three categories: degeneration and other histopathologic findings, specific types of unusual leiomyomas, and unusual growth patterns. The common types of degeneration are hyaline (>60% of cases), cystic (approximately 4%), myxoid, and red. Edema is not a phenomenon of degeneration but is a common histopathologic finding (approximately 50% of cases). Hemorrhage, necrosis, and calcification (approximately 4% of cases) may also be observed. Specific types of unusual leiomyomas include lipoleiomyoma and myxoid leiomyoma, which may have MR imaging features characteristic enough to allow differentiation from other gynecologic and nongynecologic diseases. Intravenous leiomyomatosis, metastasizing leiomyoma, diffuse leiomyomatosis, and peritoneal disseminated leiomyomatosis represent unusual growth patterns; other unusual growth patterns are retroperitoneal growth, parasitic growth, and the pattern that may occur in cervical leiomyoma. Because leiomyomas are the most common gynecologic tumors and are exclusively benign, it is important to be familiar with the variety of MR imaging appearances of uterine leiomyomas to distinguish them from other significant diseases .Endometrioma located mostly in the ovaries is a benign cystic tumor formed by the invagination of the cortex of the ovary. Invagination of the endometriotic lesions is the main phenomenon for the formation of endometriotic masses and this process is also seen in deep infiltrating endometriosis, especially in lower intestinal endometriosis lesions. Endometriotic lesions make the neighboring organs and tissues adhere to ovary to make conglomerated mass lesions as its nature.The implantation of the endometriosis into the degenerated myoma may be due to the inoculation of endometriotic cells by follicular aspirations during OR but we cannot explain the myth of the absence of endometriotic implants on pelvic organs or any remnants of the bilateral endometriomas on both ovaries since the patient had a history of laparoscopic surgery for bilateral endometriomas together with laparoscopic subserous leiomyoma extirpation. The invagination of the endometriomas from the needle insertion sites into the degenerated myoma might be the reason but this could be a probable hypothesis not the fact because the capsule of the leiomyoma was very thick.However the pedicle insertion site to the mass was very thin compared to the rest of the mass and one small leiomyoma and 3-4 soft nodules were seen at the insertion site. The biggest cystic endometriotic lesion was close to the edge of the capsule and that site was thin too.In one of the rarest disease leiomyomatosis peritonealis disseminata (LPD) endometriosis can coexist in some lesions and this may be explained due to submesothelial multipotent stem cells also called secondary Müllerian system and endometrium originates from the same epithelium; thus endometriosis can coexist with disseminated leiomyoma .Degenerated pedunculated leiomyomas can be misdiagnosed as adnexal masses both clinically and radiologically. Endometriosis can be seen in rare locations. Cystic endometriosis located in a huge pedunculated degenerated leiomyoma is an extremely rare endometriotic implantation and to the best of our knowledge this is the first case reported.


Pseudoaneurysms of the subclavian artery remain a rare complication after fracture of the clavicle. We report a case of delayed diagnosis of a subclavian artery pseudoaneurysm after a closed fracture of the clavicle in a 15-year-old patient, 3 months after the original injury while playing rugby union. Despite several attendances to the Emergency Department with vague symptoms, the final diagnosis was confirmed by duplex ultrasound and Computed Tomography of the thorax. Surgical repair was indicated due to acute limb ischaemia from distal embolisation from a large pseudoaneurysm, with the patient making a full recovery. This case highlights the need for clinical vigilance when assessing patients, particularly on repeated occasions when their recovery appears to be impaired. A thorough history and clinical examination can raise suspicion of even rare occurrences and aid prompt management. A 15-year-old boy attended the Emergency Department (ED) with a short history of a pale left arm. He denied pain but complained of some altered sensation throughout his left hand. He had a significant recent medical history, having suffered a fractured midshaft of his left clavicle see  managed Physical examination on his final visit revealed a warm but pale arm with no radial, ulnar, or brachial pulses palpable, but a normal capillary refill time of 2 seconds, and a reduced power in his intrinsic muscles of his left hand, but normal peripheral neurovascular examinations in remaining limbs and an electrocardiograph showing sinus rhythm. Chest X-ray confirmed no cervical ribs.A duplex ultrasound scan showed a loss of flow in the brachial artery below the left elbow, with thrombus partially occluding the artery. Also noted was a 3 cm abnormality in the left subclavian artery that was thought to be a subclavian aneurysm that contained thrombus.Subsequent Computed Tomography (CT) of the thorax Figures  and 3 coTransfer was arranged that day to the local acute vascular surgeon on call, where he underwent a subclavian-axillary bypass and brachial embolectomy. After 4 days of recovery as an inpatient including a heparin infusion he was discharged, symptom-free.The annual incidence rate of clavicular fractures is estimated to be between 30 and 60 cases per 100,000 people . NeurovaArterial rupture usually causes life-threatening haemorrhages and must be carefully ruled out by physical examination as well as diagnostic imaging. Physical examination of the upper limb must focus on skin color, temperature, sensation, hand function, and presence of upper limb pulses. Contrast CT represents a key diagnostic exam, while angiography offers both a diagnostic and a therapeutic approach.In 1983 Sturm and Cicero devised five criteria that lead the examining doctor to suspect an arterial injury . These cManagement options include both surgical and endovascular techniques. Surgical management remains a challenge and generally requires either a sternotomy or a supraclavicular and infraclavicular approach for safe proximal and distal control of the vessel. This approach risks significant blood loss and injuries to nearby neurovascular structures; nonsurgical options for management have been published and endovascular procedures including covered stents seem to reduce these risks but are often not available in the acute setting , 9. TheyWhile subclavian artery pseudoaneurysm remains a rare complication after fracture of the clavicle, this case clearly describes a prolonged series of symptoms that show how important are a detailed history and physical examination along with an open mind that can help reduce risks to patients life and limb.


We report a case of a 75-year-old female with a history of acute deep vein thrombosis (DVT) 6 years ago who presented with unilateral calf swelling and pain. D-dimer was normal, and compression ultrasound revealed findings typical of DVT, including an incompressible dilated and hypoechoic peroneal vein. Despite 4 months of anticoagulation for supposed recurrent DVT, pain symptoms persisted and repeat D-dimer and compression ultrasound were unchanged. A magnetic resonance imaging scan to investigate the leg demonstrated a 6-cm dissecting Baker’s cyst extending posterolaterally resulting in venous compression and distal dilation, which appeared to have been confused with a DVT. Ultrasound-guided aspiration of the cyst provided immediate and sustained relief. Herein we provide a review of the literature for the management of this rare scenario. DVT and ruptured Baker’s cysts are well known to be clinically indistinguishable, and the latter should be kept in mind when managing these patients emergently, as the initial diagnostic approach is the same, but treatment and complications are very different.4 The initial diagnostic approach consists of a clinical pretest assessment (Well’s score), D-dimer, and compression ultrasonography (CUS) of the leg, if D-dimer is indeterminate. The initial approach is more ambiguous when faced with a recurrent DVT, as no validated algorithm exists as to when to anticoagulate.5 Despite potential discrepancies in arriving at the diagnosis, it is paramount that it is the correct one, as the complications of a missed DVT or long-term unnecessary anticoagulative therapy both carry high morbidity. We report a case of an intact complicated Baker’s cyst both clinically and radiologically mimicking a recurrent DVT.The differential diagnosis for a unilateral swollen, painful lower extremity includes but is not limited to deep vein thrombosis (DVT), arterial insufficiency, Baker’s  cyst rupture, hematoma, lymphedema, thrombophlebitis, thromboangiitis obliterans, venous stasis dermatitis, popliteal aneurysm rupture, neural tumor, malignant histiocytoma, varicose veins, and cellulitis.A 75-year-old female with a history of chronic lymphocytic leukemia in remission for 23 years and left leg DVT in 2008, on estrogen replacement therapy (ERT) since 1962, presented with several months history of left calf pain. The pain was reproducible on palpation and intermittently accompanied by swelling and erythema. Physical exam demonstrated a 1.5-cm difference in circumference between the 2 calves, which were of equal temperature. Prior medical records indicated a positive D-dimer at 1.21 mg/L and acute thrombus on CUS in 2008, for which she received 6 months of anticoagulative therapy. Based on this and her continued estrogen intake, a recurrent ipsilateral DVT was suspected. A D-dimer assay was well within normal limits at 0.29 mg/L. CUS reported an acute thrombus in 1 of 2 left peroneal veins and an incidental intact 6 cm Baker’s cyst. The supposed thrombus was in the same location as the previous true one in 2008. The patient was taken off ERT and anticoagulated, with plans to continue this regimen indefinitely due to the unprovoked recurrence. Four months into treatment, however, the pain had still not entirely subsided. A repeat CUS interestingly again demonstrated identical findings, with no change in characteristic of the Baker’s cyst. The D-dimer again was within normal range. Magnetic resonance imaging to evaluate the Baker’s cyst revealed extension of the cyst inferolaterally as a lobulated ganglion/synovial cyst dissecting along the lateral margin of the medial head of the gastrocnemius muscle, without evidence of DVT . This wa6 Suspect recurrent cases are therefore directly triaged for CUS, which remains the gold standard because of cost-effectiveness, wide availability, its noninvasive nature and specificity approaching 100%.7 The added confounder in this case is ipsilateral symptomatology, which when confirmed on CUS should ideally have been reported as nondiagnostic, as it is common for previous thrombi to not completely resolve.8 In such nondiagnostic cases, the D-dimer is then given weightage. With an intermediate clinical pretest score, negative D-dimer and same vein segment findings on CUS, the recommended approach is serial monitoring with CUS or alternate, more detailed imaging.9 This would have not only ruled out a DVT, but would have evaluated the Baker’s cyst in more detail, cited it as the cause of pain, and saved the patient 4 months of discomfort and unnecessary anticoagulation. Anticoagulation would have been warranted had the D-dimer been positive.This case poses many complications at various stages in diagnosis, which ultimately led to unnecessary treatment. The patient had a history of a true acute DVT in 2008 and resumed ERT once warfarin was discontinued. On repeat presentation with similar but intermittent pain symptoms—though not typical of DVT—is within reason to assume a recurrence, hence an intermediate clinical pretest probability. Though the next step in diagnosis of suspected recurrent DVT is a D-dimer assay, it is at this point not considered a reliable tool and only comes into decision making if CUS is indeterminate. This suggested approach may be due to the fact that D-dimer may remain elevated after the first event, thereby decreasing its dependability in subsequent events.10 However, many previous studies have repeatedly reported the strong negative predictive value of D-dimer (>95%) in patients with low or intermediate clinical pretest,1113 and this highlights the important but adjunct role of D-dimer in the emergency room in the diagnosis of both acute and recurrent DVT.Certain factors can play a role in the changing sensitivity and specificity of D-dimer including extent of thrombosis and fibrinolytic activity, duration of symptoms, anticoagulant therapy, comorbidity due to surgical or medical illnesses, inflammatory diseases, cancer, elderly age, pregnancy/puerperium, and, as mentioned before, previous DVT.14 Accumulation of fluid in this medial location spares the neurovascular bundle. Occasionally the cyst may migrate posterolaterally and cause compression of one of more of the components of the popliteal neurovascular bundle  filled with synovial fluid. Baker’s cysts are the most common nonvascular condition in this location, but due to their chronic nature can cause various neurovascular manifestations as a result of enlargement and compression. The direction of extension as the cyst develops over time has been found to dictate the subsequent course of disease. Baker’s cysts tend to favor growth in the posteromedial direction due to anatomic lack of support of the synovial capsule in this area.r bundle . Symptom21 and Parlov et al22 both report this phenomenon and noted the concurrent association of rheumatoid arthritis. Chaudhuri et al also report a similar case of a simultaneous Baker’s cyst and DVT, and also acknowledge that unruptured Baker’s cysts may masquerade radiologically as DVT.23 In our case, the absence of DVT was confirmed not only by laboratory testing with D-dimer but also by a repeat false-positive ultrasound scan paired with a negative magnetic resonance angiogram. Ideally, phlebography is the diagnostic test of choice to exclude a calf vein thrombosis when an unruptured Baker’ cyst is identified on ultrasound.23 What remains unclear in this patient is how the venous system was selectively affected. It is possible that this is an early result of pressure against an easily compressible structure. In an emergency situation, such complexities are easy to overlook but are important to be aware of.Few cases of intact posterolateral dissecting Baker’s cysts are reported in the literature. ChongNo single test is reliable in the diagnosis of recurrent DVT and it is a combination of their results used at the correct time that points toward optimal management. Dissecting Baker’s cysts are a benign entity, but with progressive posterolateral extension can lead to a clinical picture identical to that of DVT. The various complications of Baker’s cysts, including rupture, direct neurovascular compression, and dissection are important to consider when this cyst is identified on initial CUS imaging in a patient with unilateral calf pain and swelling and negative D-dimer.


A 65-year-old man with a history of recurrent urinary tract infections presented after a 3-months of visible hematuria. Physical and laboratory examinations revealed anemia and impaired renal function. Ultrasound and magnetic resonnance imaging (MRI) showed an invasive bladder tumor developing in a large posterior diverticulum (A and B) with rectal deviation (A) and responsible of a left hydronephrosis. First, the patient underwent a blood transfusion and a left percutaneous nephrostomy. Two weeks later, we perfomed a cystoscopy and a transurethral resection of the tumor. Pathology revealed a locally advanced squamous cell carcinoma (SCC) (stage > p T2). The patient had no history of bilharziasis. Since the surgical extirpation was not possible, the patient was treated with chemoradiotherapy, but died 6 months later. Non-bilharzial SCC represents < 5% of vesical tumors, it is caused by chronic irritation of the urothelium and often diagnosed at an advanced stage. The intradiveticular location account for approximately 1% of all bladder tumors and make the prognosis poorer due to lack of muscle barrier. This case combine these two rares conditions.


Solitary fibrous tumors (SFTs) rarely develop in the pelvis. When they do arise, they are usually treated using surgery, although SFTs are often very large by the time of diagnosis, which makes surgical excision difficult. We report a case of a 63-year-old man who was referred to our hospital for the treatment of a giant tumor of the pelvis. Computed tomography (CT) revealed a 30 × 25 × 19 cm sized hypervascular tumor that almost completely filled the pelvic cavity. The diagnosis of SFT was made by CT-assisted needle biopsy. The feeding arteries of the tumor were embolized twice. The first embolization aimed to reduce the tumor volume, while the second one was planned a day prior to the surgery to obtain hematostasis during the operation. Tumor resection was then performed. The blood loss during the operation was 440 ml, and there was no uncontrollable bleeding. The postoperative course was uneventful. No recurrence of SFT was observed during a 2-year follow-up. Solitary fibrous tumor (SFT) is a rare mesenchymal tumor that was first documented by Klemperer and Rabin . AlthougN-butyl-2-cyanoacrylate was conducted a day prior to the operation to prevent uncontrollable bleeding  and magnetic resonance imaging (MRI) revealed a huge mass, measuring 30 × 25 × 19 cm, which occupied the pelvic cavity and was suggestive of a malignant mesenchymal tumor (Figure SFT was first described by Klemperer and Rabin in 1931 as a localized fibrous mesothelioma, but it is now recognized that SFTs can originate in various extra-thoracic sites. The age of onset of SFTs is around 50 to 60 years, and the male-to-female ratio appears to be almost equal . SurgicaIn the present case, CT revealed a giant mass that filled the pelvic cavity. The preoperative assessment revealed the patient had ischemic heart disease. To resect this tumor safely, the preoperative diagnosis was vital in order to determine the appropriate neoadjuvant therapy. On CT and MRI scans, SFTs are usually heterogeneous, with hypervascular areas showing intense enhancement, hypercellular areas showing moderate enhancement, and areas of cystic, myxoid degeneration, or necrosis showing no enhancement. However, these imaging characteristics are also observed in other hypervascular tumors with fibrous content, including most sarcomas, gastrointestinal stroma tumors, and malignant peripheral nerve sheath tumors, and hence, it is difficult to differentiate these tumors by CT and MRI findings alone . FluorodThe reported success of neoadjuvant therapy for SFTs has varied. Combs et al. reported that radiotherapy was effective in controlling SFTs of the central nervous system and spine, and some good results with radiotherapy have also been reported for abdominopelvic SFTs -13. On tUnlike the approached described above, preoperative percutaneous embolization of feeding arteries has been shown to allow a safe, complete resection to be performed, especially in cases of thoracic, cervical, and spinal SFTs -16. In tPreoperative diagnosis and the embolization of feeding arteries are essential for the successful complete surgical resection of giant abdominopelvic SFTs.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of this written consent is available for review by the Editor-in-Chief of this journal.


Intra-osseous schwannoma is a rare mesenchymal tumor. Although, the head and neck region is one of the most common sites for schwannomas, its location at the skull bone is uncommon and accounted for less than 0.2% in the largest series of bone tumors ever reported. Furthermore, it is most often a benign tumor, malignant transformation is exceedingly rare.Clinical presentation is non-specific, most often symptoms are associated with compression and invasion of adjacent organs. Neuro-imaging features are non-specific and the diagnosis is based on histological examination with immunohistochemical study.Surgery remains the aim of treatment. However, radiation therapy could be an interesting therapeutic option in unresectable tumors.This systemic review offers new clinicopathological data useful for better defining the diagnosis and clinicopathological behavior of schwannoma. The purpose of this work is to raise awareness among clinicians adding this clinical entity as a differential diagnosis when a mass of skull bone is identified. Schwannoma also referred to as neurilmoma, neurinoma, and perineural fibroblastoma is a solitary soft tissue or intra-bone lesion, most often developped from a Peripheral nerve .Schwannoma arising from Schwann cells, first described by Verocay in 1910, is most often a benign tumor, malignant transformation is exceptional . There aIntraosseous schwannomas are known to account for less than 0.2% of primary bone tumors ,3. To thClinical presentation is non-specific, most often symptoms are associated with compression and invasion of adjacent organs. The diagnosis is based on histological examination with immunohistochemical study ,7. SurgeThrough this review of the literature, we try to illuminate this extremely rare pathology. It is necessary to distinguish malignant tumors usually occuring in the context of Von Reclinghausen disease, from benign schwannomas . In factThe new World Health Organization (WHO) classification  of soft malignant peripheral nerve sheath tumour (MPNST). This WHO classification of sheath nerve tumours is resumed in Table Benign Schwannoma.According to this classification, schwannoma (including variants) is a begnin entity, whereas malignant schwanoma is included under the name of Intraosseous schwannomas affect males and females equally, with patient age ranging from 2 to 65 years. The mandible is the most common location, followed by sacrum. Other sites such as vertebra, ulna, humerus, femur, tibia, patella, scapula, rib, and small bones of the hands have been reported .Approximately 25% of the reported cases originate from the head and neck region . HoweverIn one of the most important reviews of intraosseous schwannoma, Gordon and al presumed that the diagnosis of this entity might be missed because of its rarity and atypical roentgenologic appearance .Tumor may arise centrally within the bone,Tumor can arise within the nutrient canal and produce canal expansion: tumors grow in a dumbbell-shaped configuration, enlarging the canalExtraosseous tumors can cause secondary erosion of bone: a soft tissue or periosteal tumor may cause secondary erosion of the bone and penetration into.Schwannoma is associated with sensory nerves. Therefore, the exceedingly rare occurrence of intraosseous schwannoma is due to the low density of sensory nerve fibers within bone ,13,16. SHowever, the histological origin of such intra-osseous schwannoma remains controversial. In fact, hyperplastic schwann cells of the perivascular nerve plexus, especially of autonomic nerves could explain the development of meningeal schwannoma , and eveHistologic features of intraosseous schwannomas are usually similar to that observed for soft-tissue schwannomas including Antoni A type  and Antoni B type (with less number of cells and disorganization of fusiform cells dispersed in a loose and random fashion) tissue arrangements ,13.Schwannoma is an encapsulated neoplasm, characterized by slow growing and low invasive potential, it rarely undergoes malignant transformation ,21.Important features to suggest a benign diagnosis include absence of infiltrative margins (sharp circumscription), perivascular hyalinization, disproportionally high cellularity when compared to the degree of nuclear atypia or mitotic activity, and strong and uniform immunostaining for S-100 protein ,22.A diagnosis of schwannoma with uncertain malignant potential could be evoked in front of a locally aggressive growth pattern in a histologically benign-appearing tumor .The histological diagnosis of schwannoma is difficult because of the similarity with other sarcomas, so pathologists use S100 protein which is specific for nervous cells ,23.In fact, Immunohistochemically, schwannoma is nearly uniformly positive for the S-100 protein and for vimentine [Clinical symptoms of schwannoma are not specific and depend on the location. They are most often related to compression of adjacent organs or of their invasion .The skull bone is an exceedingly rare site for intraosseous schwannoma. Only 10 cases of this location have been reported previously Table .Table 2The first documented case in the literature was published by Solodnik and al in 1986, they described an intraosseous neurinoma of petrous apex of a 59 year-old man with headache, tinnitus in the right ear, and unsteadiness .Ersahin and al reported a case of intraoessous schwannoma of parietal bone of a 4-year-old boy presented with a lump on the right side of his head with a mass witch enlarged in size progressively .The patient reported by Schiffer and al in 1991 was a 3-year-old boy with a non tender mass in the left fronto-orbital region .Sphenoidal schwannoma resembles other primary tumors of the sphenoid in symptomatology and physical signs ,6. In faTwo others cases was reported by Celli.P and al, the first of occipital bone and the second of frontal bone, both of them presented with a hard non tender mass .Another case of frontal bone reported by Goyal R and al of an 11-year-old boy presented with forehead swelling that increased progressively during a period of 2 years [Recently R.Amita published another case of frontal bone in a 41-year-old female presented with insidious onset intermittent paresthesia in right upper and lower limbs and left hemicranial headache with two episodes of generalized tonic-clonic seizures . Unni anPhysical examination, in all reported cases was normal, especially without neurological deficits.Approximately 10% of schwannomas are associated with multisystem disorders such as neurofibromatosis, schwannomatosis, multiple meningiomas, and Carney complex . HoweverThe preoperative diagnosis is often difficult, as the neuro-imaging features are non-specific, but it contributes to evaluate the extent and determine infiltration of the adjacent structures .At CT scan, intraosseous schwannomas are most often present as a lytic lesion, with sclerotic borders, or as a sharply demarcated defect that often expand the involved bone. Perilesional sclerosis may surround the area of central lucency , and som2.Malignant schwannoma or malignant peripheral nerve sheath tumour (MPNST).MRI showed an inhomogeneous lesion on T1-weighted spin-echo images, hyperintense signal on T2-weighted spin-echo images, and isointense on T2-fast images. The lesion showed peripheral intense enhancement with gadolinium ,24.2.MalMalignant peripheral nerve sheath tumour (MPNST) is a rare aggressive tumor, which represents 5% of soft tissue sarcomas. Nevertheless, there was a resurgence of this condition in patients with Von Recklinghausen disease .MPNST of the head and neck is extremely rare  and has Otherwise, solitary malignant schwannoma is very uncommon. In a large series of 232 patients with solitary malignant schwannomas, not associated with Von Recklinghausen’s disease, reported by Tapas and all , eighteeThe microscopic diagnosis of MPNST is difficult because the tumors often consist of fusiform elements packed in interlacing bundles and resemble fibrosarcoma .Malignancy is retained on cell pleomorphism, high number of mitosis and capsular infiltration ,23. AlsoIn contrast to benign and locally aggressive schwannomas, which demonstrate uniform immunoreactivity for S-100 protein, malignant entity may show patchy or absent immunoreactivity for this antigen [There is no clinical findings characteristic of MPNST. In head and neck reported cases, the chief reason the patient seeks advice is a soft tissue mass which is gradually enlarging .Prognostic factors are tumor size, grade of malignancy, speed of clinical evolution, degree of cellular pleomorphism and mitotic activity .For malignant peripheral nerve sheath tumor (MPNST), the 5-year survival is ranged from 50 to 55% in patients without neurofibromatosis but it is reduced to less than 20% in patients with this disease ,33. TheyAll reported cases in the literature were benign, therefore intraosseous schwannoma was treated by complete excision in most cases. They registered a good outcome with no local recurrence within a follow-up that ranged from 3 months to 14 years.The optimal treatment for intraosseous schwannoma has not been well established given the rarity of this entity. Total resection of intraosseous schwannomawas described as a sufficient treatment, in particular for limited tumors without invasion of adjacent structures. However, only volume reduction, without total removal or tumor control can be achieved with a surgical approach in others cases .Radical excision is based on location, shape, size and local spread. The tumor plus its bed and any attached structures should be resected en bloc .As alternative treatment, stereotactic radiosurgery and radiotherapy may be performed, when the tumor is unresectable. In fact, the extent of the resection and potential morbidity must be considered in addition to accessing the region of interest .Therefore, radio surgery may be suggested when microsurgical resection is contraindicated, as well as for patients with serious comorbidities or underlying neurofibromatosis, which often involves multiple lesions .The effect of radiotherapy has been studied in various schwannomas and has been shown to be effective in preventing tumor growth, although long-term assessments of the benefits in patient quality of life remain uncertain. Little is known about the comparative efficacy of stereotactic radiotherapy to surgery .The use of pre or post-operative adjuvant therapy is not yet well codified, but in case of incomplete resection, radiotherapy can be envisaged ,7.The role of chemotherapy in advanced malignant peripheral nerve sheath tumor (MPNST) is unclear. Most MPNSTs are biologically high-grade sarcomas that tend to recur (40%–65%) and metastasize (40%–80%). MPNST usually metastasize most commonly to the lungs .Because of the rarity of MPNST, consistent data regarding chemotherapy sensitivity are lacking. As for other unresectable and metastatic soft tissue sarcoma, doxorubicin and ifosfamide are generally considered to be the most active chemotherapeutic agents.In a recent study of EORTC soft tissue and bone sarcoma group study, that compares the outcome of patients with advanced MPNST, with those with other soft tissue sarcoma histological subtypes, the findings showed that, compared with standard first-line doxorubicin, the doxorubicin–ifosfamide regimen had the best response, whereas ifosfamide had the worst prognosis. Results of an ongoing NCI multicenter phase II trial (NCT00304083) that studies combination chemotherapy with doxorubicin, etoposide and ifosfamide in unresectable (stages III–IV) adult MPNST are awaited .The purpose of this review is to offer new clinicopathological data of intraosseous schwannomas of skull bone, useful for better defining the diagnosis and biological behavior of schwannoma specially in such unusual location.Surgery remains the main treatment. External beam radiation could be an interesting therapeutic option for unresectable tumors. This paper aims to raise awareness among clinicians adding this clinical entity as a differential diagnosis when a mass of skull bone is identified.


Clinically significant sellar cysts unrelated to pituitary adenomas are uncommon. Intracranial cholesteatomas are also rare and are most common in the middle ear and mastoid region. We report an even rarer case of cholesteatoma in the sellar region—a challenging diagnosis guided by clinical presentations, radiological signs, and biopsy, aiming at emphasize the importance of considering cholesteatoma when making differential diagnoses of sellar lesions.We present a case of cholesteatoma in the sellar region in a 56-year-old man with hypopituitarism, diabetes insipidus, and cystic imaging findings. It was difficult to make an accurate diagnosis before surgery. We present detailed analysis of the patient's disease course and review pertinent literature.The patient underwent a surgical exploration and tumor resection through a transsphenoidal approach. Pathologic results revealed a cholesteatoma. The patient's symptoms improved a lot after surgery, and the postoperative period was uneventful. Taken together, the lesion's imaging appearance, pathological characteristics, and clinical features were all unique features that lead to a diagnosis of cholesteatoma.As we did not see such reports by Pubmed and EMBASE, we believe this is the first reported case of sellar cholesteatoma presenting in this manner. This article emphasized that cholesteatomas, although rare, should be considered part of the differential diagnosis of sellar lesions. There is no predilection for either sex.1 Although cholesteatomas are not, strictly speaking, tumors or cancers, they can still cause significant problems because of their erosive and expansile properties. Here, we report a rare case of cholesteatoma originating in the sella turcica with cystic imaging findings that caused severe headache, secondary hypothyroidism, central hypogonadism, and central diabetes insipidus (DI). The lesion was successfully resected by the transsphenoidal route. To the best of our knowledge, this is the first reported case of sellar cholesteatoma presenting in this manner. The unique disease course and magnetic resonance imaging (MRI) characteristics are presented. The epidemiology, origins, and treatment of cholesteatomas are also discussed.In 1828, Cruveilhier reported the first description of “tumeurs perlees.”A 56-year-old Chinese man, with no notable medical history, had experienced severe headache, fatigue, and poor mental state for about 1 year. The pain was mainly focused in the forehead and could be alleviated by rest or analgesics. He also complained of mildly decreased bilateral visual acuity (VA) in recent months. He said he had not experienced any unconsciousness, convulsions, epilepsy, cognitive disorder, nausea, vomiting, numbness, or constitutional symptoms. On further questioning, he reported a long history of extreme thirst, urinary frequency, and occasional episodes of enuresis that he was too embarrassed to bring to the attention of a health care practitioner. He finally sought medical help at our hospital after 2 weeks of erectile dysfunction. No relevant special circumstances regarding his family history or personal history were identified. Upon ophthalmologic examination, the right VA was 1.0 and the left was 0.6. Mild blepharoptosis and temporal upper quadrant incomplete hemianopia of the left eye and some temporal scotomas of the right eye were observed. Pupillary light reflex and corneal reflex were insensitive on the left side. Neurological examination showed comparatively decreased facial sensation on the left side, especially at the regio zygomatica. Limb movement function and sensory function were normal. Both superficial and deep tendon reflexes were normal. Pathological signs and ataxia were absent. Table To relieve the patient's impaired pituitary function, severe headache, and central DI, the patient underwent a surgical exploration and resection. The sublabial transsphenoidal approach was adopted. Upon entering the spheroid sinus, yellow adherent cheesy material was encountered. No hemorrhage or cystic fluid was found. The floor of the sella was eroded and the dura was visible. Under direct fluoroscopy, the anterior, posterior, and superior extent of the lesion was curetted. No cerebrospinal fluid was observed. The cavity was filled with a free graft and the sellar floor was reconstructed with a piece of nasal septal cartilage. The specimen was composed of dry, flaky, cheesy materials, and soft tissue's tiny fragments. Postoperative paraffin section pathology revealed a combination of keratinous material and stratified squamous epithelium and confirmed the diagnosis of cholesteatoma , and cranial nerves III, IV, V (branches V1 and V2), and VI all pass through the cavernous sinus, its involvement or compression may cause cranial nerve findings like oculomotor paralysis.9 Compression on the pituitary gland from the cholesteatoma can cause gland failure, leading to pituitary insufficiency (hypopituitarism).10 The symptoms depend on which hormone is involved.11 Generally speaking, growth hormone (GH) is the first affected pituitary hormone in hypopituitarism patients, causing growth disorders in children and leads to abnormal body composition in adults. The following disorder is usually gonadotropin deficiency, leading to menstrual disorders and infertility in women and decreased sexual function, infertility, and loss of secondary sexual characteristics in men, as in our case. Thyroid stimulating hormone (TSH) and adrenocorticotropic hormone (ACTH) deficiency usually develop later in the course of hypopituitarism. TSH deficiency can lead to hypothyroidism, and thus appetite loss, weight gain, fatigue, and decreased mental function. In our case, the thyroid function tests showed low total T4 and free T4 and the TSH was at the low level of the normal range. Like our case, when lesions involve the posterior pituitary, polyuria, and polydipsia reflect loss of vasopressin secretion. Additionally, a sellar cholesteatoma can cause symptoms of increased intracranial pressure, causing various types of headache.Typically, cholesteatoma symptoms are initially mild. Clinical symptoms are generally caused by the local mass effect of the lesion on adjacent brain tissue or intracranial neurovascular elements and are likely to present once the lesion has reached an appreciable size.12 Cholesteatomas have a variety of signal intensities .14 Due to the slow growth, the peripheral edema zone is usually not evident. Ten percent to 25% of cholesteatomas cases are calcified.14On computed tomography (CT), a typical sellar cholesteatoma may exhibit a homogeneous low density focus with a smooth, well-defined boundary. Although MRI features were not typical in the present case, they are considered to provide the superior soft tissue differentiation necessary to distinguish between intracranial suppurative complications and cholesteatomas.15 The microscopic transsphenoidal approach is highly recommended, because it allows for total or subtotal tumor removal under a clear field of vision, and is relatively simpler and easier than craniotomy when the lesion invaded the lateral cavernous sinus without high morbidity.16 A chemical meningitis may occur if the tumor cyst fluid overflows to the subarachnoid space.17 During the perioperation, corticosteroids are considered to be an effective prophylactic therapy. In spite of operation, cholesteatoma recurrence incidence is still high, in some reports up to 71%.18 Many neurosurgeons consequently recommend to perform a “second exploration” 6 to 18 months later for resection of residual tumor tissue.19The ideal treatment of choice for cholesteatomas is surgical excision on the basis of the MRI features.Although uncommon, cholesteatoma should be considered part of the differential diagnosis of sphenoid sinus or sellar region masses. Clinical symptoms are generally due to the local mass effect of the tumor, and hypopituitarism and DI are also common manifestations. Cholesteatoma has variable signal intensity on MRI, and pathological results remain the “gold standard.” We recommend the microscopic transsphenoidal approach for removal of epidermoids of the sellar region.


Hemangioma is the most common benign hepatic neoplasm. The majority of cases are asymptomatic and can be confirmed by imaging examinations, including enhanced computed tomography and magnetic resonance imaging. Exophytic growth is not common and pedunculated cases are extremely rare. The present study reports a case that was pre-operatively misdiagnosed as a stomach-originating tumor. Laparoscopic exploration confirmed that this tumor was a hepatic hemangioma with a long peduncle originating from the left edge of the liver. The final diagnosis of cavernous hemangioma was confirmed by postoperative pathology. This indicates that hepatic hemangioma with a long peduncle has the possibility to be inaccurately diagnosed. Laparoscopic examination is required for such cases. Hepatic cavernous hemangioma is the most common benign tumor of the liver and occurs more frequently in females . The majA patient possessing a pedunculated hepatic hemangioma that was misdiagnosed as a tumor originating from the stomach due to atypical imaging findings was recently treated at the Cancer Hospital . In the present study, the case is reported together with a review of the literature. Written informed consent was obtained from the patient.A 52-year-old male was referred to the Cancer Hospital for ascending colon cancer, which had been confirmed by colonoscopy with biopsy. The patient had visited Chengde Central Hospital  one week prior to attending the Cancer Hospital, and the chief complaint of the patient was blood-stained stool. Colonoscopy with biopsy was performed at the local hospital, and a lesion with a diameter of ~5 cm was identified in the ascending colon. The surface of the lesion was rough, and a diagnosis of ascending colon adenocarcinoma was confirmed by biopsy. No neoadjuvant therapy was delivered to the patient. With the aim of receiving laparoscopic surgery and better comprehensive treatment, the patient was referred to the Cancer Hospital, where further examinations were performed prior to surgery. The further examinations included enhanced abdominal and pelvic CT scanning; examination of tumor markers, liver and renal function and coagulation function; chest X-ray; abdominal ultrasound examination; and re-examination of the pathological results of the local hospital by two pathologists.Enhanced CT revealed a mass in the left upper quadrant, with a maximum diameter of ~2.8 cm and a CT value of ~36 Hounsfield units . This lo12/l ; and hemoglobin, 82 g/μl . Tumor markers were as follows: α-fetoprotein, 3.2 ng/ml ; carcinoembryonic antigen, 1.7 ng/ml ; and carbohydrate antigen 19–9, 16 U/ml (0–37 U/ml). Tests for hepatitis B surface antibody (HBsAb) provided a positive result, but the samples were negative for HBeAb, HBcAb, HB s antigen (Ag) and HBeAg; therefore, the patient in the present case did not have hepatitis B.The laboratory data were as follows: White blood cell count, 4,800/μl ; red blood cell count, 5.3×10Based on preoperative examinations, including CT and blood tests, primary ascending colon cancer and cancer-related anemia were confirmed, and a left upper quadrant mass was also diagnosed. The patient was transfused with 800 ml blood and, two days after the transfusion, laparoscopic-assisted right hemicolectomy was performed. A dark red mass with a smooth surface and long peduncle originating from the left edge of the liver was identified in left upper quadrant. The mass, which had previously been suspected to be a tumor originating in the stomach, was confirmed as hepatic hemangioma by the findings of laparoscopic exploration. This tumor was isolated from the liver and extended down to the left side of the stomach  and, macFor the ascending colon lesion, a diagnosis of stage T4aN0M0 adenocarcinoma was confirmed by postoperative pathology, and chemotherapy was recommended for this patient. This patient was administered chemotherapy four weeks following surgery. Oxaliplatin was administered intravenously in addition to an oral capecitabine regimen  for 2 consecutive weeks followed by 1 week of rest, for a total of 8 cycles (24 weeks). Four cycles had been completed when this report was started. During the follow-up period, examinations including clinical examination, abdominal ultrasonography, abdominal CT scanning, chest radiography and carcinoembryonic antigen assessment should be delivered for patients once every 3 months in the first 2 years after surgery, biannually in the next 3 years and then annually . For theet al (Hemangioma is the most common benign tumor of the liver, and the incidence of hepatic cavernous hemangioma among liver tumors is as high as 20%. A diagnosis of typical hemangioma is straightforward when using a combination of various imaging techniques . Typicalet al  reportedThe majority of hemangiomas are asymptomatic, but larger hemangiomas can produce various symptoms, including an abdominal mass, pain, nausea, vomiting, jaundice, hemorrhage and even rupture. The patient in the present study did not experience any abdominal discomfort or an abdominal mass. No treatment is required for the majority of hemangiomas, with the exception of symptomatic treatment, which includes the treatment of a palpable mass, pain, increasing size or complications, including consumptive coagulopathy and rupture .In conclusion, hepatic hemangioma with a long peduncle originating from the left edge of the liver may be inaccurately diagnosed. Laparoscopic examination is required for accurate diagnosis in such cases.


Calcific myonecrosis is a rare condition in which muscle in a limb compartment undergoes necrosis and becomes peripherally calcified with central liquefaction. The patient usually presents with a slowly progressive enlarged mass that sometimes can be misdiagnosed as soft tissue sarcoma. Most of the reported cases showed that the disease occurs often after trauma or compartment syndrome. However, the case of calcific myonecrosis following snake bite is rarely reported.A 66-year-old Thai woman presented with a gradually progressive enlarged mass over a period of 10 years in her left leg. She had a history of untreated compartment syndrome after she was bitten by a snake  in her left leg when she was 14-years old. At presentation, a plain X-ray showed a large soft tissue mass at the anterior compartment of her left leg. A sheet-like mass with an enlarged central cavity combined with peripheral calcification and cortical erosion of her tibia were observed. A biopsy was performed and the result was negative for neoplastic cells. During a 5-year follow-up, the mass progressively enlarged and then became infected and finally broke through the skin. She was treated by excision of the mass and administration of antibiotics. The wound completed healed at 1 month postsurgery. There was no wound complication or disease recurrence at 1 year postoperation.The diagnosis of calcific myonecrosis was done by history taking and radiographic interpretation. In an asymptomatic patient the management should be observation and clinical follow-up. A biopsy should be avoided due to the high rate of postoperative infection. Treatment of choice in a symptomatic condition is mass excision. Calcific myonecrosis is a rare condition characterized by an area of muscle necrosis in a limb compartment with peripheral calcification and central liquefaction. Patients usually present with a slowly progressive enlarged mass that sometimes can be misdiagnosed as a soft tissue sarcoma. This disease was first reported in 1960 by Gallie and Thomson,3. HowevA 66-year-old Thai woman presented with a gradually progressive enlarged mass over a period of 10 years in her left leg. She did not have any pain, fever or weight loss. She had a history of snake bite by a Malayan pit viper to her left leg when she was 14 years old. Her leg became markedly swollen and she could not walk for 2 months. She was treated by a traditional healer. Finally, she could walk again but her ankle and toes could not perform active dorsiflexion. At the first visit, a physical examination showed a 20×10cm mass in her left leg. The mass was not tender or inflamed. Sensation was decreased over the dorsum of her left foot.A plain X-ray showed a large soft tissue mass at the anterior compartment of her left leg. Cortical erosion of her tibia was observed. A sheet-like mass with an enlarged central cavity combined with peripheral calcification resembling an eggshell and multiple fragmented calcifications in her left leg were detected Figure . A repeaEscherichia coli, Morganella morganii and Proteus vulgaris) were found in an intraoperative culture.A pathological study of the excised mass revealed tissue necrosis with hemorrhage and diffused calcification and a negative result for neoplastic cells (Figure Finally, surgery was performed for mass resection and primary closure with a vacuum drainage. Multiple microorganisms ( Figure .The vacu Figure .et al. suspected progressive enlargement happened from repeated intralesional hemorrhage[Calcific myonecrosis is a rare condition. This condition was first reported in two patients by Gallie and Thomson following Volkmann's ischemic contracture. The examorrhage.Calcific myonecrosis following snake bite is rarely reported. In the present study, the patient had a history of snake bite and the physical examination showed sequelae of untreated compartment syndrome. Compartment syndrome following snake bite has been reported. The patThe most common area of calcific myonecrosis is the anterolateral part of the leg,9. This et al. reported one case in which MRI demonstrated peripheral ring enhancement on postcontrast fat-suppressed T1-weighted images[The clinical presentation of this condition was a gradually enlarging painless mass with occasional tenderness. A plain radiograph of the mass usually showed fusiform mass with longitudinal peripheral plaque-like calcification involving the entire compartment,6. Bone d images.A differential diagnosis of this condition included soft tissue sarcoma and myositis ossificans. Soft tissue sarcoma with radiographic soft tissue calcification could be synovial sarcoma, epithelioid sarcoma or soft tissue osteosarcoma; soft tissue sarcoma has a more aggressive radiographic appearance than calcific myonecrosis and mineralization is usually distributed throughout the mass which is different from calcific myonecrosis which usually has peripheral calcification with central liquefaction. RadiogrA biopsy in calcific myonecrosis is not recommended due to the high risk of infection. The infIn a symptomatic patient, complete mass excision with flap coverage and primary closure with a suction drain or open wound for secondary intentional healing were recommended,11. In tCalcific myonecrosis is a rare condition that usually occurs after trauma or compartment syndrome. The diagnosis is done from the history and radiographic findings. In an asymptomatic patient the management should be observation and a follow-up of the clinical symptoms and signs. A biopsy should be avoided due to the high rate of postoperative infection. Treatment of choice in a symptomatic condition is mass excision.Written informed consent was obtained from the patient for the publication of this case report and the 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.VY and PS were responsible for the patient diagnosis and follow-up, KK performed the histological examination. PT and TL performed the radiographic interpretation. VY was a major contributor in writing the manuscript. All authors read and approved the final manuscript.


One of the most common causes of skeletal muscle infarction is diabetic muscle infarction (DMI), a rare complication associated with poorly controlled diabetes. We report an atypical case of DMI localized in the tibialis anterior (TA) and extensor hallucis longus (EHL) muscles of an elderly individual. A 64-year-old man with type 2 diabetes mellitus presented with a 6-month history of a palpable mass in his lower left leg. Magnetic resonance imaging (MRI) revealed that the mass exhibited heterogeneous signals on T1- and T2-weighted images and slight heterogeneous enhancement within the muscles on fat suppressed T1-weighted images. Because histopathological analysis revealed mostly necrotic muscle tissues but no neoplastic cells, we resected the affected muscles. A typical symptom of DMI is severe abrupt-onset pain in the region of the affected muscles, but the patient did not complain of pain. Therefore, the diagnosis and treatment for DMI were delayed, and widespread irreversible muscle necrosis developed. MRI findings of DMI can be similar to that of a malignant soft-tissue tumor. So, it is necessary to consider the malignant soft-tissue tumor as one of the differential diagnoses of DMI. Skeletal muscle infarction is ischemic necrosis of striated muscles of the skeleton due to long-term poorly controlled diabetes mellitus, alcoholism, compartment syndrome after blunt trauma or fracture, and vascular diseases such as acute artery thrombosis or embolism and arteriosclerosis obliterans (ASO). The typical clinical symptom is severe abrupt-onset pain in the region of the affected muscle.Herein, we describe a rare case of diabetic muscle infarction (DMI) localized in the region of the tibialis anterior (TA) and extensor hallucis longus (EHL) muscles. The patient's clinical symptom and magnetic resonance imaging (MRI) findings were atypical and interesting compared to those of previously reported patients with DMI. The patient was aware of a palpable mass in the lower left leg for 6 months but neglected it owing to a lack of pain. A palpable mass was suggestive of a malignant soft-tissue tumor; therefore, we needed to distinguish the lesion from a malignant soft-tissue tumor.3; CK level, 164 IU/L; and casual blood glucose level, 298 mg/dL. Radiography revealed no bony abnormalities and calcification of soft tissue, but there was evidence of moderate soft-tissue swelling. Computed tomography (CT) revealed a large mass  with cystic lesions in the region of the TA and EHL muscles  and calcific myonecrosis which is characterized by a slowly progressive enlarging, painless soft-tissue mass with occasional tenderness in the lower limb. The most common area of calcific myonecrosis is the anterolateral part of the lower leg. Although this condition is not fully understood, it is assumed that these lesions most likely result from posttraumatic ischemia and cystic degeneration of the muscle. Radiographs typically show a fusiform mass with peripherally oriented plaque-like amorphous calcifications. In our patient, the calcification was not seen by radiographs and CT, and so, we ruled out this disease. In cellulitis, subcutaneous swelling is seen but with no muscle involvement . NecrotiTo confirm the correct diagnosis, the clinical course, physical findings, CT and MRI features, and histopathological analysis are important. Muscle biopsy is the gold standard for diagnosis and exclusion of other diseases such as pyomyositis, necrotizing fasciitis, and soft-tissue tumors –10. HoweIn summary, herein, we reported a rare case of DMI in the TA and EHL muscles. The typical symptom of DMI is severe abrupt-onset pain in the region of the affected muscle, but our patient did not complain of pain. The diagnosis of and treatment for DMI were delayed, and widespread irreversible muscle necrosis requiring resection developed. It is true that MRI is the most sensitive test for making the diagnosis of DMI; however, in some cases, MRI finding of DMI can be similar to that of the malignant soft-tissue tumor. So, it is necessary to consider the malignant soft-tissue tumor as one of the differential diagnoses of DMI.


The impingement syndrome is defined by the compression of the rotator cuff tendons against the coracoacromial arch. Several factors contribute to this condition and they are classified as structural or functional factors. The former are changes in the coracoacromial arch, proximal humerus, bursa and rotator cuff, and the latter are related to the mechanism of the upper limb by means of synchronized activity and balanced between the rotator cuff and scapular girdle muscles. The authors report here a case of parosteal lipoma of the proximal humerus, located between the muscles deltoid, teres minor and infraspinatus causing clinical signs of impingement. It is a rare occurrence, characterized as a structural cause for the onset of this symptom. Microscopically they are composed of mature adipose cells, without any evidence of cellular atypia. there are two types of lipomas: superficial and deep. The superficial lipomas are more commonly found in the shoulder, neck and abdominal region. The deep lipomas occur less frequently, and are located in the anterior mediastinum, chest wall and retroperitoneal region, and they are divided into the following types: intramuscular, intermuscular, parosteal and intra-osseous.According to Enzinger and Weiss,-4) The parosteal lipoma is a deep lipoma that grows in an exophytic manner in the periosteum, and can produce bone erosion, neural compression or focal cortical hyperostosis. It is a rare, slow growing histologically benign tumor, comprising 0.3% of all lipomas., 3, 4Among the deeply located lipomas, the intramuscular and intermuscular types are the most common; parosteal lipoma is infrequent; and the intraosseous is rare. observed that 16% were lipomas – in that, 1.3% was intramuscular and 2.6% were located in the shoulder and axilla, in a deep site.When studying 18,677 mesenchymal tumors, KransdorfThe present case describes a patient with diagnosis of parosteal lipoma of the proximal humerus inducing the clinical signs of impingement syndrome. Searching the literature, no similar case was found.An 82-year-old female patient, with history of pain in the left shoulder for two years, reported more intense pain over the last two months. Upon onset of symptoms she sought medical treatment. The diagnosis of supraspinatus tendonitis was made based on the clinical examination and ultrasonography. The patient was prescribed conservative treatment as physical therapy . For the following 18 months, the symptoms alternated between periods of relief and intensification.Over the last 2 months, her pain markedly increased, with loss of functional capacity of the left upper limb affecting her daily activities. Elevation of this limb caused intense pain and at night, pain woke her up many times. and a positive Neer sign were verified. Other tests in physical examination and the range of motion in lateral and medial rotation compared to the opposite side were assessed and considered normal.On physical examination, the patient presented mild hypotrophy of the deltoid and on dynamic inspection, active elevation was 90° and passive 160°. Reduction in supraspinatus muscle strength during the empty can test,After an injection of 10mL xylocaine in the subacromial space, pain disappeared and the patient was able to move her shoulder normally (positive Neer test). classification, was observed.Anteroposterior radiographs of the left shoulder, axillary and supraspinatus tunnel (outlet view) were ordered. A type-II acromion, according to BiglianiThe magnetic resonance image (MRI) of the left shoulder  and 1B rRemoval of the tumor was indicated, and it was performed by posterior approach. The soft tissue tumor did not invade the subacromial space . Its uppThe tumor was resected by a marginal excision (as “shelling out the tumor”), and the deltoid reinserted in the posterior acromion. The resected mass measured 7.0x5.5x1.5cm . The hisIn the postoperative period the patient remained with thoracobrachial immobilization for the first 6 weeks, only making passive movements of lateral and medial rotation. This was followed by mild active exercises without resistance, and after 2 months, she began on muscle strengthening. The patient has been asymptomatic 26 months after surgery.The normal function of the shoulder muscle structure depends on specific requirements such as: preserved integrity and tonus of the rotator cuff muscles , normal capsular laxity, integral coracoacromial arch, thin and lubricating bursae, and concentricity of the glenohumeral and coracoacromial rotational spheres. Alterations of this intricate mechanism are the most common causes of shoulder pain problems. In the case reported, the lipoma was of the parosteal type, growing in the compartment between the deltoid, infraspinatus, teres minor muscles and the humerus.The shoulder is shaped by four anatomic barriers : the scapula with its muscles; the clavicle; the proximal humerus; and the deltoid muscle. In these spaces, the tumors grow centrifugally when in contact to these anatomic barriers.The tumor of this patient increased the pressure in this compartment upon muscle contraction, altering the concentric relation of the rotational spheres. In its movement arch, the joint between the humerus and scapula is formed by two concentric spheres.The humeral sphere is represented by the head of the humerus  and the sphere of the coracoacromial arch formed by the lower surface of the anterior acromium and the coracoacromial ligament (with a larger radius). Both spheres have the same rotational center and together maintain the best condition of stability for the shoulder and for the available surface for transfer of the scapular load. In this case, when raising her arm, the synchrony in contraction of the deltoid, infraspinatus and teres minor muscles is interrupted, due to the lipoma interposed between them. The motion loses its coordination causing the impact of the greater tuberosity against the coracoacromial arch.The range of motion in arm elevation in the scapular plane is zero to 180°. In the initial stage of movement up to 90°, fixation of the scapula occurs over the chest wall by contraction of the trapezius and anterior serratus muscles. The muscles of the rotator cuff lower and fix the head of the humerus in the glenoid cavity, and, at this time, the deltoid muscle, with predominance of its mid- and posterior portions, acts by raising the arm. When the upper limb reaches an elevation of 90°, the greater tuberosity in order to move under the coracoacromial arch, requires the external rotation of the humerus, produced by the contration of the infraspinatus and the teres minor muscles. These muscles act in synchrony producing a smooth and coordinated motion.Resection of the tumor restored the concentricity of the two spheres of movement  during the lateral rotation in the final degrees of elevation, due to the recovery of congruity of the glenohumeral joint in its entire movement arch, leading to relief of symptoms of impingement syndrome. A limitation of this case report was the lack of electroneuromyography requested to patient; this diagnostic exam could detect a compression of axillary nerve in the quadrangular space that mimics the symptoms of patients.To find articles evaluating patients with subacromial syndrome related to lipoma, we searched MEDLINE via PubMed (1966 to July 2013), EMBASE (1980 to 2013 Week 20), and LILACS (1982 to July 2013). There was no language or publication status limitation to our search. We also checked references of articles and reviews for other potentially relevant studies. Our search strategy combined the specific terms (“shoulder impingement syndrome” [Mesh] OR “shoulder joint” [Mesh] OR “rotator cuff” [Mesh]) AND “lipoma” [Mesh].-15)The search strategy (completed in July 2013) identified a total of 36 records from the following databases: PubMed (19), EMBASE (11), LILACS (6). The search resulted in the identification of six articles that evaluated patients with shoulder condition associated with lipoma. reported a case of lipoma located in the subdeltoid region, that produced symptoms of glenohumeral instability. Nisolle et al. presented a 44-year-old man with bursal lipoma arborescens of the right shoulder associated with a rotator cuff tear. Relwani et al. described a case of a 52-year-old woman with classic signs of shoulder impingement and the patient had an anterior subacromial lipoma causing the symptoms. Two case-report articles illustrated two cases of a 45-year-old man and a 51-year-old man with signs and symptoms consistent with impingement syndrome whose etiology was intramuscular lipoma involving the supraspinatus muscle., 14 In addition, a recent case report presented a 38-year-old male patient with symptoms mimicking both glenohumeral instability and subacromial impingement due a subdeltoid intermuscular lipoma. In all cases the symptoms disappeared after surgery and physical therapy.Rohrbough and JobeWe considered our search strategy comprehensive, with no language restrictions applied. It also included handsearching (grey literature) and searches for ongoing and recent narrative reviews and case reports. However, it is possible that we have neglected some potential studies describing a similar case. Therefore, to our knowledge, the present case illustrated in this article is an atypical case of a parosteal lipoma of the proximal humerus that caused signs and symptoms of subacromial impingement. The mechanism that trigger the symptoms was preoperatively diagnosed by the MRI test. , 2 São mais comuns em mulheres de 30 a 60 anos e se apresentam clinicamente como uma massa móvel, circunscrita, de consistência macia e, em geral, indolor.Lipomas são os tumores de tecido conjuntivo mais frequentes, formados por nódulos encapsulados de gordura que podem conter tecido fibroso. À microscopia, são compostos por células adiposas maduras, sem qualquer evidência de atipia celular. o superficial e o profundo. Os lipomas superficiais são geralmente encontrados em ombros, pescoço e região abdominal. Já os profundos são menos frequentes, localizam-se no mediastino anterior, na parede torácica e na região retroperitoneal, sendo classificados nos seguintes subtipos: intramuscular, intermuscular, parosteal e intraósseo.Há dois tipos de lipomas, segundo Enzinger e Weiss:-4) O lipoma parosteal é um tumor profundo, de crescimento exofítico no periósteo, que pode causar compressão de nervos, erosão óssea ou hiperostose cortical focal. É um tumor raro, benigno e de crescimento lento, que representa 0,3% de todos os lipomas., 3, 4Entre os lipomas profundos, os tipos intramuscular e intermuscular são os mais comuns; o lipoma parosteal é pouco frequente, e o intraósseo é raro. observou que 16% eram lipomas, sendo 1,3% intramuscular e 2,6% localizados no ombro e na axila, em região mais profunda.Ao estudar 18.677 tumores mesenquimais, KransdorfEste relato de caso descreve uma paciente com diagnóstico de lipoma parosteal no úmero proximal, que desencadeou os sinais clínicos da síndrome do impacto. Nenhum caso semelhante foi encontrado em busca na literatura médica.Paciente do gênero feminino, 82 anos, com história de dor no ombro esquerdo há 2 anos e queixa de intensificação da dor nos últimos 2 meses. Procurou assistência médica com o início dos sintomas. O diagnóstico de tendinite do supraespinhoso foi feito com base no exame clínico e na ultrassonografia. Foi prescrita fisioterapia  como tratamento conservador. Durante 18 meses, apresentou alternância de sintomas, com períodos de alívio ou intensificação.Nos últimos 2 meses, a dor aumentou muito, com perda de capacidade funcional no membro superior esquerdo, que interferiu em suas atividades diárias. A elevação desse membro causava dor intensa, que a fazia despertar à noite muitas vezes.empty can test), e sinal positivo no teste de Neer. Outros testes no exame físico e a amplitude de movimento na rotação lateral e medial foram comparados ao membro contralateral e considerados normais.Ao exame físico, a paciente apresentou hipotrofia leve do deltoide e, à inspeção dinâmica, a elevação ativa foi de 90° e a passiva foi de 160°. Observaram-se redução na força do músculo supraespinhoso, durante o teste de Jobe .Foram solicitadas radiografias em incidência posteroanterior do ombro esquerdo, axila e túnel do supraespinhoso. Foi relatado acrômio tipo II pela classificação de Bigliani.A ressonância magnética (RM) do ombro esquerdo  e 1B mosFoi indicada a excisão do tumor, que foi realizada por acesso posterior. O tumor de tecido mole não invadiu o espaço subacromial . Sua extshelling out, e o deltoide foi reinserido no acrômio posterior. A massa removida media 7,0x5,5x1,5cm , frouxidão capsular normal, arco coracoacromial íntegro, bursas delgadas e lubrificadas, e concentricidade das esferas de rotação glenoumeral e coracoacromial. As alterações desse intricado mecanismo são as causas mais comuns de problemas de dor nos ombros. No caso relatado, o lipoma era do tipo parosteal e crescia no compartimento entre os músculos deltoide, infraespinhoso, redondo menor e o úmero.O ombro é moldado por quatro barreiras anatômicas : escápula com seus músculos; clavícula; úmero proximal; e o músculo deltoide. Nesses espaços, os tumores crescem na direção centrífuga, quando em contato com essas barreiras anatômicas.O tumor desta paciente aumentava a pressão do compartimento nas contrações musculares, alterando a relação concêntrica das esferas de rotação. Em seu movimento de arco, a articulação entre o úmero e a escápula é formada por duas esferas concêntricas.A esfera umeral é representada pela cabeça do úmero (com o menor raio), e a esfera do arco coracoacromial é formada pela superfície inferior do acrômio anterior e o ligamento coracoacromial (com o raio maior). As duas esferas têm o mesmo centro de rotação e juntas mantêm a melhor condição de estabilidade para o ombro e para a superfície disponível para transferir a carga escapular. Neste caso, ao levantar seu braço, a sincronia na contração do deltoide, infraespinhoso e redondo menor é interrompida, devido ao lipoma interposto entre os músculos. O movimento perde sua coordenação e causa o impacto da tuberosidade maior contra o arco coracoacromial.A amplitude de movimento na elevação do braço, no plano escapular é de zero a 180°. Na fase inicial do movimento até 90°, a fixação da escápula ocorre sobre a parede torácica, pela contração dos músculos trapézio e serrátil anterior. Os músculos do manguito do rotador abaixam e fixam a cabeça do úmero na cavidade glenoide, e, ao mesmo tempo, o músculo deltoide, com predominância das porções média e posterior, atua ao levantar o braço. Quando o membro superior alcança uma elevação de 90°, a tuberosidade maior, para se movimentar por baixo do arco coracoacromial, requer a rotação externa do úmero, produzida pela contração dos músculos infraespinhoso e redondo menor. Esses músculos agem em sincronia, e produzem um movimento suave e coordenado.A ressecção do tumor restabeleceu a concentricidade das duas esferas de movimento  durante a rotação lateral nos graus finais de elevação. Isso ocorreu pela recuperação da congruência da articulação glenoumeral em seu arco completo de movimento, que levou ao alívio de sintomas da síndrome do impacto. A limitação deste relato de caso foi a falta de eletroneuromiografia, solicitada à paciente. Esse exame complementar poderia detectar a compressão do nervo axilar no espaço quadrangular, que mimetiza os sintomas de pacientes.shoulder impingement syndrome” [Mesh] OU “shoulder joint” [Mesh] OU “rotator cuff” [Mesh]) E “Lipoma” [Mesh] [“síndrome do impacto no ombro” OU “articulação do ombro” OU “manguito do rotador” E “lipoma”].Para encontrar artigos que avaliassem pacientes com a síndrome subacromial relacionada ao lipoma, fizemos a busca em MEDLINE via PubMed (1966 a julho de 2013), EMBASE  e LILACS (1982 a julho de 2013). Não houve limites de idiomas ou estado da publicação em nossa busca. Verificamos também as referências de artigos e revisões para outros estudos potencialmente relevantes. Nossa estratégia de busca combinou os termos específicos (“-15)A estratégia de busca  identificou um total de 36 registros nos seguintes bancos de dados: PubMed (19), EMBASE (11), LILACS (6). O resultado da busca foi a identificação de seis artigos que avaliaram pacientes com doença de ombro associada à lipoma. relataram um caso de lipoma localizado na região do subdeltoide, que causava sintomas de instabilidade glenoumeral. Nisolle et al. apresentaram o caso de um homem de 44 anos com lipoma arborescente na bursa do ombro direito, associado à laceração do manguito do rotador. Relwani et al. descreveram o caso de uma paciente de 52 anos, com sinais clássicos de impacto no ombro; a paciente tinha um lipoma subacromial anterior que causava os sintomas. Os dois artigos de relato de caso ilustram dois casos de pacientes masculinos – 45 e 51 anos, com sinais e sintomas consistentes com síndrome do impacto, cuja etiologia era lipoma intramuscular que envolvia o músculo supraespinhoso., 14 Além disso, um relato de caso recente apresentou um paciente masculino, de 38 anos, com sintomas que mimetizavam tanto a instabilidade glenoumeral como o impacto subacromial, devido a um lipoma intermuscular subdeltoide. Em todos os casos, os sintomas desapareceram após a cirurgia e fisioterapia.Rohrbough e JobeConsideramos nossa estratégia de busca abrangente, sem nenhuma restrição quanto a idiomas. Incluímos também busca manual (literatura cinzenta) e buscas por revisões e relatos de casos recentes e em andamento. Entretanto, é possível que tenhamos negligenciado alguns estudos potenciais que descreviam um caso semelhante. Portanto, em nosso entender, o relato deste artigo é um caso atípico de um lipoma parosteal do úmero proximal, que resultou em sinais e sintomas de impacto subacromial. O mecanismo que desencadeou os sintomas foi diagnosticado no pré-operatório por RM.


MYC gene amplification, a genetic aberration that is increasingly unifying the various clinicopathologic subdivisions of angiosarcoma. We therefore report the MYC gene status in a case of angiosarcoma arising at an AVG site.Angiosarcoma arising in association with an arteriovenous graft (AVG) or fistula is a unique clinicopathologic scenario that appears to be gaining recognition in the literature. Among reported cases, none has described high-level Certain predisposing conditions have been clearly associated with angiosarcoma, including (i) radiation exposure, such as ultraviolet light in skin cases and therapeutic irradiation in breast cases; (ii) longstanding lymphedema ; and (iii) exogenous toxins  in liver cases . AngiosaAn AVG or fistula is an artificial connection between an artery and a vein created with synthetic materials such as polytetrafluoroethylene (PTFE) or Dacron . Implant MYC gene amplification in angiosarcomas suggest a genetic basis for the disease [ MYC gene is a potent oncogene that is amplified in various clinicopathologic subdivisions of angiosarcoma, including secondary (postirradiation and lymphedema-associated) and a subset of primary angiosarcomas  [ MYC amplification status has not yet been described in the unusual setting of AVG-associated angiosarcoma; we therefore report MYC amplification status in one such case.Recent findings of frequent high-level disease . The MYCnd bone) –19. MYC A 63-year-old Hispanic man presented in 2013 for evaluation of left arm pain in an area where an AVG had been placed 15 years previously . The AVG had not been in use for eight years owing to a kidney transplant in 2005. Prior to the transplant, the patient required regular hemodialysis due to end-stage renal disease from chronic hypertension and diabetes.Physical examination revealed swelling and tenderness of the AVG site, which was attributed to probable thrombosis. This was pursued by angiogram, which was interpreted as a thrombosed pseudoaneurysm at the site. The angiogram also disclosed an unexpected finding: a destructive mass involving the elbow. Further imaging with MRI studies revealed a 20 cm mass encircling the elbow and tracking distally into the forearm. The mass was biopsied to show angiosarcoma, resulting in transhumeral amputation. Six months after the amputation, the patient is alive without evidence of sarcoma.Initial biopsy of the mass disclosed clusters of malignant epithelioid cells adjacent to poorly formed vascular spaces that showed strong, diffuse expression of vascular markers by immunohistochemistry . Patchy  MYC was performed on formalin-fixed, paraffin-embedded tissue sections cut at 5 mm using commercially available break-apart FISH probe-set for the MYC locus (8q24), with the 5′ probe labeled with Spectrum Red and the 3′ probe labeled with Spectrum Green . With this probe-set a yellow fusion signal is produced by the juxtaposition of the 5′ and the 3′ probe when the MYC locus has a normal configuration. Standard laboratory protocols and quality control measures were followed for this study. In each case, 100 interphase nuclei were analyzed in a blinded manner by two technicians . Amplification of the MYC locus was defined as the presence of increased number of MYC signals (more than 6) in tumor cells. Clear high-level MYC amplification was seen in large areas, with an average of more than 20 signals per cell (FISH analysis for the quantitation ofper cell . MYC amplification in this case of AVG-associated angiosarcoma expands the spectrum of recognized clinicopathologic subtypes of angiosarcoma bearing this aberration and suggests they share similar pathogenesis. The present case exhibited large regions of clear signal amplification by FISH, consistent with the most commonly observed pattern described in the literature for angiosarcoma [ MYC gene amplification is augmentation of a cell's preexisting gene expression program [ MYC amplification in this case does not necessarily exclude a pathogenic role for the synthetic graft material. There is evidence to suggest that the fibrous capsule that develops around foreign material may stimulate carcinogenesis by providing a home-base for macrophages, which secrete cytokines, growth factors, and free radicals that can induce genetic damage, even after fibrosis is complete [ MYC gene aberration in foreign body-associated angiosarcoma. Although the fibrous capsule in this case was fully appreciated, documentation of fibrous encapsulation tends to be inconsistently reported [The finding ofosarcoma . One of  program  and prom program . The precomplete . Perhapsreported .Alternatively, the graft material may itself directly provoke angiogenesis and subsequent tumorigenesis. Indeed, newer-generation “biopolymers” seek to incorporate bioactive molecules that directly stimulate vascular regeneration . Further