Well differentiated neuroendocrine tumours (carcinoids), arising from cells of the diffuse neuroendocrine system, represent the most commonly encountered gastric endocrine tumours. Gastrointestinal stromal tumours (GISTs), which stem from interstitial Cajal cells located within the wall of the gastrointestinal tract and have a characteristic immunoreactivity for CD117 (c-kit protein), account for the majority of gastrointestinal mesenchymal neoplasms. Simultaneous occurrence of a GIST with a well differentiated neuroendocrine tumour in the stomach is very rare.Clinical history, endoscopy and histopathological findings were utilized for our diagnostic considerations.We report the coexistence of a high risk GIST with a well differentiated neuroendocrine tumour of benign clinical behavior, both located in the stomach, in a 62-year-old man previously operated for a gastric well differentiated neuroendocrine tumour with uncertain malignant behaviour.Even single well differentiated, sporadic, NETs of small size may coexist with GISTs. An appropriate initial therapeutic approach combined with a scrupulous follow-up seems to play a significant role in terms of preventing a metastatic disease. Gastrointestinal neuroendocrine tumours (NETs) are thought to derive from cells of the diffuse neuroendocrine system of the gastrointestinal (GI) tract . In the Gastrointestinal stromal tumours (GISTs) are mesenchymal neoplasms stemming from the interstitial cells of Cajal localized within the wall of the GI tract ,6. GISTsGISTs have been reported to coexist with a variety of neoplasms, the percentage of such cases ranging from 4.5% to 33% ,13; in sWhat is more, coexistence of GISTs with gastrointestinal tract endocrine tumours, such as ileal well differentiated NET  or well In this context, we hereby present the case of synchronous occurrence of a GIST and a well differentiated NET, both located in the stomach of a male patient. Our report seems to be distinctive as it comprises unique clinical and histopathological findings.A 58-year-old male was admitted for chronic muscular pain. During hospitalization, an episode of melena occurred, following which he underwent both colonoscopy and gastroscopy; the latter disclosed an approximately 1.2 cm large lesion in the greater curvature of stomach Figure -23. AdjaHowever, four years post-op, CT showed a well delineated, 3.5 cm large, intramural lesion in the esophagogastric junction. Serum gastrin levels were within normal limits. The patient underwent excision of the remaining part of the stomach; this corresponded to a subtotal gastrectomy (with subsequent reconstruction of the GI tract) specimen with a 35 cm long greater and a 14.5 cm long lesser curvature, respectively, together with a 1.9 cm long duodenal cuff. A stenosis was observed in the incisura angularis; moreover, a protruding, multilobular, 3.5 cm large tumour was located close to the esophagogastric junction, on the anterior wall of the stomach, presenting, upon sections, a whitish color with brownish foci and a fibrous consistency. The remaining gastric mucosa was unremarkable.Histology showed the tumour to consist of interlacing bundles of spindle cells Figure . A totalMoreover, in the stenotic area of the incisura angularis (vide supra), a totally excised, 0.4 cm large, well differentiated NET of benign clinical behavior was identified: it was located in the mucosa and submucosa and consisted of a monomorphic cellular population, with inconspicuous mitotic activity, forming adenoid or solid aggregates Figure . An AlciOf the previous reports regarding the simultaneous occurence of GIST and well differentiated NET in the stomach we achieved to retrieve data only for three cases. Specifically, one case concerned a 69-year old male with negative family history of cancer who underwent removal of a sessile polypoid mass in the corpus of the stomach. Histological examination of the resected specimen demonstrated a submucosal borderline GIST, while in the overlying mucosa a well differentiated NET (carcinoid), invading the lamina propria and initially infiltrating the submucosa, was recognized. Neither H. pylori microorganisms nor foci of intestinal metaplasia were identified in the surrounding mucosa. The patient died of unrelated cause (heart attack) twelve months after the surgical intervention, while imaging findings were all negative concerning metastatic deposits from the above-mentioned lesions .The second case concerned a 65-year-old female with a low-risk GIST on the anterior wall of the upper gastric corpus concomitant with a type III well differentiated NET localized on the posterior wall of the upper gastric corpus; no recurrence of either tumour occurred 28 months after excision . In the Regarding pathogenetic mechanisms implicated in the dual development of GIST and well differentiated NET in the stomach, data are still insufficient. Though a role of H. pylori infection cannot be excluded, it is at present not clear, perhaps due to the small number of cases so far reported. Thus, Lin et al. did not conclude any definite causal relationship among GIST, well differentiated NET and H. pylori infection , a pointGastric well differentiated NETs account for 8.7-41% of all gastrointestinal well differentiated NETs . Their cIn our report, both well differentiated NETs were single lesions; despite the fact that the first tumour arose in the context of endocrine cell hyperplasia, the absence of serum autoimmunity indices precludes its classification as a type I gastric well differentiated NET; both tumours, therefore, correspond to type III according to the WHO classification -4.According to the WHO classification, benign behavior of well differentiated NETs is associated with the following criteria: cytologically bland tumour confined to mucosa and/or submucosa, non-angioinvasive, less than 1 cm in size, non-functioning; these features are mainly found in tumours arising in the context of A-CAG or MEN-1/ZES. On the contrary, uncertain malignant behavior of well differentiated NETs is associated with a nonfunctioning, cytologically bland tumour, measuring 1 to 2 cm in diameter, confined to the mucosa and/or submucosa. Angioinvasion may be present in these lesions -23. ThisLimited surgical interventions (including endoscopic manipulations) remain the mainstay treatment for type I gastric well differentiated NETs . PartialGISTs, thought to arise from interstitial Cajal cells of the gastrointestinal wall ,6, demonOptimal therapy includes surgical excision and treatment with imatinib. The latter is appropriate for non-operable tumours, cases where total excision is impossible or for recurrences ,30.Concerning prediction of clinical behavior, the initial proposal formulated by the National Institute of Health (NIH) GIST Workshop in 2001 defined the risk for aggressive behavior based on tumour size (single largest dimension) and mitotic count (number of mitotic figures per 50 HPF) , classifIn conclusion, we presented a rare case of a well differentiated NET concurrent with a GIST in the stomach. Gastroenterologists and pathologists, in particular, should be aware of this rare phenomenon given that even single well differentiated, sporadic (unrelated to hypergastrinemia or A-CAG), NETs of small size may coexist with GISTs, as it was shown in our case. A meticulous follow-up  should be performed to all patients suffering from the afore-mentioned neoplasms so as the devastating consequences of a metastatic disease to be avoided.The authors declare that they have no competing interests.All authors have made substantive intellectual contribution to the case report. VDS: Writing of manuscript, conception and design of case report. PGF: Writing of manuscript. KT: Analysis of endoscopic findings. VL: Revising and editing of manuscript, histological diagnosis. DT: Analysis and interpretation of clinical data. EMT: Analysis and interpretation of clinical data. AM: Revising of manuscript. IGP: Revising and editing of manuscript, histological diagnosis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/11/27/prepub


Precursor B-cell lymphoblastic lymphoma (PBLL) is an infrequent subtype of lymphoblastic lymphoma (LBL) that commonly affected site for the diagnosis is the skin, followed by the head and neck. In this report, we presented a special case of PBLL located at the left arm and detected with magnetic resonance imaging (MRI) and ultrasonography (US). This kind of PBLL is similar to a peripheral nerve tumor in clinical and radiographic manifestation. It is already documented that lymphoblastic lymphoma (LBL) is an uncommon entity of non-Hodgkin’s lymphoma (NHL) with an incidence of less than 1% for B-cell LBL among all NHLs . B-cell A 22-year-old man was referred to a physician complaining of severe pain for 6 months from a progressively growing mass in the left arm. Medical history was unremarkable and the patient was not receiving any medication. He denied weight loss, night sweats and other unusual symptoms. Physical examination identified a fusiform palpable mass extending from the middle of the left arm to the elbow, combined with muscle weakness and numbness on forced flexion and supination. The laboratory results of kidney and liver functional tests, as well as the white blood cell counts and serum lactate dehydrogenase (LDH) levels, were within the normal range. The cerebrospinal fluid immunocytochemical analysis, bone marrow aspiration and biopsy showed negative for any malignancy. In addition, no positive symptoms were found on chest radiography or abdominal ultrasound (US).Magnetic resonance imaging (MRI) revealed a well-defined mass located in the medial compartment of the left arm, with homogeneous and intermediate signal intensity on the axial T2-weighted image Figure A and isoHigh-resolution US established a marked hypoechoic lesion on the left distal arm. The hypoechoic lesion showed a clear round halo which was completely and concentrically encased in the median nerve in transverse sonograms. The median nerve was much larger than normal and was characterized by swollen fascicles Figure A. LongitThrough surgery, a well-defined and fusiform mass was found on the left arm. The tumor extending along the neurovascular bundle and in continuity with the median nerve seemed to originate from the median nerve. After resection of the fragile fleshy mass, the marked swollen median nerve was also noticed Figure . The medHistologic examination revealed a diffuse dense monomorphic infiltration from small to intermediate-sized lymphoblasts Figure A showing6/L, and no red blood cells (RBCs). The diagnosis of central nervous system (CNS) involvement was established. MRI of the brain was unremarkable. Neck, chest, and abdomino-pelvic sonography revealed no other involvement site except for a few axillary lymph nodes less than 10 mm in size. The patient died of multiple organ failure early in the course of high-dose methylprednisolone treatment shortly after being readmitted. Request for autopsy was denied.Clinical symptoms including severe pain and numbness were relieved soon after the surgical procedure of decompression. Local radiotherapy was applied to his left arm. PET and Gallium scintigraphy were not performed at diagnosis under cost constraints. He received two cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy in the following 2 months. The patient was readmitted to our hospital due to persistent headache for a week before initiation of further chemotherapy. Cerebrospinal fluid (CSF) examination showed glucose 2.90 mmol/L, increased protein at 0.60 g/L, 90% mononuclear cells, 10% polykaryocytes, karyocyte count 90 × 10LBL is a rare disease that shares the same biologic features as the acute lymphoblastic leukemia (ALL). Indeed, LBL and ALL are considered to be a single entity (lymphoblastic leukemia/lymphoma T and B types) in the World Health Organization (WHO) classification of precursor lymphoid neoplasms . LBL is The presenting signs and symptoms with LBL are shown in the primary sites where the disease is involved . HoweverThe MRI findings in our patient are similar to those of musculoskeletal lymphoma in the previous studies ,10, suchThe advantage of sonography in comparison with MRI is its ability to trace the imaged nerve segments in a single study and with superior resolution . The enc6/L or more white blood cells (WBCs) on CSF cytospin. The presence of CNS leukemia is an adverse prognostic factor and a potentially fatal complication of lymphoma [PBLL is a highly aggressive subtype of lymphoma, with frequent bone marrow involvement, and a 5% to 10% incidence of CNS involvement [lymphoma . The mailymphoma , as was lymphoma ,5. The vWe experienced a PBLL presenting as a mass, and posing diagnostic difficulties for the referring clinician and radiologist. This could be mistaken for an enlarged neurogenic tumor.Written informed consent was obtained from the patient’s parents 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.ALL, Acute lymphoblastic leukemia; CNS, Central nervous system; CSF, Cerebrospinal fluid; H & E, Haematoxylin and eosin; LBL, Lymphoblastic lymphoma; LDH, Serum lactate dehydrogenase; MRI, Magnetic resonance imaging; NHL, Non-Hodgkin’s lymphoma; PBLL, Precursor B-cell lymphoblastic lymphoma; RBC, Red blood cell; US, Ultrasound; WBC, White blood cells; WHO, World Health Organization.The authors declare that they have no competing interests.XFS carried out the study design and writing. WYL and WG helped to draft the manuscript and participated in the literature search. XY performed the operation on the patient. FX performed acquisition of data and helped to draft the manuscript. All authors read and approved the final manuscript.


Situs inversus totalis (SIT) is not itself a premalignant condition, however, rare synchronous or metachronous multiple primary malignancies have been reported. Herein we present a case of synchronous transverse and sigmoid colon cancers and a case of metachronous rectosigmoid colon and gastric cancers in patients with SIT.A 66-year-old male with SIT was referred for a two-month history of hematochezia. Synchronous colonic tumors were found on the proximal transverse and sigmoid colon. The patient underwent open total colectomy and was discharged without incident. A 71-year-old female with rectosigmoid colon cancer and SIT underwent laparoscopy-assisted low anterior resection. Fourteen months after the surgery, the patient developed a single hepatic metastasis and underwent hepatic segmentectomy (S6). Forty-six months after laparoscopy-assisted low anterior resection, the patient developed metachronous early gastric cancer on the antrum and underwent radical subtotal gastrectomy with gastroduodenostomy. The patient is doing well without recurrence for 28 months. The anatomical arrangement of human organs is described by three categories: situs solitus, situs inversus, and situs ambiguus. Situs solitus indicates the normal arrangement of the heart and intra-abdominal organs. Situs inversus is a rare congenital deformity and is classified as either situs inversus totalis (SIT) or partial situs inversus. Unlike partial situs inversus, in cases of SIT, the left and right aspects of the thoracic and intra-abdominal organs are inverted like a mirror image . Situs aSitus inversus itself is not a premalignant condition; however, rare synchronous and metachronous multiple primary gastrointestinal malignancies have been reported in the literature. On review of the Korean literature, one case of synchronous gastric and esophageal cancers in a 49-year-old male with SIT  and one A 66-year-old male was referred to the Colorectal Surgical Department for a two-month history of hematochezia. The patient had been diagnosed with alcoholic liver cirrhosis four years prior. Barium double contrast study and colonoscopy showed ulcerative tumors on the proximal transverse and sigmoid colon Figures  and 1b. A 71-year-old female was referred to the Colorectal Surgical Department for a four-month history of tenesmus and intermittent hematochezia. Physical examination and routine laboratory studies were unremarkable. Barium double contrast study and colonoscopy showed ulcerofungating tumors on the rectosigmoid colon Figure . An abdoIn the general population, the reported incidence of synchronous colon cancer ranges from 3 to 8% , and theThe occurrence of malignancy in patients with situs abnormalities may be sporadic, though some have suggested a possible relationship between situs abnormalities and cancer. One theory is that unidentified genes affecting left-right axis arrangement may be related to cancer susceptibility. The pathogenesis underlying this hypothesis has not been well characterized .The diagnosis of synchronous gastrointestinal malignancy or metachronous malignancy during follow-up is straightforward due to advances in endoscopy and radiological imaging. However, before surgical treatment, careful preoperative anatomic evaluation is important because situs abnormalities may accompany major vascular anomalies . FortunaIn this study, when performing laparoscopic surgery in patients with rectosigmoid colon cancer, the operator was positioned on the left side of the patient, which is opposite the position used for a normal patient. The right-handed operating surgeon had difficulties performing distal rectal transection through a left lower quadrant port and thus used four endoscopic staple cartridges. Oms and Badia  proposedAlthough double primary gastrointestinal malignancies associated with colon cancer in patients with SIT are very rare, the possibility of synchronous lesions or the occurrence of metachronous cancer of the alimentary tract should not be overlooked, and careful preoperative evaluation is important for successful surgical treatment.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.SIT: Situs inversus totalis.The authors declare that they have no competing interests.IYK took part in the design. HR and DSK acquired the data. YWK drafted the manuscript and made revisions. All authors read and approved the final manuscript.


Large bowel seed bezoars are rare and are mostly due to seeds of sunflower, prickly pear cactus, sesame and cucumber. We present a rare case of sigmoid colon seed bezoar due to Box Myrtle seeds because of an underlying benign stricture. A bezoar is the result of the ingestion of indigestible or poorly digestible substances that accumulate in the gastrointestinal tract in the form of a mass. It can result from any substance that is capable of forming concretions within the gastrointestinal tract. The classification of a bezoar is according to the foreign material that constitutes its core and includes - trichobezoar (hair), phytobezoar (fruits or vegetable fibers), lactobezoar (milk curd), lithobezoar (rock-like substances) or combinations like trichophytobezoars.2 Cases o79A 35-year-old female patient presented in the surgery department with dull abdominal pain in the left paraumblical region. She gave a history of progressively worsening obstipation for the past 2 years for which she was using laxatives. No clinical features of obstruction were present. Her routine laboratory tests were normal, except for mild leukocytosis.“Kaiphal” or Box Myrtle along with the seeds about 3 weeks ago. Based on the USG findings and history, a diagnosis of colonic seed bezoar was suggested. Contrast-enhanced CT scan of the abdomen revealed the presence of a mass-like lesion in the sigmoid colon involving an approximately 7-cm segment. It was composed of multiple tightly packed ovoid densities having a seed-like appearance, the size of individual seeds ranging from 4 to 8 mm. These showed a hyperdense periphery  with a relatively hypodense center  with air in the interstices, giving a mottled appearance. Mild associated inflammatory changes were present with circumferential mural thickening (3-4 mm) and stranding of the pericolonic fat [The abdominal radiograph showed localized mottled lucencies in the left lower abdomen. USG revealed mild wall thickening in the region of the sigmoid colon with the presence of an intraluminal, curvilinear, hyperechoic arc-like surface casting a prominent posterior acoustic shadow . Scanninonic fat . A tightThe patient was taken up for colonoscopy and the stricture was dilated. The seed bezoar was disimpacted and 300 g of largely undigested seeds were removed. Biopsy taken from the stricture revealed fibrosis, and no evidence of malignancy was detected.Seed bezoars occur after consuming large quantities of seeds either by eating the fruit together with the seeds or by eating the seeds themselves. In one retrospective study in Israel on fecal impaction by seed bezoars in the rectum in hospitalized patients, phytobezoars were found in 30 patients. The seed bezoars were composed of prickly pear seeds in 12 patients, watermelon seeds in 10 patients, sunflower seeds in 4 patients and popcorn kernel and pomegranate seeds in one patient each.[“Kaiphal,” also known as Box Myrtle or Myrica esculenta, is a tree found abundantly in the Indian Himalayas. It bears small berry-like fruits that are usually consumed without seeds. Our patient had consumed large quantities of this fruit along with the seeds because of a lack of awareness. The seeds then became impacted in the sigmoid colon due to the presence of a benign short segment stricture. There is one case report of a patient who presented with large bowel obstruction, which was found to be due to a sesame seed bezoar in the sigmoid colon proximal to a benign postoperative anastomotic site stricture.[tricture.While plain radiographs of the abdomen may be useful in the evaluation of intestinal obstruction, bezoars themselves are only rarely identified. This is because the imaging feature of a bezoar is not characteristic, and can be mistaken for feces or abscess. USG may show the presence of an intraluminal mass with a hyperechoic arc-like surface showing marked acoustic shadowing and may CT scan is considered to be the imaging modality of choice for confirming gastrointestinal bezoars, and shows an intraluminal mass with air in the interstices or an inhomogeneous mass with a mottled gas appearance. CT scan also determines the point of obstruction; it can confirm that the bezoar is the underlying cause of obstruction and also helps detect the existence of additional bezoars. Our pati


Neuroendocrine tumors (NETs) frequently metastasize to the liver, but it is rare to find them there as primary tumors. Isolated polycystic liver disease (PCLD) is a rare autosomal dominant disease. There is no known association between polycystic liver disease and neuroendocrine or other tumors. We report a case of a 64-year-old female with a past medical history of isolated PCLD who presented with increasing abdominal pain over a two-week period. Our patient underwent open surgical biopsy one month after presentation. The histological examination and immunohistochemical findings suggested an intermediate grade neuroendocrine tumor. A 24-h delayed whole-body scintigraphy technique was utilized for the identification and localization of neuroendocrine tumors via the administration of In-111-labeled OctreoScan; however, no extrahepatic accumulation was observed. No previous studies in the literature describe a patient with PCLD and a primary or metastatic neuroendocrine tumor of the liver. Neuroendocrine tumors (NETs) frequently metastasize to the liver, but it is rare to find them there as primary tumors. NETs represent 2% of all tumors in the gastrointestinal tract and they have an annual incidence of 2–3 individuals out of 100,000 per year, with an overall slight preponderance in females (Isolated polycystic liver disease (PCLD) is a rare autosomal dominant disease with an incidence of <0.01%. The majority (>80%) of PCLD patients are clinically asymptomatic. Certain patients develop symptoms of a cystic enlarging liver, which causes morbidity and mortality . In PLCDThe study was approved by the ethics committee of General Hospital of Naoussa, Naoussa, Greece. Written informed consent was obtained from the patient’s family.A 64-year-old female presented with increasing abdominal pain over a two-week period. The patient was a non-smoker, did not consume alcohol and denied any systemic symptoms of fever, weight loss or anorexia. No cardiac, neurological or other symptoms were reported. The patient had a past medical history of isolated PCLD, which was discovered two years previously, and an ectopic left kidney. No family history of polycystic kidney or liver disease was reported. A clinical examination revealed massive hepatomegaly, and this was confirmed by ultrasonography. No other abnormalities were detected.Laboratory investigations revealed that the patient had normal renal function with an estimated glomerular filtration rate of >60 ml/min. The hemoglobin, white cell count differentials and coagulation screen were all within the normal range. Liver function tests revealed raised alkaline phosphatase and γ-glutamyltransferase levels of level of 475 and 531 IU/l, respectively, and a slightly low albumin level of 2.2 g/dl with a total protein level of 6.4 g/dl. The levels of total bilirubin and alanine transaminase were 2.5 mg/dl and 50 IU/l, respectively. Tumor marker levels, including those of AFP, CEA, CA 19-9 and CA 125, were not observed to be elevated.Contrast computed tomography (CT) examination of the abdomen confirmed massive hepatomegaly and a polycystic liver with multiple scattered cystic formations. A number of these included septals, hemorrhagic material and several nodular-compact internal lesions, which was corroborated following intravenous contrast injection .The patient underwent open surgical biopsy one month following presentation. The histological examination and immunohistochemical findings suggested an intermediate grade neuroendocrine tumor .A 24-h delayed whole-body scintigraphy technique for the identification and localization of neuroendocrine tumors via the administration of In-111-labeled OctreoScan was used; however, no extrahepatic accumulation was observed.Two weeks after the biopsy, the patient presented with dyspnea. A large right pleural effusion was confirmed by X-ray of the chest and triplex, while ultrasound examination of the legs revealed deep venous thrombosis (DVT). The patient succumbed a few days later.Despite significant physical examination and radiological findings, the majority of patients remain asymptomatic with preserved liver function, and only mild elevations in the γ-glutamyltransferase and alkaline phosphatase levels are observed . CertainSurgery remains the mainstay of treatment when patients become symptomatic. Surgical intervention comprises cyst aspiration and sclerosis, fenestration with and without hepatic resection and orthotopic liver transplantation .Primary neuroendocrine tumors of the liver are rare. The frequency of primary NETs reported to occur in the liver or biliary tract is <1%. Unknown primary sites or uncommon sites account for 11–14% of cases . NeuroenThere is no known association between PCLD and primary or metastatic neuroendocrine tumors. A rare correlation between PCLD and intracranial meningiomas was recently described, which was likely to have occurred by chance rather than to represent a previously unrecognized association between PCLD and cranial meningioma .Additionally, a case of liver failure in a patient affected by PCLD and liver metastases from breast carcinoma was described . ExtrahePatients with neuroendocrine tumors may be evaluated by computed tomography (CT) or magnetic resonance imaging (MRI), and the functional status of these tumors is assessed by physiological imaging via scintigraphy, with agents such as radiolabeled meta-iodobenzylguanidine (MIBG) or radiolabeled octreotide (Octreoscan) . An-111-No studies in the literature describe a patient with autosomal dominant isolated PCLD and a primary or metastatic neuroendocrine tumor of the liver. The death of our patient did not allow for further diagnostic examination, such as a positron emission tomography (PET) scan, to exclude any primary site other than the liver. However, the scintigraphy test and the MRI of the chest and abdomen did not reveal any suspicious regions in organs other than the liver.


An ectopic or accessory limb attached to the back is an extremely rare and strange condition, and there are only a few documented cases in the worldwide literature. The first case was described by Jones and Larkin (1889). There are several theories regarding the origin of this condition. Asymmetric conjoined twinning which is located dorsally in the vertebral column (rachipagus) is the most probable diagnosis of our patient. Conjoined twinning is very rare and the incidence is 1 per 50 000 live births. Rachipagus is even rarer, with no more than 30 case reports so far ). In this report, we present a patient who underwent successful surgical excision of a third arm attached to the back in the midline over the low-dorsal region. Differential diagnoses including teratoma and fetus in fetu are discussed. A female baby was born by C/S after an uncomplicated full-term pregnancy, weighing 3500 g with Apgar scores 8 and 9 at the first and fifth minutes, respectively. The patient did well; she was referred to our Pediatric Care Unit.Antenatal course was uneventful and no history of maternal medication or harmful drug use or exposure to radiation during pregnancy was reported. Her mother was followed up during pregnancy. She had several prenatal ultrasound examinations, but her daughter's abnormality was diagnosed postnatally.On physical examination, a malformed accessory extremity, resembling a rudimentary structure like a tiny arm, was attached to the back, in the upper-dorsal region of the vertebral column Figures . The accAbdominal and cranial ultrasonography (USG), thoracic computed tomography, and magnetic resonance imaging (MRI) were performed. Cranial USG showed no abnormality. Brain and medulla spinalis were normal in MRI except a 2 cm lipoma located at the same level with the origin of the ectopic extremity. There was no associated meningocele or myelocele. Abdominal organs appeared normal on USG. Thoracic CT revealed spina bifida from 5th cervical to 7th dorsal vertebrae level . CoronalThe MRI demonstrated that medulla spinalis terminated between L3 and L4 vertebraes. Ectopic arm was originated from subcutaneous soft tissues and it did not extend to deeper neural elements. It ended with interspinous ligament Figures . RoutineSurgical operation was performed when the baby was two months old. Midline skin incision was performed between the first and the seventh thoracic vertebrae of the dorsal region. Incision extended around the accessory extremity so that the periphery of the mass and its globular appendages were liberated. The mass was attached firmly to the laminae of the dorsal vertebrae. It was excised totally. There was no relationship between the mass and the underlying dura mater, and intraspinal structures. A significant closure defect was observed at the level of the fifth thoracic vertebrae, and a single level laminectomy was made using a Kerrison punch. Dura mater was incised and a spinal lipoma was observed. However, it was wrapped tightly around the nerve fibers; thus it could not be excised. Finally, closure of the subcutaneous tissues and skin was performed. The infant did not require postoperative ventilation and made an uneventful recovery. She began oral feeding with no complications on the same day, six hours after the operation. She was discharged on the fourth day of hospitalization. Histopathological examination revealed normal muscle tissue extending along the ectopic extremity and three bones resembling metacarpal bones and phalanges. There were no neural, cartilaginous, or vascular tissues. At the bottom of the mass, the lesion was covered by a thin-walled hemorrhagic mucosa. Microscopically, a primitive type intestinal mucosa resembling colonic mucosa was noted in this region. DNA analysis was performed. DNA samples from the blood and hair of the autosite and from the skin and muscle of the parasitic twin were extracted using the rapid Chelex-100 method. A sex locus (amelogenin gene) and 15 STR loci were amplified using the Powerplex TM 16 system. DNA analysis revealed that the parasitic twin in this report had an identical genotype to the autosite, which indicated that it was of monozygotic origin. The patient is currently 14 months old and completely healthy.Heteropagus is a term used to describe the development of an asymmetrical form of twinning when one of the twins monopolizes the placental blood at the expense of other fetus with consequent ischaemic atrophy of the latter . Some paBased on the typical appearances and histological results, diagnosis of rachipagus is made easily but rarely the differential diagosis may be required from teratoma and fetus in fetu , 10. TerNeural tube defects associated with ectopic limbs have been reported in a few cases. Krishna et al. reported accessory legs associated with spina bifida and rudimentary external genitalia . Sharma In summary, a case of rachifagus is presented herein, which had the limb buds very similar to extremities, was located at the midline of the dorsal region, and attached to the vertebral column. The literature of this amazing condition was reviewed. We concluded that this anomaly was limited to the infant's dorsum. Nevertheless, other midline pathologies including vertebral column, medulla spinalis, and heart should be kept in mind. Thus, careful preoperative examination of the patient is essential for a good postoperative outcome.


Colon interposition is an established technique for esophageal reconstruction. We describe the case of primary adenocarcinoma arising in a colonic interposition graft that was performed after total esophagectomy for recurrence adenocarcinoma derived from the Barrett esophagus. In 1911, Kelling and Vuillet described the anatomic and surgical bases for the use of colon as replacement for the esophagus .Early postoperative complications are common, including necrosis of the transplant, leaks, fistulae, and strictures at the anastomoses. Late complications are rare. We describe an unusual late complication of a primary adenocarcinoma arising in the interposed colon after a right colonic bypass in a patient with adenocarcinoma derived from the Barrett esophagus.A 66-year-old male presented with history of progressive dysphagia for solid food.Six years ago, he underwent a proximal gastrectomy and distal esophagectomy for adenocarcinoma derived from Barrett esophagus. Four years later, an esophagoscopy revealed a recurrence at the anastomotic site. A biopsy of the lesion showed a well-differentiated adenocarcinoma of the esophagus. Further investigation showed no evidence of metastatic disease, and a three-stage procedure with total esophagectomy was performed. The right-sided colon from the ileocaecal junction to the mid-transverse colon was used in a prevertebral position to reestablish continuity between the cervical esophagus and the remnant of the pyloric antrum. Histological examination revealed a pT2N0 lesion, and the patient recovered well without major complications. Two years after this intervention, the patient developed a progressive dysphagia for solid food. Endoscopy showed a circumferential mass arising from the colon , and bioHistological examination revealed a pT2 tumor of the colon and one normal lymphenode. The patient recovered well with a good functional conduit and remained disease-free now at 24 months.The potential use of a pedicled segment of colon to bypass esophageal pathology was first described since the early sixthies. Colonic grafts have been used in the treatment of both benign  and malignant oesophageal pathology . Early complications of this procedure are common, including graft necrosis, anastomotic leak, fistulae, and stricture of the anastomosis –5. OtherLate complications are rare: progressive fibrostenosis of the graft, peptic colitis with ulceration of the colonic segment, gastrocolic reflux, and colopericardial and colobronchial fistula were described , 7. The Primary carcinoma arising in a colonic interposition is obviously rare. Review of literature showed only 11 cases . These cThe late development of dysphagia in a patient with a colonic interposition graft should be examined seriously.Contrast studies of colonic grafts can be difficult to interpret due to altered anatomy. Barium esophagography has the advantage of providing functional evaluation of the graft and integrity of the conduit anastomosis. However, radiographic evaluations and interpretations of the interposed colon may be difficult if there is unfamiliarity with the various surgical procedures and the postoperative appearances , 11.Endoscopy with biopsy should therefore be considered.Computed tomography plays a limited role in the examination of the interposed colon. It may provide valuable evaluation of the extent of the tumor invasion and for the staging preoperatively.So far, there is no definable association between the primary carcinoma of the esophagus or stomach and the colon cancer , 21.As more patients are followed over a long period, the later sequelae of colon interposition will become more evident. Whether the interposed segment of colon is more likely to develop carcinoma than a normally sited segment of colon remains to be seen. In our case, a pre-existing lesion of the colon was indeed missed: during the examinations preoperatively an existing little spot was not remarked on PET scan . This waOn the other hand, to rule out the existence of a second primary cancer arising in the interposed colonic mucosa, an endoscopy of the colonic graft should be considered regularly as follow up in the postoperative period.In summery, malignancy arising in the interposed colon graft is rare. Total colonoscopy should be included in the preoperative setting when interposition of colonic segment needs to be used for replacement of the esophagus. This is to detect unexpected lesions.Development of new symptoms in a patient with a colonic graft should always be taken seriously and investigated.


Multiple symmetrical lipomatosis, or Madelung's disease, is a rare disease of unknown etiology. It is characterized by the presence of loose adipose tissue deposits localized in the cervical region and in the upper body. The neoformations grow slowly and their initial consequence is purely esthetic. They can, however, lead to compression of the laryngotacheal area and of the esophagus. This disease usually affects middle-aged males from the Mediterranean area with a history of alcohol abuse. Although most cases have been sporadic, a few authors have indicated that the disorder may be hereditary. It is thought that this pathology originates from an alteration in lipid metabolism. Since the patients were asymptomatic temperance and diet was proposed, surgical removal of the lipomatose mass is the treatment of choice in case of complications due to fat mass compression on upper aerodigestive tract. The authors present three cases of Madelung's disease with different and particular manifestations. Multiple symmetric lipomatosis (MSL) is a rare disease also known as Madelung's disease, Launois-Bensaude syndrome, and benign symmetric lipomatosis. The disorder was first described by Brodie in 1846 , 3.MSL is different from simple obesity, which is characterized by the presence of well-distributed total body fat. In patients affected by MSL symmetric, nonencapsulated fat masses are present in the face, neck, occipital region, and supraclavicular fossa. Fat deposits around the cervical region form a “buffalo hump” and a “horse collar,” while, fat deposits around the parotid region may appear as “hamster cheek.” Fat can penetrate deeply in the surrounding tissues, involving vessels, nerves, and muscles and compressing trachea and esophagus.The etiology is unknown although autosomal dominant or mitochondrial inheritance has been postulated. However, the great majority of cases of MSL occur in men aged between 30 and 70 years with known alcoholism (in 60/90% of cases). The disorder predominantly affects white males  of Mediterranean and eastern European populations .The diagnosis is usually easily made on the basis of the history, and clinical appearance. CT or MRI imaging further confirm the diagnosis and value the deeper fatty tissue distribution.A 65-year-old man presented to our department complaining severe dyspnea and with an 8-year history of a slowly growing fatty mass in the neck, trunk, and upper parts of the arms. The patient began to have difficulty breathing for the last two weeks according to the gradual growth of the mass. The patient had a history of heavy alcohol consumption, altered lipid metabolism, and was a nonsmoker. Laryngoscopic examination revealed fatty infiltration of the left preepiglottic and parapharyngeal space with reduction of the lumen of the laryngeal vestibule determining dyspnea . Compute A 55-year-old man presented with progressively enlarged masses around his neck for more than 7 years. He had a 25-year history of alcohol abuse. Laboratory examination showed elevated transaminases. Physical examination showed multiple soft masses involving the neck, occipital region, suprasternal, and supraclavear fossa . CT scan A 58-year-old man presented with a 5-year history of a painless, soft, and slow-growing swelling of the neck, upper trunk, upper back, and shoulders . The patTwo different types of lipomatosis have been identified: familial multiple lipomatosis (FML) and multiple symmetric lipomatosis (MSL). FML is characterized by discrete lipomas that interest the extremities and generally are absent from the neck and shoulders. MSL is a rare disorder marked by the presence of multiple, symmetric nonencapsulated fat masses in the face, neck, upper trunk, and occasionally other areas. Frequently associated findings include hyperlipidemia, hyperuricemia, gout, diabetes mellitus, hypertension, hypothyroidism, liver disease, and polyneuropathies.The pathogenesis of Madelung's disease is still unknown. Nevertheless, several hypothesis such as defect in the adrenergic stimulated lipolysis, a primary defect within the surface membrane of the adipocyte cell, or a defect in brown mitochondrial DNA (both in inherited and acquired defect) have been proposed , 6.The clinical course of MSL is characterized by a rapid progressing growth of the fat deposits during the early phases of the disease, which thereafter either slowly progresses or remains stable for many years. The long-term lipomatous deposits are often large and cosmetically deforming, furthermore they can cause compression of the upper aerodigestive tract and of great veins. Consequently the patient may complain of dyspnea, dysphagia, and venous stasis in advanced cases –10. MaliAlcohol withdrawal and weight reduction are recommended, although they cannot reverse or stop the course of disease. Medical treatment is not effective. Liposuction was proposed as MSL treatment in patients with smaller masses . SurgicaThe cases, described above, characterize three manifestations of the disease. The first one, beside cosmetic appearance, complained of involvement of the left-superior mediastinum and the laryngotracheal region with compression and dislocation of larynx and superior part of trachea. Fat tissue penetrated in larynx reducing the supraglottic space and provoking inspiratory dyspnea. Up till now, only 7 documented cases of direct laryngeal involvement by proliferating adipose tissue in MSL were reported in literature. All the authors proposed the same treatment: a surgical lipectomy in order to decompress the laryngotracheal region and a microsuspension direct laryngoscopic approach to remove the obstructive laryngeal mass , 10.The second patient complained about his cosmetic aspect and was in trouble finding clothes fitting his neck. Because of aesthetic, psychological, and social reasons the patient was submitted to surgical treatment. Abstinence from alcohol was recommended to decrease the rate of recurrence.The third subject presented the typical picture of the disease with thickened soft tissue in anterior neck, nape, and upper trunk. In this case, there was no history of heavy alcohol consumption, signs of altered lipid metabolism, or other metabolic disorders. The surgery was planned in order to reduce the size of lipomatous masses and patient's inability to move neck and arms freely. In the treatment of our patients we did not consider liposuction because of the extension of fatty deposits. Moreover, lipectomy by open surgery is recommended for proper identification of major vessels and nerves and offers the chance of more extensive debulking.


Urethra mucosa prolapse is a benign condition in which there is a circular protrusion of the distal urethra through the external urethra meatus. It is more commonly seen in prepubertal black girls and postmenopausal white women. It is rare in the reproductive age group. This case describes the presentation and management of an 18-year-old adolescent with urethra mucosa prolapse. Urethral mucosa prolapse is a benign condition which was first described in 1732 by Solingen [Estrogen deficiency has been associated. It may be complicated by strangulation.Urethra mucosa prolapse is a rare condition and even more rare in the reproductive age group. We present this case of urethra mucosa prolapse in an 18 year old adolescent.Miss U. A. is an 18-year-old student of a tertiary institution. Her last menstrual period was 10 days prior to presentation which was normal in quantity and duration. She presented in the gynaecological emergency unit of the State Specialist Hospital Ondo with a history of bleeding per vaginam of about 2 days duration prior to presentation. Bleeding was associated with passage of clots. There was no associated abdominal pain, and she is not sexually active. There was no history of vagina trauma or instrumentation. She attained menarche at the age of 14 years and menstruates for 3 days in a cycle of 26–28 days. Examination revealed a healthy looking but anxious young female. She was not pale, anicteric, and afebrile. Vital signs revealed temp = 36.8°C, pulse rate = 100 beats/min, respiratory rate = 18 cycles/min and blood pressure = 120/80 mmHg.There was no tenderness on abdominal examination and no palpably enlarged organ. Vagina examination revealed intact hymen. There was a polypoid hyperemic mass with a central dimple actively bleeding with some clots on it . The perAn assessment of urethra mucosa prolapse was made which was confirmed by passing a size 16 F urethra catheter through the dimple . InvestiUrethral mucosa is a rare condition. It is seen more in prepubertal girls and postmenopausal white women . This isThe urethra is composed of inner longitudinal and outer circular-oblique smooth muscle layers. Usually, a natural cleavage plane is present between the inner and outer muscle layers. A prolapsed urethra may result from these 2 muscle layers separating after a sudden episodic increase in intraabdominal pressure. Disruption of these muscle layers results in complete and circular eversion of the urethral mucosa through the external meatus and leads to urethral prolapse. Swelling and congestion of the prolapsed mucosa create a purse-string effect around the distal urethra, impeding venous return and exacerbating vascular congestion. If left untreated, urethral prolapse may progress to strangulation and eventual necrosis of the protruding tissues. The fundamental anatomical defect of urethral prolapse is the separation of the longitudinal and circular-oblique smooth muscle layers . SurgicaPrepubertal urethral mucosa prolapse is predominantly asymptomatic. Often it is an incidental finding during routine examination. The most common presentation is vaginal bleeding associated with a periurethral mass. Until urethral prolapse is definitively diagnosed, the presence of blood in the genital area should raise the suspicion of sexual abuse in this age group. In rare circumstances, children may present with voiding disturbances such as dysuria, frequency, introital pain, or haematuria.Patients with postmenopausal urethral prolapse are often symptomatic. Vaginal bleeding associated with voiding symptoms is fairly common. If the prolapsed urethra is large, the mucosal mass may become strangulated, which results in venous obstruction, thrombosis, and necrosis of the prolapsed tissue.Upon physical examination, urethral prolapse appears as a doughnut-shaped mass protruding from the anterior vaginal wall. The mass may be painful and tender to palpation. The mucosa is ulcerated in most cases and usually bleeds upon contact. The congested mucosa may appear bright red or dark and cyanotic.Diagnosis of urethra mucosa prolapsed is clinical and is made by visualization and catheterization of the central opening within the prolapsed urethra mucosa . ExtensiTreatment can be either surgical or medical. Medical treatment includes local hygiene, sitz bath, topical antibiotics, steroid, or estrogen creams . Most ofUrethra mucosa prolapse is a rare condition. It is primarily associated with prepubertal girls and postmenopausal women. This case has shown that it can occur even in the reproductive age group. A high index of suspicion and careful clinical examination can help identify some of the cases within this age group especially when girls present with unexplained genital bleeding.


Metastatic tumors to the spleen are rare but are usually found in conjunction with metastasis to other organs. The most common sources of splenic metastasis are breast, lung and colorectal cancers as well as melanoma and ovarian carcinoma. A solitary carcinosarcoma metastasis to the spleen of any origin is very rare. To the best of our knowledge, there are fewer than 30 reported cases of ovarian primary tumors with solitary metastasis to the spleen, and only three solitary primary carcinosarcomas to the spleen have been reported, of which one is female. We present what is, to the best of our knowledge, the first case of a solitary metastatic carcinosarcoma to the spleen arising from a primary ovarian carcinsarcoma.A 72-year-old Hispanic woman status post-total abdominal hysterectomy for ovarian carcinosarcoma presented with complaints of early satiety and abdominal pain for the past two months with a 30-lb unintentional weight loss. An initial computed tomographic scan of her abdomen and pelvis revealed a 30 cm × 27 cm splenic mass with displacement of the left kidney, stomach and liver. The patient was found to have a solitary metastatic carcinosarcoma of the spleen with biphasic epithelial (carcinomatous) and mesenchymal (sarcomatous) elements consistent with carcinosarcoma.Carcinosarcoma of the spleen is a rare tumor. Carcinosarcomas are a biphasic neoplasm comprising malignant epithelial and mesenchymal components arising from a stem cell capable of differentiation. They can arise anywhere in the female genital tract, most commonly from the endometrium. Even though it is rare, carcinosarcomas can metastasize to the spleen. This unique case of a solitary splenic metastasis from ovarian carcinosarcoma has particular interest in medicine, especially for the specialties of surgical oncology, pathology and hematology/oncology. Malignant nonlymphoreticular neoplasms involving the spleen are rare. Splenic metastases from solid tumors occur in late stages of a disease process, are due to hematogenous dissemination confined to the splenic parenchyma and are usually found in conjunction with metastases to other organs . The moset al.  were theet al. ,6. We prA 72-year-old Hispanic woman presented with complaints of early satiety and abdominal pain for the past two months with a 30-lb unintentional weight loss. Her medical history included a total abdominal hysterectomy with bilateral salpingo-oophorectomy performed in Mexico for ovarian cancer seven years previously. The pathology report described an ovarian carcinosarcoma. Her physical examination revealed a large left upper quadrant mass which was tender to palpation. An initial computed tomographic scan of her abdomen and pelvis revealed a 30 cm × 27 cm splenic mass in coronal view with displacement of the left kidney, stomach and liver , the patient underwent embolization of her splenic artery as a cautious approach to prevent hemorrhage.Prior to her splenectomy and after appropriate vaccination  mechanical factors impeding hematogenous implantation of neoplastic cells because of the flow and course of blood through the splenic vasculature and (2) an inhibitory effect of the splenic microenvironment on neoplastic cells  mechanic. Other hSplenic metastases may occur by direct extension, transperitoneal spread, hematogenous route or lymphatogenous route or by a combination of these phenomena. The main metastatic pathway to the spleen is hematogenous, and it is generally accepted that by the time a metastatic tumor is found in the spleen, multiple secondary tumors can be found in other organs. Splenic metastasis is often associated with terminal cancer, and isolated splenic metastasis is rare . ImplantOn the basis of gross and microscopic descriptions, splenic metastases can be categorized according by the type of splenic invasion: parenchymal-only, capsular or capsular with parenchymal invasion . OvarianSplenic metastases are most often incidentally detected by ultrasonography or computed tomography in follow-up of cancer patients or in the work-up performed of any event related to cancer. Splenic metastases are a part of multi-visceral metastatic disease. Metastatic tumor of the spleen diagnosed in patients with widespread visceral dissemination of primary tumor has no clinical importance, because the overall prognosis is very poor. However, splenectomy can be performed as a palliative treatment option in those patients with symptomatic splenomegaly .The appropriate choice of post-operative chemotherapy is debatable. Because of the rarity of this condition, no randomized trials have been conducted to determine the best therapy. The median overall survival in ovarian carcinosarcoma appears to be extended with the use of platinum-based therapies . The recet al. [et al. [Duska et al.  reported [et al.  reported [et al. .Carcinosarcomas are a biphasic neoplasm comprising malignant epithelial and mesenchymal components arising from a stem cell capable of differentiation. The most common sources of splenic metastasis are breast, lung, colorectal and ovarian carcinomas as well as melanoma. They can arise anywhere in the female genital tract, most commonly from the endometrium. It must be noted again that because of the rarity of this condition, there is no consensus on the appropriate chemotherapy regimen. Complete surgical resection appears to offer the best chance of long-term survival. Carcinosarcoma of the spleen is a rare tumor. Only three cases of solitary primary carcinosarcomas of the spleen have been reported. To the best of our knowledge, this is the first reported case of a metachronous solitary splenic metastasis from ovarian carcinosarcoma.The authors declare that they have no competing interests.Written informed consent was obtained from the patient for 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.AO was involved in drafting the manuscript and acquisition of data. He analyzed and interpreted the patient data regarding the disease process. TG was the attending surgeon who made substantial contributions to the analysis and interpretation of data. He revised the manuscript critically for important intellectual content. SP performed the histological examination of the spleen and was a contributor in writing the manuscript. All authors read and approved the final manuscript.


We present a 27-year-old female patient admitted with an anterior mediastinal mass. She complained of chest discomfort and hemoptysis which began seven months prior. She had given birth five months prior. Thoracic X-ray showed an anterior mediastinal mass. Thorax computed tomography (CT) confirmed a well-defined anterior mediastinal mass with 13 × 12 cm diameter, extending to the right hemithorax. It was composed of cystic spaces and discrete areas like soft tissue and fat. Serum Ca 19-9 level was elevated. CT features were consistent with a mature teratoma. During median sternotomy, the tumor revealed adhesions to the right lung and the right subclavian artery. Histologically, the tumor was diagnosed as a mature teratoma. Estrogen and progesterone receptors were detected to be positive in the resected tissue. We conclude that alterations in hormone levels during pregnancy might be the cause of rapid tumor growth which leads to hemoptysis. Earlydiagnosisof mediastinaltumorsis raresince symptoms usually arise after compression of the theadjacent structures . Most ofA 27-year-old female patient had beeninvestigated seven months ago because ofhemoptysis andchest painduringpregnancy. Thechestradiography revealed a 13 × 12 cm hypodense lesion with smooth margins at mediastinum.There was no specific feature in her medical history except a full term birth five months ago.Routine laboratory tests and HCG, AFP, CEA, CA 15-3, and prolactin levels were normal whereas CA 19-9 was elevated (126 U/mL).CT showed a lobulated lesion filling the anterior mediastinum. Lesion contained a large amount of fat, solid components, and calcifications. The mass extended from rightbrachiocephalicvein to therightatrioventricularsulcus and was locatedadjacent tothe branchesof the aortaandpulmonary veins. There were intraparenchymal small cystic areas and a linear density in the anterior segment of right upper lobe. Thoracicmagnetic resonance imaging(MRI) showed amasswith fat, liquid, and solid components, pressing on the heart .Median sternotomy was performed and a mass lesion with tight adhesions to pericardium, left and right mediastinal pleura, right upper lobe, and brachiocephalic vein was detected in anterior mediastinum. Tumor excision and the right upper lobe wedge resection were performed. During excision, hair, and cartilage tissue protruding from the mass were observed. Pathological specimen was443 grams and 13 × 12 × 6 cm in size. Skin, skin appendages, cartilage, bone tissue, bone marrow elements, respiratory, and gastrointestinal epithelium were observed in microscopic examination. Tissue had mature components, which were stained with glial S100 and GFAP, consistent with teratoma. Emphysematous changes, thickening of alveolar septa, and interstitial mononuclear infiltration were detected in the lung specimen, and the surgical margins were tumor free .Estrogenandprogesteronereceptorswere detected to be positive in the resected tissue .The patient was discharged on postoperative seventh day.There were no complications during 5 months of followup.Teratomas were described first in 1953 by Willis as a tumor that contained tissues different from the affected organ . EstrogeAlthough most teratomas are asymptomatic, symptoms such as chest pain, dyspnea, and cough may be seen. There is no other case in the literature who became symptomatic during pregnancy and treated afterpregnancy like our patient literature. Uyama et al. reported that the alterations in sex hormones in menarche may have played a role in the rapid tumor growth . When teTeratomas are seen in anterior mediastinum with about 8–10 cm size, appearing to protrude into a hemithorax on plain chest radiography . CT has Mature teratomas are treated by surgical resection. Sternotomy is the most preferred method to achieve optimal exposure , 6, 8.ThWe conclude that alterations in hormone levels during pregnancy such as estrogen and progesterone might have stimulated the sensitive tumorcellsleading totumorgrowth in our case. Thus, the tumor became symptomaticdue to mass effectand increased inflammation led to adhesions tosurrounding tissues.


The latissimus dorsi (LD) flap is one of the most common flaps used in plastic surgery based on its dominant thoracodorsal pedicle as well as free tissue transfer. The “distally based” or “reverse” fashion design has been used to repair myelomeningoceles, congenital diaphragmatic agenesis, or thoracolumbar defects. We present a case of a large lumbar defect after cancer resection covered by a combined tegument solution starring the “reverse” LD flap in its muscular version with a cutaneous gluteal flap. This flap is a safe and reliable way to cover large distal lumbar defect. Covering the lumbar region was always a challenge for plastic surgeons. Although different pedicled muscular and musculocutaneous flaps were described around this area, the repair of large defects is still a difficult matter , 2. We pA 69-year-old man was referred for treatment of a massive infected tumor situated in the left lumbar region, 12 months after left nephrectomy for squamous cell carcinoma of the kidney. On clinical examination the mass was located on the lobotomy scar and measured 15 cm .The abdomino-pelvic CT scan showed a mass in the left lumbar region, measuring 95 × 75 × 65 mm and invading the 11th rib. This mass extends to the ipsilateral latissimus dorsi muscle which seems to be invaded in the lower part and to the iliopsoas muscle .The biopsy revealed a squamous cell carcinoma. Recurrence of the renal tumor was evoked, and surgery was indicated.The tumor was removed through a circular incision, section of the lower insertion of the latissimusdorsi, the quadrates lumborum, the iliopsoas, and the two obliquus muscles. The peritoneal cavity was opened. The distal part of the 11th rib was removed with a pleural wound which was repaired. The excised tissues included also a nodule located at the superiorpart of lobotomy scar, and a second one was situated in the left retrocolic area Figures  and 4.The LD outline was marked as well as its upper limit. The paraspinal perforators were outlined about 5 cm from the midline, and the penetration of the perforators through the muscle was estimated about 9 cm from the vertebral column . No DoppAn oblique incision was made from 10 cm down to the axilla to the defect. The LD was identified . The thoWe found three large perforators originating from the ninth, tenth, and eleventh intercostal pedicles, located 5 cm from the midline of the back and penetrating the muscle after 3 to 4 cm .The sacrifice of the ninth pedicle was necessary to allow the LD muscle to reach the defect satisfactorily.The muscular flap was tacked with some absorbable sutures after covering the peritoneal cavity using a mersilene mesh . The deaFifteen days later a good granulation tissue was obtained and a skin graft was made .On gross examination, the surgical specimen weighed 1200 g and measured 25 × 15 × 10 cm. It contained a white-mostly-necrotic nodule measuring 12 × 10 × 10 cm. On histological examination, the tumor presented a malignant squamous cell proliferation with atypia. Lateral limits of resection were not infiltrated. The posterior limit was exiguous.The histological examination concluded to well-differentiated squamous cell carcinoma.The postoperative course was complicated by a superficial infection treated with antibiotics and wound care and some seroma spontaneously evacuated with dressing. The coverage of this important defect was a success, and the patient was completely recovered from his wound after 6 weeks. The multidisciplinary comity took the decision to follow up the patient without any adjuvant treatment. No recurrence was observed after 8 months, but a back wall weakness was noted . One yeaManagement of massive soft-tissue defects in the lumbar region is still a major challenge for plastic surgeons. This anatomical region is like a “no man's land” for us. The local solutions are rare, and the standard free tissue transfer is not an easy job, especially if the recipient vessels for microsurgical reconstruction like the gluteal arteries are far or sometimes not available.Reverse latissimus dorsi (LD) flap has been described mainly for closure of congenital diaphragmatic agenesis, myelomeningocele and spinal cord syndrome, or some thoracolumbar defects –7. But sWe will not discuss the oncological aspect of the treatment, but we will focus on our method to cover this massive lumbar defect. The LD has a double vascularization as described by Mathes and Nahai  and if iWhereas Stevenson et al.  observedThe exact vascular territory of each segmental pedicle is unknown , 14, andWe believe that the “reverse” LD flap is a good option to cover this particular region. It is simple, safe, and reliable. It also provides a backup plan like the microsurgery in case of failure.We present a case of large lumbar defect covered using the latissimus dorsi flap in its reverse fashion with a satisfactory result. This pedicled flap has a good trophicity and offers an amplified rotation vector allowing reaching lower trunk areas. It is a reliable solution to solve difficult plastic tegument problems and cover large surface defects.


Although vertebral and epidural metastases are common, intradural metastases and intramedullary spinal cord metastases are rare. The indications for the treatment of intramedullary spinal cord metastases remain controversial. We present the first biopsy-proven case of an intramedullary spinal cord metastasis from adenocarcinoma of the prostate.® radiosurgery to the resection cavity at a marginal dose of 27Gy to the 85% isodose line. At three months follow-up, our patient remains neurologically stable with no new deficits or lesions.Our patient was a 68-year-old right-handed Caucasian man with a Gleason grade 4 + 3 prostate adenocarcinoma who had previously undergone a prostatectomy, androgen blockade and transurethral debulking. He presented with new-onset saddle anesthesia and fecal incontinence. Magnetic resonance imaging demonstrated a spindle-shaped intramedullary lesion of the conus medullaris. Our patient underwent decompression and an excisional biopsy; the lesion’s pathology was consistent with metastatic adenocarcinoma of the prostate. Postoperatively, our patient received CyberKnifeWe review the literature and discuss the indications for surgery and radiosurgery for intramedullary spinal cord metastases. We also report the novel use of stereotactic radiosurgery to sterilize the resection cavity following an excisional biopsy of the metastasis. Adenocarcinoma of the prostate affects up to 70% of men over 80 and is the second leading cause of cancer-related death in men . Skull aA 68-year-old, right-handed Caucasian man was diagnosed with Gleason grade 4 + 3 adenocarcinoma of the prostate in March 2009. A partial prostatectomy and pelvic node dissection was completed, and our patient started androgen blockade with leuprolide (Lupron), dutasteride (Avodart) and bicalutamide (Casodex). His prostate specific antigen (PSA) levels decreased from an initial value of 41.6 to 0.07 ng/ml in April 2010. In May 2010, one month prior to admission, a transurethral debulking of his prostate was completed for difficulty in initiating a urine stream and an indwelling Foley catheter was left in place. In the 48 hours prior to admission, he developed a worsening saddle anesthesia. On the day of admission, June 10 2010, he described increasing headache as well as new-onset fecal incontinence but denied weakness. His past history, family history and a review of his systems were not significant.On admission, his mental status, cranial nerve and upper extremity examinations were unremarkable. A motor examination was intact in his legs but there was significant numbness below his ninth thoracic vertebra. Reflexes were absent in his lower extremities. Rectal sensation and tone were absent.Magnetic resonance imaging scans of his brain and thoracic and lumbar spine showed two irregularly enhancing lesions. The first, 2cm in diameter, was in the region of the fourth ventricle but was without secondary hydrocephalus. The second was a spindle-shaped intramedullary lesion of the conus medullaris Figures , 2 and 3Our differential diagnosis included ependymoma, astrocytoma, a metastasis from the known prostate cancer or a metastasis from an undiscovered second primary tumor.Because of our patient’s increasing neurological deficit, and given the uncertainty of the diagnosis, a decompression and an excisional biopsy were undertaken on the day of admission. With somatosensory and motor evoked potential monitoring, a twelfth thoracic to first lumbar vertebral laminectomy was completed. The level of the lesion was confirmed using intraoperative ultrasound. On opening the dura, abnormal appearing tissue was immediately identified involving the posterior surface of the conus. A small biopsy was consistent with malignant tissue. A more aggressive resection to the edges of the abnormal appearing tissue was completed and his cord appeared adequately decompressed. The closure was uneventful.On microscopy, the lesion showed sheets and nests of cells with abundant cytoplasm and prominent nucleoli. Mitoses were common. Intracytoplasmic and extracellular mucin was demonstrated. AEI/AE3 cytokeratin, CAM5.2, CK7, and CK20 were positive. PSA, Prostatic specific acid phosphatase (PSAP), thyroid transcription factor-1 (TTF-1), caudal type homeobox-1 (CDX-1), and S100 were negative. The pathology was consistent with metastatic adenocarcinoma of the prostate Figure .® radiosurgery. The spinal resection cavity, contoured to the edge of the enhancing tumor on a postoperative scan, was treated to a marginal dose of 27Gy at the 85% isodose line in three sessions. Our patient remains neurologically stable three months after treatment, with no new neurological deficits and no new lesions.Following surgery, his sensory changes improved and the motor examination remained intact. His bowel and bladder function remained poor. The intracranial lesion and the resection cavity in the conus were both treated with CyberKnifeAlthough vertebral and other epidural metastases are common, intradural metastases are rare. ISCMs represent only 0.9% to 2.1% of autopsy cases in patients with cancer and only 5% of these are identified antemortum . To dateet al. demonstrated in a case report that PSA in the CSF may be a useful diagnostic tool for detecting intradural prostate metastasis [The diagnosis of ISCMs is usually radiographic. Myelography may show a fusiform enlargement of the cord but is non-diagnostic in 40% of cases. Although cerebral spinal fluid (CSF) is frequently abnormal, malignant cells are present in only the minority of cases. Interestingly, Schaller tastasis . There aConventional radiation has been the historic treatment of choice ,3,9. It ®, at a 15Gy marginal dose in three fractions. Their patient had no recurrence in the 26 months of follow-up. Shin et al. [Several authors have described SRS as a primary treatment for ISCMs. Parikh and Heron  describeet al. [et al. [® SRS after resection instead of WBRT. Local control was 86% in those treated to the margin of the enhancing tumor, but was 100% in those where the treatment volume extended 2mm beyond the edge of the contrast-enhancing resection cavity. A subsequent course of WBRT was required for other lesions in 19% of patients (in a mean of six months after SRS). Mean overall survival was 15 months but excluding non-neurological causes of death was 16.9 months. Hwang et al. [An SRS boost to the resection cavity is an appropriate postoperative alternative to WBRT in patients with brain metastases. Kim et al.  describe [et al.  presenteAt present, there is no study in the literature that directly compares success rates for radiotherapy alone, surgery alone or surgery plus radiotherapy for ISCMs. We feel it is likely that the efficacy of the various treatments of ISCMs would parallel that of brain metastases, and that a local boost to a resection cavity in the spinal cord should be as effective as conventional postoperative spinal radiation while potentially decreasing risk and minimizing the length of treatment. It also seems reasonable to use SRS for lesions, such as prostate lesions, that respond poorly to conventional radiation and are shown to respond well to SRS in the brain .This patient had good residual lower extremity function and a lesion whose pathology was uncertain. Surgery was recommended to preserve function, was completed without incident and was followed by clinical improvement. After surgery, conventional radiation and SRS treatment were considered. An SRS boost to the resection cavity was recommended once the pathology confirmed the metastasis as from the prostate.Metastases to the intramedullary spinal cord are rare and typically occur late in the course of the disease. Surgery is appropriate for those patients who can tolerate the operation and who are in danger of permanent loss of function or who have intractable pain. After surgery, conventional spinal radiation has been provided to decrease the risk of local recurrence. There is risk to spinal radiation and not all tumors are radiosensitive. We propose that a local cavitary boost with SRS may be as effective as conventional radiation for some tumors while offering greater convenience and perhaps less risk.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.CSF, Cerebral spinal fluid; ISCM, Intramedullary spinal cord metastasis; PSA, Prostate specific antigen; SRS, Stereotactic radiosurgery; WBRT, Whole brain radiotherapy.The authors declare that they do not have any competing interests.RL, AV, JE and JD collected, analyzed and interpreted the patient data, conducted the literature review and were the major contributors in manuscript drafting. BJ and RA provided critical revisions of the manuscript. RL, AV, JE, JD and SC participated in patient evaluation, administration of treatment and enrolling the patient. SC conceived of the study and participated in its design and coordination and helped to draft and review the manuscript. All authors read and approved the final manuscript.


Introduction. Chondroid syrinoma of the external auditory canal is an extremely rare benign neoplasm representing the cutaneous counterpart of pleomorphic adenoma of salivary glands. Less than 35 cases have been reported in the international literature. Case Presentation. We report a case of a 34-year-old male in whom a rapidly growing, well-circumscribed tumor arising from the external auditory canal was presented. Otoscopy revealed a smooth, nontender lesion covered by normal skin that almost obstructs the external auditory meatus. MRI was performed to define the extension of the lesion. It confirmed the presence of a 1.5 × 0.8 cm T2 high-signal intensity lesion in the superior and posterior wall of EAC without signs of bone erosion. The patient underwent complete resection of the tumor. The diagnosis was confirmed by histopathologic examination. Conclusion. Although chondroid syringoma is extremely rare, it should always be considered in the differential diagnosis of an aural polyp. Chondroid syringomas are usually asymptomatic, slow-growing, single benign tumors in subcutaneous or intradermal location. In our case, the new information is that this benign tumor could present also as a rapidly growing lesion, arising the suspicion for malignancy.  Chondroid syringoma or mixed tumor of skin is a benign neoplasm of sweat gland origin. It arises most frequently in the nose, cheek, scalp, forehead, upper lip, and chin. Chondroid syringomas of the external auditory canal are extremely rare. Less than 35 cases have been reported in the international literature. All authors agree that the tumors in this location derive from the ceruminous glands in the skin of the external auditory canal. The tumor is usually presented in patients between 20 and 60 years as a slowly growing, encapsulated, painless subcutaneous mass. In the case reported here, the tumor presented as rapidly growing solid mass in the external auditory canal of a young man. We discuss the diagnosis, differential diagnosis of this mass, and the relevant literature.A 34-year-old Caucasian man, resident doctor, was referred to our Department of Otolaryngology with the complaint of a painless mass in the posterior wall of the right EAC associating with a reduction in hearing. He has been noticed the lesion three months ago. The otoscopy revealed a smooth, nontender lesion covered by normal skin that almost obstructs the external auditory meatus . The thrChondroid syringoma is a rare mixed tumor of the skin that was first described by Hirsch and Helwig in 1961 . ChondroTypically, tumor presents in male patients between 20 and 60 years as a slowly growing, painless, subcutaneous mass [The diagnosis is usually made retrospectively based on histopathological findings. Mixed tumor of skin histopathologically consists of tubuloductal epithelial structures of sweat gland origin and is associated with chondroid changes . DiffereAlthough chondroid syringomas of external auditory canal are slowly growing tumors, in this case, the rapid growing of the skin lesion raised the suspicion of a malignancy. Therefore, surgical excision and histopathological examination were compulsory to exclude this possibility. Preoperative evaluation by MRI is superior to that by CT, enabling differential diagnosis of other tumors of EAC and indicates possible erosion in the bony tissue . For casChondroid syringoma should be included in the differential diagnosis of small subcutaneous nodules in the EAC, in middle-aged male patients. Although malignant forms and recurrence are extremely rare, wide excision of the tumor and long-term followup are the most effective ways of management.


This study reports a case of bilateral rifabutin-associated uveitis in a child with a history of acute myeloid leukemia.We utilized a clinical case description and brief discussion.Mycobacterium avium complex pulmonary infection. Work up for infectious and neoplastic etiologies was negative. The uveitis initially responded to topical corticosteroids, but recurred when the drops were tapered. Fluorescein angiography demonstrated diffuse vasculitis of small retinal vessels and cystoid macular edema. After rifabutin was discontinued, the uveitis and vasculitis slowly resolved.A 17-year-old girl presented with acute bilateral anterior uveitis, a hypopyon in the left eye, and moderate bilateral vitritis. She had a history of acute myeloid leukemia status post-allogeneic hematopoietic stem cell transplant 5 years earlier. She was receiving rifabutin for a biopsy-proven Fluorescein angiography demonstrated widespread retinal vasculitis which is a rare manifestation of rifabutin-associated uveitis. Mycobacterium avium complex (MAC) infection. It is frequently used in immunocompromised patients with human immunodeficiency virus (HIV) or a history of organ or stem cell transplantation. Anterior uveitis and hypopyon are well-recognized and frequently reported complications of rifabutin treatment; however, posterior involvement is relatively rare [Rifabutin is a semisynthetic derivative of rifampin that is effective for the prophylaxis and treatment of ely rare , 2. HereA 17-year-old Eritrean girl presented with a 5-day history of redness, tearing, and photophobia which started in her right eye (OD) and then involved her left (OS). She recalled similar, but less severe symptoms over the 2 months prior to presentation. Her medical history was significant for acute myeloid leukemia diagnosed 5 years earlier. She was treated with chemotherapy and received an allogeneic hematopoietic stem cell transplant 6 months after diagnosis. She developed graft-versus-host-disease (GVHD) of the gastrointestinal tract, lungs, and skin with mild ocular surface involvement, but these issues were stable at the time of presentation to the eye clinic.On initial examination, pinhole visual acuity was 20/32 in each eye (OU), and intraocular pressures were 14 mmHg OU. Small non-granulomatous keratic precipitates were present OU. The anterior chambers had 3+ and 4+ cells , and bilateral moderate vitritis was noted. The left eye also had a hypopyon (less than 1 mm) and posterior synechiae of the iris  showed diffuse retinal vascular leakage and late staining of the optic nerves in both eyes Fig. . A more Anterior uveitis and hypopyon are the most frequent manifestations of rifabutin-associated uveitis; however, severe cases may develop dense vitritis with large yellow-white opacities or panuveitis resembling endophthalmitis , 4. Desp3. In each of the single case reports by Arevalo and Vaudaux, the rifabutin-associated uveitis was unilateral and the posterior findings were focal. Arevalo’s patient had AIDS and a CD4 count of 3 cells/mm3; a focal area of sclerosed retinal vessels was noted after intraocular injections of vancomycin and gentamicin for presumed endophthalmitis. In the case from Vaudaux, the patient had been treated with systemic prednisone for chronic obstructive pulmonary disease 4 months prior to developing uveitis, but was otherwise immunocompetent. The FA and ocular coherence tomography (OCT) confirmed unilateral cystoid macular edema. In our immunocompetent patient, the vasculitis was notable for its diffuse and bilateral nature and slow resolution after the discontinuation of rifabutin.Although mild to moderate vitritis frequently develops in rifabutin-associated uveitis, posterior involvement is less frequent –7. SimilRifabutin-associated uveitis was initially described in HIV-positive patients, but it may also occur in patients who are immunocompetent . Only a We describe a case of rifabutin-associated hypopyon uveitis in a young immunocompetent patient with an unusual degree of diffuse bilateral retinal vasculitis. While the anterior chamber and vitreous inflammation disappeared rapidly after discontinuation of rifabutin, resolution of the retinal vasculitis took several months. Fluorescein angiography helped assess the extent and severity of uveitis as well as guide the topical corticosteroid taper.


Pure ovarian choriocarcinoma can be gestational or nongestational in origin. Nongestational choriocarcinoma of the ovary is extremely rare, and its diagnosis is very difficult during the reproductive years. We present a case of a 33-year-old woman diagnosed with pure nongestational ovarian choriocarcinoma. Following surgery, multiple courses of a chemotherapy regimen of etoposide, methotrexate, and actinomycin-D (EMA) were effective. Choriocarcinoma of the ovary is a rare aggressive tumor, which may be either gestational or nongestational in origin. Most occurrences are gestational in origin and usually metastasize to the ovary from a uterine or tubal choriocarcinoma. In contrast, pure nongestational choriocarcinoma of the ovary (NGCO) is extremely rare, and diagnosis is very difficult in women of reproductive age,2. We prA 33-year-old woman  presented to our hospital with complaints of lower abdominal pain and vaginal bleeding for several days. Her last menstrual period occurred three weeks before her presentation, and previous menstrual cycles were regular. Her husband had undergone vasectomy several years ago. Her medical history and family history were unremarkable. The general condition of the patient appeared to be good; however, pelvic examination revealed a mass in the left ovary. Chest radiograph was normal. The urine test result for human chorionic gonadotropin (hCG) was positive, and serum β-hCG level was 74,612 mIU/ml. Transvaginal ultrasound (TVS) revealed a left adnexal mass of 5 × 4 cm with profuse abdominal fluid accumulation.According to a diagnosis of left tubal pregnancy, laparoscopic exploration was performed. The left ovary was as large as a tennis ball and was ruptured and surrounded by a hematoma. A cystic mass of 2 × 2 cm was found on the right ovary and both fallopian tubes were intact. A 3-cm white-yellow mass and a 1-cm nodule were scattered in the peritoneal cavity. Approximately 500 ml of intraperitoneal blood was noted. Left oophorectomy, right ovarian cystectomy, and peritoneal mass biopsies were performed. On the second and fifth postoperative day, serum β-hCG levels were 17,963 mIU/ml and 10,172 mIU/ml, respectively. Histological examination showed a choriocarcinoma of the left ovary and corpus luteal cyst of the right ovary. Peritoneal biopsies showed ovarian tissue with marked central change of the corpus albicans and partial covering of choriocarcinomatous nests. The tumor cells were composed of cytotrophoblastic cells forming clusters of cytotrophoblast separated by streaming masses of syncytiotrophoblasts , methotrexate (100 mg/m2), and actinomycin-D (0.5 mg), at seven-day intervals without major complications. After six courses of chemotherapy, the β-hCG level decreased to normal (2.74 mIU/ml) and remained normal thereafter. A further three courses were completed for consolidation. The patient remains without evidence of disease five years after initial diagnosis.Endometrial biopsy was performed to rule out gestational origin. Histological examination of the endometrium revealed few fragments of basal endometrium with focal, early proliferative-phase regions without trophoblastic lesions. The patient received nine courses of EMA chemotherapy, including etoposide  can occur following pregnancy and is characterized by presentation in the uterine cavity. NGCO moet al. first described the diagnostic criteria for NGCO in 1963. These include absence of disease in the uterine cavity, pathological confirmation of disease, and exclusion of molar pregnancy and of intrauterine pregnancy[Saito regnancy. All theA comparison of case reports of ovarian choriocarcinoma is presented in TableBecause of the small number of patients with pure ovarian choriocarcinoma, a consensus on the treatment regimen including surgery and chemotherapy is lacking. Our report adds data that can be helpful in both diagnosis and treatment of this rare disease.Written informed consent was obtained from the patient for publication of this report and accompanying images. A copy of this written consent is available for review by the Editor-in Chief of this journal.EMA: etoposide, methotrexate, and actinomycin-D; GCO: gestational choriocarcinoma of the ovary; hCG: human chorionic gonadotropin; NGCO: nongestational choriocarcinoma of the ovary; TVS: transvaginal ultrasound.The authors declare that they have no competing interests.YJC made substantial contributions to conception and design, and acquisition of data. She also drafted the manuscript and revised its final form. KYC and YWK were involved in analysis and interpretation of data. DYR contributed to interpreting the data and gave final approval of the version to be published. All authors read and approved the final manuscript.


Adult intussusception (AI) following blunt abdominal trauma (BAT) is a rare surgical condition. We present a case of delayed diagnosis of ileocecal junction intussusception with a perforation of small bowel in a 34-year-old male with a history of fall from height. Initial exploratory laparotomy revealed shattered spleen requiring splenectomy. Initial abdominal computerized tomography scanning (CT) scan showed dilated small bowel with no organic obstruction. Patient started to improve with partial distention and was shifted to rehabilitation unit. On the next day, he experienced severe abdominal distention and vomiting. Abdominal CT showed characteristic intussusception at the distal ileum. Secondary exploratory laparotomy revealed severe adhesions of stomach and small bowel to the anterior abdominal wall with dilated small bowel loops and intussusception near the ileocecal junction with perforation of small bowel. The affected area was resected and side-to-side stapled anastomosis was performed. Though small bowel intussusception is a rare event, BAT patients with delayed symptoms of bowel obstruction should be carefully evaluated for missed intussusception. Intussusception is the telescoping of one segment of the gastrointestinal tract into an adjacent one and usually occurs in children . John HuThe increased utility of computerized tomography scanning (CT) helps in early evaluation of patients with abdominal pain and confirms the diagnosis for the possible AI without subsequent delay . DefinitIn the literature, small bowel intussusception due to blunt abdominal trauma (BAT) has not been extensively reported and only few case reports are described . Herein,3 u/L), normal platelet (246 × 103 u/L), and high sensitive troponin T (90 ng/L). Patient was shifted to operation theatre immediately.A 34-year-old male patient presented with BAT with history of fall from 10-meter height. On presentation, the patient was hypotensive (blood pressure of BP 81/43 mmHg) with heart rate of 130 beat per min. He had depressed fracture of left frontoparietal skull bone, contusion with abrasion of left side of face, mild chest wall hematoma, and abdominal guarding. Patient was intubated immediately with rapid sequence induction. Focused abdominal sonography for trauma (FAST) was positive; chest X-ray showed left subcutaneous emphysema with fractures of the left 6th, 7th, and 10th ribs. Chest tube was inserted and massive transfusion protocol was activated. Initial laboratory investigations showed an INR of 1.2, low pH 7.16, base excess −9.4, low hematocrit (17%), high myoglobin (2549 ng/mL), creatinine 139 umol/L, low hemoglobin (10.1 g/dL), high white blood cell count , normal WBC (7300 u/L), and platelet count (130000 u/L).A CT scanning of the head showed comminuted depressed fracture of left frontoparietal bone with minimal subdural hematoma, subarachnoid hemorrhage, tiny hemorrhagic contusions of left temporal area, and fracture of left zygomatic arch. Neck and chest CT scanning revealed evidence of C6 facet fracture and fractures of left 5–8 ribs anteriorly and left 6-7, 9–12 ribs posteriorly with left hemo- and pneumothorax and bilateral lung contusions. With a smooth course in trauma intensive care unit (TICU), the patient was started enteral feeding through nasojejunal feeding tube after 24 hours and then he was extubated 2 days later. After removal of nasojejunal tube, the patient developed abdominal distention; for that nasogastric tube was inserted and 1100 mL fluid was removed initially. After a couple of days in the surgical ward, the patient showed a wax and wane course of abdominal distention. All serum electrolytes were within normal range.Further CT scan of the abdomen showed dilated small bowel with no organic obstruction . FinallySmall bowel intussusception in BAT patients is uncommon and few cases were published. Historically, Leichtenstern reported a series of 326 cases of intussusception; of these cases, only 8% had past history of trauma as an etiology for intussusception . The mecDuncan and colleagues  identifiA recent case report described an ileoileal intussusception after BAT in patient presented with symptoms of intestinal obstruction after a fall from a ladder . Though Benjelloun et al.  presenteControversial findings have been reported for the exact treatment of adult intussusception. However, surgical resection has been advocated by many investigators –17. HoweIn conclusion, the delayed presentation of small bowl intussusception after BAT is uncommon phenomenon. The diagnosis is difficult due to nonspecific and episodic symptoms which require a high index of suspicion. Abdominal CT is the modality of choice for diagnosis. Treatment requires resection of the small bowel if it is nonviable. Therefore, BAT patients with symptoms of bowel obstruction should be carefully evaluated for the possibility of intussusception.


A 19-year-old man presented with a 5-year history of back pain radiating to the lower extremities and paresthesis of the toes during the last year. Plain X-ray revealed a large cauliflower shaped exophytic mass at the level of T8, T9 and T10 vertebrae. Computed tomography (CT) and magnetic resonance imaging (MRI) showed an abnormal bony mass arising from the posterior arch of T9 with protrusion to the spinal canal and marked cord compression. The cortex and medulla of the lesion had continuity with those of the T9 vertebra. Surgical en bloc resection was performed and the patient’s symptoms resolved. The histopathologic diagnosis was osteochondroma. In patients with symptoms of myelopathy, in addition to more common etiologies, one should also be aware of rare entities such as osteochondroma. Osteochondromas, also known as exostoses, are the most common primary bone tumors comprising more than one third of all benign bone tumors . They caA 19-year-old man presented to the neurology clinic of Valiasr hospital in Arak (Iran) with a 5-year history of back and lower extremity pain. During the last year, he also had numbness and paresthesia of the toes. There was no history of previous trauma or surgery and the past medical history was unremarkable. The neurologic exam confirmed bilateral spastic paraparesia with bilateral hyperactive deep tendon reflexes in both legs and a positive Babinski response.Plain X-ray of the thoracic region revealed a large cauliflower shaped exophytic mass at the level of T8, T9 and T10 vertebrae . ComputeBone window computed tomography scan showed an abnormal bony mass arising from the posterior arch of T9 with protrusion to the spinal canal and marked compression of the spinal cord . CT alsoMagnetic resonance imaging (MRI) confirmed presence of a bony mass, compressing the spinal cord. Cortical bone had low signal intensity in all pulse sequences, and the medullary component had an appearance of a yellow marrow. The cartilage cap was seen as a thin peripheral band (maximum thickness: 3mm) with intermediate to low signal intensity on T1-weighted images and high signal intensity on T2-weighted images Figures .At surgery, a predominantly bony mass originating from the lamina of T9 vertebra was removed. Histopathologic study showed a bony lesion with a cartilaginous cap indicating osteochondroma.At the follow-up period, the patient’s symptoms completely resolved and neurologic functions gradually returned to normal.Osteochondromas are developmental lesions rather than true neoplasms . These lThe HME cases are more likely complicated. Complications of exostoses include adjacent vascular and neural injury, fracture, osseous deformity, bursal formation and malignant degeneration . ExostosSpinal involvement is more common in HME. In this condition, thoracic and lumbar vertebrae are more commonly affected, while the solitary type mostly affects the cervical spine particularly the atlantoaxial region . Sacral Diagnosis of spinal exostosis may be difficult on plain radiography owing to the complex anatomy , 9. X-raMalignant degeneration is best assessed by measuring the maximal cartilage cap thickness and MRI is more accurate than CT in this regard . It is sMRI often shows yellow marrow signal in the central aspect of the lesion. The cartilage cap is often thin and has low to intermediate signal on T1-weighted images and high signal on T2-weighted images Figures  and 4.Fat signal intensity within the medullary component of the spinal osteochondroma in MR imaging can occasionally be mistaken for a lipomatous neoplasm, particularly in small lesions projecting into the spinal canal . Thin-seOur case highlights the value of MRI for early diagnosis of spinal osteochondroma. Obviously, early diagnosis and therefore early treatment would prevent future permanent neurologic deficits. In cases of spinal cord compression, in addition to more common causes like discopathy, trauma and metastasis, one should be also aware of rare entities such as osteochondroma and this is particularly important in patients with HME. Whether MRI of the spine should be used as a screening test in HME can be a subject for future studies.