Metastatic disease in the sinonasal region occurs rarely and the primary site may be elusive. This case highlights the possibility of an occult renal tumor manifesting with nasal symptoms and the risk of severe bleeding following nasal biopsy.We report the case of a 79-year-old Caucasian woman who presented with a six-week history of intermittent left-sided nosebleeds. She was fit, without previous surgery or anticoagulation. Nasal endoscopy and computed tomography showed a hemorrhagic mass occupying her left ethmoid cells and middle meatus. After a highly hemorrhagic biopsy, the lesion was histologically confirmed as clear cell carcinoma. Screening revealed a right kidney mass with widespread metastases. Palliative radiotherapy to the sinonasal metastasis and systemic treatment rendered her free of symptoms nine months after initial presentation.General practitioners and ear, nose and throat (ENT) doctors are very often confronted with epistaxis. A small minority of patients with epistaxis show a primary or metastatic nasal mass. Detection of the origin of secondary sinonasal masses requires a high index of suspicion and examination of infraclavicular sites by a multidisciplinary team. Renal cell carcinoma metastases are prone to severe bleeding during any surgical intervention, therefore, preoperative embolization is recommended. Resection or radiotherapy to the sinonasal metastasis of renal origin is justified in order to prevent recurrent nosebleeds. Epistaxis is a common complaint that usually responds to conservative measures. Failure to control epistaxis after coagulopathies have been excluded should raise the suspicion of a nasal tumor. Nasal malignant tumors are usually primary and account for 0.3% of all neoplasms and 3% of all head and neck neoplasms . OccasioThe aim of this report is to describe a rare case of occult renal cell carcinoma (RCC) presenting with massive epistaxis due to a nasal cavity-ethmoid metastasis. The diagnostic difficulties and the current treatment options for metastatic renal cell carcinoma to the sinonasal region will be briefly discussed.A 79-year-old Caucasian woman presented to our ENT department with a six-week history of recurrent progressive left-sided epistaxis. Her medical history was negative for hypertension, diabetes mellitus, surgery, bleeding tendencies and anticoagulation treatment. Laboratory tests showed marginally low haemoglobin levels 10 mg/dl) and normal calcium and lactate dehydrogenase (LDH) levels. On nasal endoscopy, a highly vascular mass arising from the left middle meatus was noted  [5% [8]. TA differential diagnosis of nasal bleeding lesions should include angiofibromas, hemangiopericytomas, hemangiomas and other less vascular malignant lesions such as adenocarcinomas, melanomas and metastatic tumors from the breast and lungs. A paranasal sinus CT scan may provide some hints about the benign or malignant nature of the lesion, such as bone erosion and remodeling , hypervascularity, expansion of the sphenopalatine foramen and pterygopalatine fossa (angiofibromas). Magnetic resonance imaging (MRI) shows the true extent of the lesion, infiltration of the skull base and leptomeningeal metastases. Biopsy of a suspicious nasal lesion is imperative to guide further workup, but severe hemorrhage may occur . Some auPatients with metastatic RCC have a poor prognosis with a median survival of seven to 11 months . HoweverMetastatic RCC is resistant to radiotherapy and chemotherapy although a variable response has been reported . AccordiSinonasal lesions presenting with epistaxis are rare. RCC metastases to the nasal cavity and paranasal sinuses should be included in the differential diagnosis of nasal bleeding lesions. Biopsy and resection of such lesions may result in profuse bleeding and, therefore, pre-operative embolization is recommended. RCC sinonasal metastasis signifies advanced disease with compromised survival. Resection or radiotherapy of the nasal metastasis with palliative intent will improve quality of life and the choice of treatment modality depends upon the patient's physical status and preference.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journalThe authors declare that they have no competing interests.GF participated in the clinical care of the patient in the ENT Department, performed the literature review and wrote the report. AA participated in the clinical care of the patient in the Urology Department, examined the urology literature and contributed to the discussion section of this report. SB was the leading consultant in the care of this patient; additionally, he supervised and corrected this report. All authors read and approved the final manuscript.


We report a case of acute idiopathic scrotal edema (AISE) in a 4-year-old boy who presented with acute scrotal pain and erythema. The clinical features, ultrasound appearance, and natural history of this rare diagnosis are reviewed. In this report, we highlight the importance of good ultrasound technique in differentiating the etiology of the acute scrotum and demonstrate the color Doppler “Fountain Sign” that is highly suggestive of AISE. Acute idiopathic scrotal edema (AISE) is a benign, self-limiting condition which is a rare cause of acute scrotal erythema. It is more common in the pediatric population than in adults. AISE is a difficult but important diagnosis, as correctly identifying it can avoid unnecessary surgical exploration of the scrotum. We present a case of AISE in a 4-year-old boy confirmed following ultrasound and surgical exploration and highlighting the clinical and sonographic features which in retrospect were indicative of the diagnosis. A four-year-old boy was referred to the emergency department from his primary care physician with a four-hour history of bilateral scrotal pain, swelling, and redness. The patient had no medical or surgical history of note. On examination, the scrotum was diffusely erythematous with erythema extending to the perineum. The left hemiscrotum was enlarged and exquisitely tender to palpation. The right hemiscrotum was of normal size and mildly tender in comparison. An ultrasound was organized which showed marked bilateral scrotal skin thickening and small bilateral hydroceles . There wThe acute scrotum is a diagnostic challenge, both in the pediatric and adult setting. Epididymitis and testicular torsion are the most common causes of acute scrotal pain, especially in adolescents. Torsion of the testicular appendages has a higher incidence in the prepubertal age group .AISE is often a diagnosis of exclusion. It was first described by Qvist in 1959 who reported a prevalence of 20% .The exact etiology of AISE is unclear. It has been hypothesized that it represents a hypersensitivity reaction related to a variant of angioneurotic edema , 5. It hSwelling and erythema in the scrotal wall is characteristic , but theUltrasound is the imaging modality of choice in the investigation of the acute scrotum. Thickening and edema of the scrotal wall, hypervascularity of the scrotum, and normal appearance of the testes are considered specific for the condition , 6.Geiger has described the “Fountain Sign,” a novel finding on color Doppler interrogation which is highly suggestive of the diagnosis. The “Fountain” depicted on transverse imaging of the scrotum  is due tOther sonographic findings described in AISE include mild reactive hydrocele and enlarged, hypervascular inguinal lymph nodes .The differential diagnosis for AISE includes other causes of acute scrotum such as epididymitis, testicular torsion, torsion of the testicular, and epididymal appendages and other conditions such as hydrocele and inguinal hernia. Lymphatic malformations of the scrotum can also present with bilateral scrotal pain and hydrocele.Ultrasound has characteristic findings in each of these diagnoses. Testicular torsion is characterized by hypovascularity of the affected testis, high resistance arterial blood flow as demonstrated by increased resistive indices on Doppler interrogation, and enlargement of the testis. In some cases of testicular torsion the intrascrotal portion of the edematous spermatic cord can be visualized at the upper pole . TorsionEpididymitis and epididymoorchitis are characterized by increased size and vascularity of the epidydimi with or without involvement of the testis. Torsion of the testicular or epididymal appendages can be seen as a characteristic round extratesticular nodule, frequently accompanied by scrotal skin thickening or hydrocele .Lymphatic malformations of the scrotum are characterized as multicystic, extratesticular masses with moving internal echoes on ultrasound. The internal septa may show vascular flow on color Doppler .AISE is a self-limiting condition, which tends to resolve in 3–5 days. NSAIDs and antibiotics have been used in management. A correct diagnosis can avoid surgical intervention and the characteristic ultrasound findings can be particularly helpful given the overlap in clinical presentation with testicular torsion and other conditions. The use of Doppler ultrasound was shown to reduce the rate of surgical exploration by more than half in one study . The impIn conclusion, AISE is a rare cause of acute scrotum but important to recognize as it is a benign, self-limiting condition. The characteristic findings on ultrasound are those of edematous thickening and increased vascularity of the scrotal wall which produces the “Fountain Sign” on transverse color Doppler imaging. The testes and epididymis are normal in appearance and enlarged, hypervascular inguinal lymph nodes may be seen. Correct diagnosis can prevent unnecessary surgical exploration.


Urachal affections are rare. Their variable ways of presentation may represent a diagnostic challenge. Urachal sinuses are a rare type of these abnormalities. They are usually incidental findings and remain asymptomatic unless a complication (most commonly the infection) occurs. Infection of the urachal sinus would clinically present as purulent umbilical discharge, abdominal pain, and periumbilical mass. We report herein a case of infected urachal sinus in male adult. The diagnosis was suspected clinically and confirmed with ultrasonography and computed tomography scan. A preoperative cysto-fibroscopy showed normal aspect of the bladder and excluded sinus communication. An initial broad spectrum antibiotic therapy followed by complete excision of the sinus and fibrous tract without cuff of bladder has been therefore performed. The postoperative course was uneventful. No recurrence was observed after 18 months of followup. Histological examination did not reveal any sign of malignancy. Since the first description by Cabriolus in 1550, few cases of urachal sinuses have been reported in literature. Urachal abnormalities result from incomplete obliteration of the foetal urachus. They are rare in adults comparing to children . Diagnos3 and elevated C-reactive protein (42 mg/L). The urinalysis and renal function were within normal values. Culture of the umbilical discharge grew Klebsiella pneumonia, and blood culture was negative. Abdominal ultrasonography showed echoic collection in a midline cavity within the anterior abdominal wall. Computed tomography scan confirmed the diagnosis of infected urachal sinus showing a heterogeneous collection with calculus and gas formation communicating with the umbilicus . Two days after apyrexia, cystoscopy and excision of the infected urachal sinus were performed simultaneously. Cystoscopy confirmed no evidence of a bladder anomaly. An infraumbilical midline incision was used to excise the sinus and fibrous tract . The posThe urachus is a vestigial remnant of at least two embryonic structures: the cloaca, and the allantois. The tubular urachus normally involutes before birth, remaining as a fibrous cord between the transversalis fascia anteriorly and the peritoneum posteriorly and attaches the umbilicus to the bladder dome.Histologically, it presents with 3 layers: an innermost layer of modified transitional epithelium similar to the urothelium, a middle layer of fibro-connective tissue, and an outermost layer of smooth muscle continuing the detrusor , 3. UsuaUrachal abnormalities result from incomplete obliteration of the foetal urachus. There are five types of urachal abnormalities: (1) patent urachus, in which the entire tubular structure fails to close 50%); (2) urachal cyst, in which both ends of the canal close leaving an open central portion (30%); (3) urachal sinus, which drains proximally into the umbilicus (15%); 4) vesicourachal diverticulum, where the distal communication to the bladder persists (3–5%); and (5) alternating sinus, which can drain to either bladder or umbilicus [ vesicour0%; (2) uUrachal sinus abscess usually occurs by infection of mucinous secretion via the umbilicus. The commonly cultured microorganisms from the pus are Escherichia coli, Enterococcus faecium, Proteus, Streptococcus viridans and Fusobacterium , 5. In oThe clinical signs and symptoms are nonspecific, as urachal sinus is largely asymptomatic until they become infected. However, the presence of the triad of symptoms including a tender midline infraumbilical mass, umbilical discharge and sepsis should arouse suspicion of urachal sinus .Differential diagnosis of this condition includes anomalies of the vitelline ducts (such as Meckel's diverticulum), patent omphalomesenteric duct, infected umbilical vessel, appendicitis, or omphalitis .Ultrasonography could help in establishing the diagnosis in 77% of patients. In our case, ultrasonography was not specific and computed tomography scan was used to confirm the diagnosis and analyse the connection to surrounding structures.Urachal sinus can be complicated by stone and gaseous formation as was seen in our patient. Other reported complications include rupture into the peritoneal cavity leading to peritonitis, uracho-colonic fistula, and neoplastic transformation . The risAlthough the innermost layer of the urachus is mainly transitional cell, adenocarcinoma (mostly mucinous) is the predominant histological type. This is probably due to metaplasia arising from chronic inflammation.  Urachal cyst treatment depends on the presence of complications or associated conditions. Noninfected urachal sinus are usually removed in a single-step radical excision of the remnant which removes the entire lesion with or without a bladder cuff via open or laparoscopic surgical approach . This inInfected urachal sinus is rare in adults. Presentation is atypical; therefore, a high index of suspicion is required in order to achieve a diagnosis. A triad of infraumbilical mass, umbilical discharge, and sepsis is suggestive. Ultrasound and computed tomography scan confirm the diagnosis and analyses the surrounding anatomical connections. An antibiotic regimen according to bacterial sensitivity is recommended prior to the surgical intervention. In order to prevent recurrence and malignant transformation, complete surgical excision with or without a bladder cuff is the standard treatment.


Cloacal malformation is an extremely rare fetal pathological condition that presents as a variety of defects. It predominantly affects females, with prevalence of 1 in 50,000 births. Prenatal ultrasonography on a 20-year-old caucasian woman (G4P1A2) at 33 weeks of pregnancy showed the fetus having a large cystic mass in the lower abdomen with a single septum, bilateral hydronephrosis, ambiguous genitalia, and a single umbilical artery. The pregnancy developed accentuated oligohydramnios, and presence of a fetal brain-sparing effect was diagnosed using arterial Doppler velocimetry. The newborn showed abdominal distension, ambiguous genitalia, and rectal atresia, with a single perineal opening. Pelvic ultrasound done on the first day after delivery revealed the presence of a large retrovesical septated cystic mass of dense content in the fetal abdomen, and bilateral hydronephrosis. Hysterotomy was performed, and 70 mL of dense liquid was drained through an abdominal colostomy. The infant died on the 27th day of life as a result of infectious complications. Prenatal diagnosing of female urogenital anomalies is usually difficult because of their rarity, different types of manifestation, and lack of characteristic ultrasound signs. Presence of a septated cyst with dense content in the fetal abdomen confirms the finding of hydrometrocolpos, thus raising clinical suspicion of a cloacal anomaly. Cloacal anomalies comprise a rare pathological condition that is observed in female fetuses. They present in various forms depending on the kind of malformation and the gestational age at the time of diagnosis , 2. The Cloacal malformation is a condition in which there is a single opening for the genital, urinary, and gastrointestinal tracts. Embryologically, this confluence normally persists only up to the fifth week of pregnancy. Persistence of a cloacal condition is caused by an abnormal development of the urorectal septum . Most of the cases that have been described were diagnosed in the third trimester or immediately after birth , 4. The We present a rare case of cloacal anomaly, in which the diagnostic suspicion came from obstetric ultrasonography and confirmation came from pelvic ultrasonography on the newborn, in association with the surgical findings.A pregnant 20-year-old white woman (G4P1A2) was referred to our obstetric service with an ultrasound report of a single pregnancy of 33 weeks that had been developing with oligohydramnios and fetal hemodynamic centralization. Morphological assessment on the fetus showed the presence of a large septated cystic mass in the fetal abdomen in the region of the bladder . This maPrenatal diagnoses of female urogenital anomalies is usually difficult. These defects are rare, manifest as varying defects and particularly in the late stages of pregnancy lack characteristic ultrasound signs –3, 9.Cloacal malformation  is caused by an malformation of the urorectal septum that divides the anorectal canal from the urogenital tract and results in different anomalies such as female hypospadias, double uterus, vesical diverticulum, double vagina, imperforate vagina, or other more complex anomalies .In this case, the cloacal anomaly presented as a double uterus (uterus didelphys), which was identified because of hydrometrocolpos which was revealed by the median septum that divided the two uterine units. The bladder with minimal repletion was identified during ultrasound scan of the newborn by pelvic via; realizing the emptying of bladder, which allowed the understanding that the septate image was the uterus. It is often impossible to distinguish the bladder from the uterus (hydrometrocolpos) on ultrasound images, but this difference is seen accurately through magnetic resonance imaging (MRI) , 8. HayaIn literature cases of cloacal anomaly have been reported to be associated with fetal ascites. Fetal urine would drain through the Fallopian tube to peritoneal cavity; this process would develop a chemical reaction that would determine the tubal obstruction, hydrometrocolpos, and resolution of ascites . No asciAlthough ultrasonography is able to identify the large abdominal cystic mass, its origin cannot be determined in most cases. The differential diagnosis includes intestinal atresia, ovarian cysts, megabladder-microcolon-intestinal hypoperistalsis syndrome, and obstructive uropathy .In this case, the presence of an abdominal septated cyst in the central region of the fetal pelvis confirmed the finding of uterine duplication with hydrometrocolpos, thus increasing the clinical suspicion of a cloacal anomaly, which was confirmed during the postnatal period.


Pneumoperitoneum is most commonly the result of a visceral perforation and usually presents with signs of acute peritonitis requiring an urgent surgical intervention. Non-surgical spontaneous pneumoperitoneum (not associated with a perforated viscus) is an uncommon entity related to intrathoracic, intra-abdominal, gynecologic, iatrogenic and other miscellaneous causes, and is usually managed conservatively. Idiopathic spontaneous pneumoperitoneum is an even more rare condition from which both perforation of an intra-abdominal viscus and other known causes of free intraperitoneal gas have been excluded.We present the case of an idiopathic spontaneous pneumoperitoneum. A 69-year-old Greek woman presented with acute abdominal pain, fever and vomiting. Diffuse abdominal tenderness on deep palpation without any other signs of peritonitis was found during physical examination, and laboratory investigations revealed leukocytosis and intraperitoneal air below the diaphragm bilaterally. Her medical history was unremarkable except for previous cholecystectomy and appendectomy. The patient did not take any medication, and she was not a smoker or an alcohol consumer. Emergency laparotomy was performed, but no identifiable cause was found. A remarkable improvement was noticed, and the patient was discharged on the seventh postoperative day, although the cause of pneumoperitoneum remained obscure.A thorough history and physical examination combined with the appropriate laboratory tests and radiologic techniques are useful tools in identifying patients with non-surgical pneumoperitoneum and avoiding unnecessary operations. Pneumoperitoneum is the result of a gastrointestinal (GI) tract perforation in more than 90% of cases . PerforaHowever, sometimes pneumoperitoneum not associated with a perforated viscus can occur; this is called spontaneous pneumoperitoneum (SP) or "non-surgical" pneumoperitoneum. SP is associated with intrathoracic, intraabdominal, gynecologic, iatrogenic or other miscellaneous causes . AlthougA 69-year-old Greek female patient presented at our emergency department (ED) with a two-hour history of abdominal pain and vomiting. Her medical history was unremarkable except for previous cholecystectomy and appendectomy. The patient did not take any medications, and she was not a smoker or an alcohol consumer.3/μL; neutrophils, 86%) and an elevated C-reactive protein . An upright chest radiograph demonstrated free subdiaphragmatic air bilaterally (Figure She looked ill with a blood pressure of 130/85 mm/Hg, a pulse rate of 90 beats/min, respirations of 25 breaths/min and a temperature of 38.5°C. A thorough physical examination revealed diffuse abdominal tenderness on deep palpation without any other signs of peritonitis. The laboratory examination was unremarkable except for polymorphonuclear leucocytosis (white blood cell [WBC] count, 15 × 10An emergency laparotomy was performed for a suspected perforation in the upper GI tract. A few adhesions caused by previous cholecystectomy and appendicectomy were observed without any signs of peritoneal irritation or peritoneal fluid. The stomach and duodenum were fully mobilized, and the lesser sac was explored, but no evidence of perforation was found in the distal esophagus, stomach or duodenum. The small bowel and colon were also examined, but no leakage was observed. Subsequently, dilution of methylene blue in normal saline was instilled into the stomach through the nasogastric tube, but no obvious leakage was noted. Afterward, the abdominal cavity was filled with 2000 cc of normal saline, and air was again infused through the nasogastric tube into the stomach, but no air leakage from the upper GI tract was noted. Finally, because no cause of the pneumoperitoneum had been found, the operation was completed by placing a double-lumen drain.The postoperative course was uneventful, and the patient showed a significant and prompt recovery. The subdiaphragmatic air disappeared six days postoperatively Figure . The patSP is associated with intrathoracic, intraabdominal, gynecologic, iatrogenic and other miscellaneous causes ,2. SP haThe cause of pneumoperitoneum and the clinical signs determine its mode of treatment, surgical or not. When signs and symptoms of "acute abdomen" are present, surgical management is mandatory, but in cases of nonsurgical pneumoperitoneum with mild symptoms and without any signs of peritonitis, conservative treatment is indicated .A detailed history and physical examination can be very helpful in distinguishing surgical from nonsurgical pneumoperitoneum, thus avoiding unnecessary laparotomies . MoreovePlain chest or abdominal radiography is the most common imaging examination for the diagnosis of even very small amounts of intraperitoneal free air in the ED setting , but abdIt has been proposed that in some cases with idiopathic pneumoperitoneum, a subclinical small visceral perforation may have occurred, permitting only the leakage of air and not of bowel contents . Finallyet al. [et al. [et al. [et al. [We report the case of a patient who underwent an urgent but nondiagnostic exploratory laparotomy, although she had compelling evidence for a surgical pneumoperitoneum. A minority of pneumoperitoneum cases are considered idiopathic, but many of them undergo surgical exploration . van Gelet al.  reported [et al.  reported [et al.  found 19 [et al.  reportedCurrently, laparoscopic exploration instead of laparotomy can be the operation of choice in cases of pneumoperitoneum because it can both determine and treat the cause, offering all the advantages of minimally invasive surgery.A thorough history and physical examination combined with the appropriate laboratory tests and radiologic techniques are useful tools in identifying patients with nonsurgical pneumoperitoneum and avoiding unnecessary operations.CT: computed tomography; ED: emergency department; GI: gastrointestinal; SP: spontaneous pneumoperitoneum; WBC: white blood cell.Written informed consent was obtained from the patient for the publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MP participated in the patient's treatment, had the idea for the case report, contributed to the first draft and performed all of the revisions. PZ collected the patient's data, participated in the first draft and performed all of the revisions. AO participated in the imaging diagnosis of the case and contributed to the writing of the paper. MK participated in the patient's treatment and contributed to the writing of the paper. GK contributed to the writing of the paper. CS participated in the patient's treatment and participated in the final revision. All authors read and approved the final manuscript.


Nodular fasciitis is the most common pseudosarcomatous lesion of soft tissue. Ki67 was considered as a useful marker for distinguishing some benign and malignant lesions. To study the usefulness of Ki67 in diagnosis of nodular fasciitis, the expression of Ki67 was examined by using immunostaining in 65 nodular fasciitis specimens, 15 desmoid fibromatosis specimens and 20 fibrosarcoma specimens. The results showed that there was a variable Ki67 index in all 65 cases of nodular fasciitis, and the mean labeling index was 23.71±15.01%. In majority (70.77%) of all cases,the index was ranged from 10% to 50%, in 6.15% (4/65) of cases the higher Ki67 index (over 50%) could be seen. The Ki67 proliferative index was closely related to duration of lesion, but not to age distribution, lesion size, sites of lesions and gender. Moreover, the mean proliferative index in desmoid fibromatosis and fibrosarcoma was 3.20±1.26% and 26.15±3.30% respectively. The mean Ki67 index of nodular fasciitis was not significantly lower than fibrosarcoma, but higher than desmoid fibromatosis. The variable and high Ki67 index in nodular fasciitis may pose a diagnostic challenge. We should not misdiagnose nodular fasciitis as a sarcoma because of its high Ki67 index. The recurrence of nodular fasciitis is rare; and the utility of Ki67 immunostaining may be not suitable for recurrence assessment in nodular fasciitis.http://www.diagnosticpathology.diagnomx.eu/vs/4782335818876666The virtual slide(s) for this article can be found here:  Nodular fasciitis(NF) is the most common pseudosarcomatous lesion of soft tissue. This lesion was often misdiagnosed as a sarcoma because of its rapid growth, rich cellularity, and mitotic activity ,2. RecenWe collected 65 cases of NF from the First Affiliated Hospital of China Medical University from 1995 to 2009. The patients with NF included 37 men and 28 women. Ages of all patients ranged from 8 to 84 years, and the average age was 37 years. The clinical findings were summarized in Table All the resected specimens were fixed with 10% neutral-buffered formalin and embedded in paraffin blocks. Tissue blocks were cut into 4-μm slides, deparaffinized in xylene, rehydrated with graded alcohols, and immunostained with anti-Ki67. In addition, S-100, CD34, Desmin, cytokeratin (CK), Vimentin and α-SMA were also used for making the diagnosis.Sections were stained with a streptavidin-peroxidase system . The chromogen used was diaminobenzidine tetrahydrochloride substrate , slightly counterstained with hematoxylin, dehydrated and mounted. For the negative controls, the primary antibody was replaced with PBS. The sections were observed under five high power fields which showed the relatively higher Ki67 staining, and 500 tumor cells (exclusive of red cells and inflammatory cells) were counted in each field. The location of Ki67 staining was on the nuclear.t test was used to compare data from Ki67 staining. P values less than 0.05 were considered statistically significant.All statistical calculations were performed by SPSS version 18.0 for Windows software . The chi-square test or the Of all 65 patients with NF, the majority of them suffered the rapid growth mass, and 30.77% (20/65) of patients had the tenderness or slight pain. The sites, lesion size, duration and age distribution were listed in Table Histologically, all cases showed variably myxoid to fibrous, which composed of plump immature-appearing myofibroblasts. The cells had oval, pale-staining nuclei with prominent nucleoli. In some cases, highly cellular areas could be seen, and the myofibroblasts showed plentiful mitotic figures Figure .By imunohistochemical staining, all cases of NF were positive for Vimentin and SMA, negative for S-100, CD34, Desmin and CK, and Ki67 was expressed in all 65 NF specimens. In 23.08% (15/65) of all cases, the Ki67 labeling index was less than 10%, while in 6.15% (4/65) Ki67 index was over 50% . The mean Ki67 index in 20 cases of fibrosarcoma was 26.15±3.30%, not significantly higher than that in NF (P =0.472) . That is, the Ki67 index in cases of NF with the duration no more than 2 months was significantly higher than these with the duration more than 2 months  found a recurrence 18 and 26 months after the resection respectively. One of the recurred cases was from head and neck, another was from lower extremity. The duration was 5 months and 6 months respectively. And the Ki67 index in the two recurred cases was approximately 9% and 15% respectively.NF is a pseudosarcomatous, self-limiting reactive process which was first described by Kornwaler et al. in 1955 as “subcutaneous pseudosarcomatous fibromatosis” . HistoloDespite this entity has been well described, NF is still often misdiagnosed as a sarcoma or other malignancies because of its rapid growth, rich cellularity, and mitotic activity. So, in addition to histological appearances, some diagnostic markers including proliferative markers should be used for differential diagnosis. Ki67 antigen is a marker of proliferating cells, and is rapidly degraded after mitosis. For the short half-time, it has been suggested that Ki67 staining is more accurate and specific than the counting of mitoses or PCNA staining . Oshiro In addition, we found that the Ki67 labeling index was closely related to duration of lesion, but not to age distribution, lesion size, sites of lesions and gender. This suggests that if the duration was shorter, the myofibroblasts might have the higher proliferative activities, so the cells showed the higher expression of Ki67. That is, in the earlier stage of the lesion, the majority of myofibroblasts might be in immature status, conversely, if the lesion had a long history, only few of the proliferative cells might have high proliferative activities. In contrast, the Ki67 index in fibrosarcoma and fibromatosis was not associated with the duration. This phenomenon may represent self-limiting reactive process of NF. Acording to Allen, nearly all nodules have been effectively treated by local excision, in the series of 895 cases only 9 (1%) reappeared after attempted complete surgical excision . ThompsoOur results indicate there is a variable expression in all 65 cases of NF. The variable expression of Ki67 in NF may cause a diagnostic confusion. We should not misdiagnose NF as a sarcoma because of its high Ki67 expression. The Ki67 proliferative index may be related to the duration of the leison. The Ki67 staining may be not suitable for prognosis assessment in NF.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in Chief of this Journal.The authors declare that they have no competing financial interests. No part of this article has been published or submitted elsewhere, and there are no financial or other relationships that might lead to a conflict of interest of this article.LXY and WL participated in the histopathological evaluation, performed the literature review, acquired photomicrographs and drafted the manuscript. ZY carried out the immunohistochemical stains evaluation. DSD conceived and designed the study. WEH revised the manuscript. All the authors read and approved the final manuscript.


Gastric adenocarcinoma after gastric bypass for morbid obesity is rare but has been described. The diet restriction, weight loss, and difficult assessment of the bypassed stomach, after this procedure, hinder and delay its diagnosis. We present a 52-year-old man who underwent Roux-en-Y gastric bypass 2 years ago and whose previous upper digestive endoscopy was considered normal. He presented with weight loss, attributed to the procedure, and progressive dysphagia. Upper digestive endoscopy revealed stenosing tumor in gastric pouch whose biopsy showed diffuse-type gastric adenocarcinoma. He underwent total gastrectomy, left lobectomy, distal pancreatectomy and splenectomy, segmental colectomy, and bowel resection with esophagojejunal anastomosis. The histopathological analysis confirmed the presence of gastric cancer. The pathogenesis of gastric pouch adenocarcinoma is discussed with a literature review. Obesity is a global problem, causing significant morbidity and mortality . SurgeryHelicobacter pylori (Hp) positive. He treated the Hp using amoxicillin and clarithromycin and the endoscopy was repeated showing Hp negative. After surgery he had dietary restriction and lost 40 kg. Upper digestive endoscopy revealed a stricture lesion in the gastric pouch and the biopsies confirmed a signet-cell undifferentiated adenocarcinoma. The computed tomography (CT scan) revealed a large abdominal tumor affecting the excluded stomach and with signs of invasion of the left hepatic lobe and the pancreas  of 42 and type 2 diabetes. An upper digestive endoscopy performed before surgery was considered normal and revealed pancreas .The patient underwent total gastrectomy, including the excluded stomach, distal pancreatectomy and splenectomy, left hepatectomy and segmental colectomy with Roux-en-Y esophagojejunal anastomosis, and primary colocolic anastomosis because there was true carcinomatosis invasion of adjacent organs Figures  and 3. TAfter 16 months, the patient was admitted to the emergency with intestinal obstruction. Exploratory laparotomy revealed numerous intestinal adhesions and bowel obstruction at multiple points. He underwent an ileocolic anastomosis. Biopsies of the adhesions were inconclusive. Nevertheless, a PET-CT showed peritoneal carcinomatosis Figures  and 5. PThe incidence of esophagogastric cancer after bariatric surgery is rare; however, about 30 cases of adenocarcinoma have been described in the last years , 5. The Endoscopy is considered the most sensitive diagnostic modality to aid in the detection of premalignant dysplasia or malignant gastric lesions . EndoscoThere are conditions that have been associated to greater risk of gastric adenocarcinoma, such as family history, blood type-A, hereditary nonpolyposis colon cancer, and the Li-Fraumeni syndrome. There also exist precancerous lesions such as adenomatous polyps, dysplasia, intestinal metaplasia, and Menetrier's disease. In patients with these conditions with higher risk of developing gastric cancer, a resection of the bypassed stomach can be considered at the time of RYGBP .The diagnosis of esophagogastric malignancies after bariatric procedures can be difficult because weight loss, vomiting, and inability to eat normal quantities of food can be attributed to the expected results of surgery , 5.The cases of gastric carcinomas after bariatric surgeries previously reported by Raijman et al. , Lord etOn the other hand, gastric adenocarcinomas have been described after vertical banded gastroplasty (VBG). Ziraik et al. , PapakonHelicobacter pylori (Hp) is one of the etiologic factors associated to gastric cancer [The c cancer , 26. Thuc cancer .The authors, in recent publications, advise that an adequate preoperative gastric evaluation by upper digestive endoscopy should be performed on all candidates before surgical treatment for obesity . Finally, there must be a high index of suspicion, if any sign of malignancy was found during an endoscopy, for earlier detection and treatment of gastric carcinoma, improving patient outcomes.


The ribs are essential structures of the osseous thorax that provide certain significant information and aid interpretation of radiologic images in daily routine practice. Intrathoracic rib is a rare congenital anomaly that is usually discovered incidentally, but may cause in vain interventions in case of being unaware. We herein report an intrathoracic rib in a girl whose chest X-ray was strange enough to obtain a spiral computed tomography (CT) scanning for a definitive diagnosis afterwards. Ribs are composed of three developmental compartments and embryologically originate from the somites . In arouA six-year-old girl was taken to the hospital with symptoms of respiratory tract infection (respiratory distress and fever). She had no history of lung or any other systemic disease. She had also not suffered from chest trauma and surgery before, but she had scoliosis. The routine laboratory blood test results were within normal limits. A hyperdense lesion on the right hemithorax linearly extending inferolaterally from the medline was seen on chest X-ray . Spiral There are various types of congenital anomalies of the ribs, including developmental fusion. These anomalies occur in 0.15%-0.31% of the population . The devType II is described as a bifid intrathoracic rib originating from a distal rib. Type III is a rib depressed into the thoracic cavity. The fourth type represents combination of type II and type III. This case resulted from the vertebral body, therefore it was considered as a type I-a.An intrathoracic rib is an innocuous congenital anomaly which usually does not require any treatment. Although no treatment was applied in the case, it may bring about an uncertainty in diagnosis and an unnecessary therapy. So spiral CT scan has an important role in highlighting the circumstances. In our patient, it accurately characterized the intrathoracic rib with its appearance and origin  and 3. SIn conclusion, intrathoracic ribs should be kept in mind in the differential diagnosis of parenchymal lesions. The diagnosis without any necessary intervention is essential for contemporary medicine at present. Spiral CT demonstrates the origin and extent of the intrathoracic rib with high accuracy. It therefore appears to be the modality of choice for this very rare anomaly as well.


We report on a very rare case of a cervical ligamentum flavum cyst, which presented with progressive myelopathy and radiculopathy. The cyst was radically extirpated and our patient showed significant recovery. A review of the relevant literature yielded seven cases.An 82-year-old Greek woman presented with progressive bilateral weakness of her upper extremities and causalgia, cervical pain, episodes of upper extremity numbness and significant walking difficulties. Her neurological examination showed diffusely decreased motor strength in both her upper and lower extremities. Magnetic resonance imaging of her cervical spine demonstrated a large, well-demarcated cystic lesion on the dorsal aspect of her spinal cord at the C3 to C4 level, significantly compressing the spinal cord at this level, in close proximity to the yellow ligament and the C3 left lamina. The largest diameter of this lesion was 1.4 cm, and there was no lesion enhancement after the intravenous administration of a paramagnetic contrast. The lesion was surgically removed after a bilateral C3 laminectomy. The thick cystic wall was yellow and fibro-elastic in consistency, while its content was gelatinous and yellow-brownish. A postoperative cervical-spine magnetic resonance image was obtained before her discharge, demonstrating decompression of her spinal cord and dural expansion. Her six-month follow-up evaluation revealed complete resolution of her walking difficulties, improvement in the muscle strength of her arms , no causalgia and a significant decrease in her preoperative upper extremity numbness.1-weighted and hyperintense appearance on T2-weighted magnetic resonance images, with contrast enhancement of the cystic wall. Surgical extirpation of the cyst is required for symptom alleviation and decompression of the spinal cord. The outcome of these cysts is excellent with no risk of recurrence.Cervical ligamentum flavum cysts are rare benign lesions, which should be included in the list of differential diagnosis of spinal cystic lesions. They can be differentiated from other intracanalicular lesions by their hypointense appearance on T It is well known, that cystic intracanalicular cervical spinal lesions may cause compression of the spinal cord and/or the exiting spinal nerve roots, resulting in the development of myelopathy and/or radicular symptomatology. This may eventually evolve to irreversible myelomalacia if the underlying pathology remains untreated. Various malignant pathological entities, as well as a large group of benign lesions, may present as solely or partially cystic lesions of the cervical spine. The malignant group includes cystic astrocytomas, schwannomas, meningiomas, ependymomas or metastatic lesions, while the benign lesion group includes synovial, ligamentum flavum, posterior longitudinal ligament, discal, perineural, arachnoid and dermoid cysts or hematomas . These bIn our current communication, we report a case of a cervical ligamentum flavum cyst, presenting with severe progressive cervical myelopathy and radiculopathy. Our diagnostic and therapeutic approaches are presented, along with a systematic review of the pertinent literature.An 82-year-old Greek woman presented to the outpatient clinic of our department, complaining of bilateral weakness of her upper extremities and causalgia, as well as significant walking difficulties. Her symptoms started approximately three months earlier and were progressively worsening. Our patient reported that she had always had cervical pain and spontaneously resolving episodes of upper extremity numbness, but her current symptomatology was more intense and bothersome.Her past medical history was significant for idiopathic arterial hypertension, diabetes mellitus, hypercholesterolemia, hypothyroidism, ischemic heart disease, depression and osteoporosis. Her past surgical history revealed surgically treated bilateral carpal tunnel syndrome several decades ago. Moreover, she had unilateral knee and hip arthroplasties three and 13 years ago respectively.Her neurological examination showed diffusely decreased motor strength in both her upper and lower extremities. Her left arm muscle groups including deltoid, biceps and triceps showed 3/5 strength, while on her right side the same muscles showed 4/5 strength. Similarly, decreased muscle strength, mainly of her quadriceps and adductors, was noted in her lower extremities; 4/5 on her right and 3/5 on her left side. Burning pain and hypoesthesia were elicited upon examination in the distribution of the C4 and C5 sensory dermatomes, more prominent on her left side. There were no other light touch deficits. Her proprioception and temperature sensation were normal in both arms and legs. Her deep tendon reflexes were equally decreased in both biceps and triceps muscles bilaterally, while her right patellar reflex was less brisk than her left one. In addition, our patient complained of progressive gait impairment, which significantly limited her daily activities.Magnetic resonance imaging (MRI) of her cervical spine demonstrated a large, well-demarcated cystic lesion on the dorsal aspect of her spinal cord at the C3 to C4 level Figure . This leUnder general endotracheal anesthesia and motor and somatosensory evoked potential intra-operative monitoring, our patient was positioned in the prone position, with her head secured on a three-point Mayfield fixation device.in toto, while the underlying displaced dura immediately expanded. Meticulous hemostasis was performed, and the surgical wound was closed in anatomical layers.A midline, vertical skin incision extending from her occiput to the C7 spinous process was made. Meticulous subperiosteal muscle dissection was performed and the spinal processes and the laminae of C2 to C4 were bilaterally exposed. The C3 spinous process was removed, and bilateral C3 laminectomies were performed. The C3 laminae had become paper-thin, most probably secondary to the long-standing pressure caused by the underlying cyst. A large, well-demarcated cyst was exposed, which occupied the epidural space and had displaced the underlying dura and spinal cord , no causalgia and a significant decrease in her preoperative upper extremity numbness.The resected cyst had a firm, fibro-elastic wall, while its content was a yellowish thick gel. Microscopic examination demonstrated that the cystic wall had no lining, and there were no calcium or hemorrhagic deposits. Scattered histiocytes were observed in the cystic wall. No evidence of neovascularization was present in our specimen.Intracanalicular extradural cysts represent a rare clinicopathological entity -8. They Taking into consideration these terminology and classification issues, the incidence of true ligamentum flavum cysts is extremely low -9. The mThe exact pathophysiologic mechanism responsible for ligamentum flavum cyst development remains unclear ,5-8. It The ligamentum flavum cysts may enlarge and can cause cervical spine stenosis, especially in patients with concomitant degenerative changes -4,6-9. IMRI of the vertebral column is considered the method of choice for the diagnosis of patients with intracanalicular space-occupying lesions. Ligamentum flavum cysts appear as well-demarcated, isointense lesions on T1-weighted images, while they are usually hyperintense on T2-weighted images -9. HowevSurgical extirpation of the cyst through bilateral or unilateral laminectomy, depending on their location and their size, constitutes the treatment of choice in all the reported cases ,4,6-9. IThe macroscopic appearance of the ligamentum flavum cysts is that of a fibrous, thick cystic wall with gelatinous or mucinous yellowish content ,5,6,8,9.et al. [Complete cyst removal is associated with complete or nearly complete symptom resolution and overall excellent clinical outcome. In the vast majority of the reported cases the preoperative symptoms were usually resolved within a period of a few weeks of the operation, as in our case ,5,7-9. Cet al.  have repThe presence of a cystic mass on a cervical spine MRI study should always raise the possibility of a ligamentum flavum cyst, although these cysts represent a quite rare pathological entity. The MRI features that may differentiate them from other intracanalicular lesions are their hypointense appearance on T1 and hyperintense appearance on T2 imaging, with contrast enhancement of the cystic wall. Surgical extirpation of the cyst is required for symptom alleviation and decompression of the spinal cord. Spinal fusion usually is not necessary, unless wide exposure and multiple level laminectomies were required for a large cyst removal. The outcome of these cysts is excellent with no risk of recurrence.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.The authors declare that they have no competing interests.All authors contributed in writing the manuscript. All authors read and approved the final manuscript.


Gastric duplications are uncommon developmental abnormality reported to present with different clinical scenarios. We present a 2-1/2-year-old Nigerian female who started having intermittent massive lower gastrointestinal haemorrhage at 5 months of age. She subsequently developed a lower chest wall mass and enterocutaneous fistula. She was found to have gastric duplication with fistulous communication with the descending colon, spleen, and lower chest wall. To the best of our knowledge, this is the first paper on gastric duplication resulting in intermittent massive lower gastrointestinal bleeding mainly from splenic capsular erosion and fistula and enterocutaneous fistula resulting from erosion of anterior abdominal wall. Gastric duplication is hence an important rare cause of intermittent massive lower gastrointestinal haemorrhage and spontaneous enterocutaneous fistula in the paediatric population. Gastric duplications are rare congenital anomalies accounting for 4%-5% of all gastrointestinal malformation . They arThe symptoms depend on the location. They are usually nonspecific or they may result secondary to complication.We report a case of gastric duplication who presented with intermittent massive lower gastrointestinal bleeding and enterocutaneous fistula. A fistulous connection to descending colon, spleen, and lower anterior chest wall was discovered.The patient is a 2-1/2-year-old Nigerian female child who presented with recurrent massive lower gastrointestinal haemorrhage since 5 months of age, left-sided lower chest wall swelling of 9 months duration which was gradually increasing in size but later formed a sinus and started discharging mucopurulent and haemorrhagic effluent 2 days prior to presentation and chest pain of 1-year duration. On account of bleeding, the patient had been transfused severally in the past and she had an exploratory laparotomy in a tertiary hospital 8 months prior to presentation. However no abnormality was found by the operating surgeon. Her symptoms did not improve. There is no history of bleeding disorder in the family. Haemoglobin genotype is AA.E. coli. Acid fast bacilli test was negative and Mantoux test was not significant. The histology of the biopsied lymph nodes was in keeping with reactive hyperplasia. Packed cell volume (PCV) on admission was 27%.On examination at presentation, she was pale, not dyspneic, but she had a slightly tender left axillary lymphadenopathy. Vital signs were stable. There was an asymmetrical, ill-defined chest wall mass overlying the 9th and 10th ribs with a central sinus discharging mucoid and haemorrhagic fluid. The surrounding skin was erythematous and edematous. Examination of the abdomen revealed a transverse infraumbilical incision scar. No other abnormality was noted. A chest radiograph done suggested periosteal reaction involving the 9th and 10th ribs. Wound swab MCS, wound biopsy, and biopsy of 2 enlarged and discrete axillary lymph nodes were done. A wound swab culture grew Three days on admission, faeces started discharging from the sinus on the left lower chest wall. She developed 3 episodes of massive lower gastrointestinal bleeding with bleeding per rectum and bleeding through the enterocutaneous fistula site. Packed cell volume dropped to 23% and 21% and patient was transfused to build up the PCV to 30%. Fistulograph done showed the free flow of contrast into the descending colon .She was worked up for exploratory laparotomy. Intraoperative findings included gastric duplication measuring 4 × 5 cm, originating from the greater curvature. It did not communicate with the gastric lumen. There was a fibrous cordlike extension extending from the body of pancreas to the gastric duplication consisting principally of pancreatic tissue. The gastric duplication had a fistulous connection to the descending colon, measuring about 1.5 cm in diameter and the same fistulous tract also causing splenic capsular erosion and splenic fistula and a communication to the lower chest wall causing colocutaneous fistula. Figures  and 3. SHistology of the specimen confirmed gastric epithelium , while tMany theories have been postulated to account for the aetiology of gastric duplication, with none of them explaining the malformation completely. They include aberrant recanalization of the gastrointestinal tract, persistent embryological fetal gut diverticulum, and uteroischaemic events .This case fulfilled the morphological criteria described by Ladd for gastrointestinal duplication, which include the presence of well developed smooth muscle, epithelial lining from the alimentary tract, and an attachment to some part of the alimentary tract . The mucOur patient developed intermittent massive rectal bleeding with the initial episode presenting at 5 months of age. Similar reports of massive lower gastrointestinal bleeding have been reported in a 5 months and 11 months old females , 6. BothThe source of bleeding in our patient was primarily from the splenic capsular erosion and fistula with contribution from colonic ulcers. This differs from the case reported by Mahnovski et al. , where tMassive upper gastrointestinal haemorrhage has also been reported as a complication of gastric diverticulum .Erosion of the lower chest wall was responsible for the significant chest wall soft-tissue edema, periostitis involving the 9th and 10th ribs, and discolouration of skin. The picture was initially confused to be a rib osteomyelitis or an unsuspected rib fracture. The case reported by Bonacci and Schlatter also reported chest and anterior abdominal wall edema, 7th rib periosteal changes and pleural effusion , 5. ThisThe treatment modality depends on the presentation. Surgery is indicated in symptomatic or complicated cases.This case illustrates an unusual presentation of gastric duplication. Gastric duplication is a rare cause of recurrent massive lower gastrointestinal haemorrhage associated with lower chest wall enterocutaneous fistula.


Fibroepithelial stromal polyps are site-specific mesenchymal lesions that are commonly found in the vulvovaginal region in premenopausal females. These polyps usually are less than 5 cm in diameter and are most commonly identified during routine gynecological examination. Although the stromal polyp is benign, its differential diagnosis includes some malignant vulva lesions making it critical to ensure that an accurate pathologic diagnosis is made.We present a case of a 21 year old female with a giant fibroepithelial stromal polyp of the vulva. Upon review of the literature this is the largest reported fibroepithelial stromal polyp to date.Fibroepithelial stromal polyps can grow as large as 390 grams and can be 18.5-cm in diameter. Microscopic evaluation of the polyp is critical in the exclusion of malignancy with this diagnosis. Fibroepithelial stromal polyps are a type of mesenchymal lesion that typically occur in women of reproductive age. These polyps are site-specific and have a predilection for the vulvovaginal region. They are most frequently found in the vagina. Infrequently they occur on the vulva and cervix and rarely are found in extra-genital sites. These polyps are hormone sensitive and most commonly occur in pregnancy. However they can also be seen in premenopausal females who are on hormone replacement therapy. These lesions typically do not grow larger than 5-cm in diameter and are found incidentally during routine gynecologic exams. They caA 21 year old nulliparous female presented to the emergency department (ED) with the complaint of right lower quadrant abdominal pain. During her ED course, she admitted that her real reason for presentation was for examination of a mass that had been growing on her right labium. Following a brief physical examination by the ED physician, the gynecology team was consulted and verification was made of a right labial mass. The patient admitted that she first noticed a marble-sized “bump” on her right labium about six months earlier. The bump increased in size over the course of the six months until its current size on presentation. She reported being too embarrassed and afraid to address the growth but due to the polyp’s burdensome size she was forced to present for evaluation. She was on day two of her menstrual cycle and denied any nausea, vomiting or any constitutional symptoms. The patient denied any significant medical or surgical history. She denied any history of sexually transmitted disease or gynecology-related surgery. She reported a history of regular menstrual cycles with a menstrual index as follows - menarche at age 10, 30 day cycle intervals and 4 to 6 day cycle lengths with moderate flow. She had not been sexually active for over a year and was on no contraception. She was a non-smoker and denied alcohol or drug use. Her physical exam was remarkable only for a large, non-tender, skin colored, grapefruit-sized ulcerating pedunculated mass extending from the right labium majus. Transvaginal ultrasound showed normal anatomy of the uterus and ovaries but also described a broad-based encapsulated soft tissue mass of the right labium at the level of the clitoris. The patient was discharged home for follow up with outpatient Gynecology-Oncology. Physical exam by the oncologist again verified a right labial pedunculated mass. The stalk was noted to be vascular with an area of ulceration over the serosal surface of the polyp. There was no increase in the size of the mass with valsalva. An in-office procedure to amputate the polyp was completed at the oncologist’s office. The base of the mass was infiltrated with Xylocaine, 3 large Kelly clamps were placed across the base and the mass was excised. The pedicle was ligated with 0 Vicryl suture and adequate hemostasis was obtained. The patient received Percocet for pain control with instructions for a 1- week follow up appointment. At her follow up appointment the vulva was noted to be healing well and the stalk was retracted. The pathology report returned as a giant fibroepithelial stromal polyp and she was advised to return to her routine gynecologist for continued surveillance.Fibroepithelial stromal polyps usually occur in women of reproductive age. They vary in size but are commonly polypoid and exophytic. The margins of these polyps merge with normal tissue and their vascular supply is usually thick-walled with a central core. Below are the gross pictures of the polyp in our case Figures  and2.Malignancy must be excluded in every diagnosis of fibroepithelial stromal polyp. The characteristic morphologic features as described above should serve as a guide in making this distinction. However, sarcomas may be grossly similar in appearance to fibroepithelial stromal polyps and for this reason microscopy is critical for final diagnosis. Microscopically, the most characteristic feature of a fibroepithelial stromal polyp is the presence of stellate and multinucleate stromal cells which are usually identified near the epithelial-stromal interface. The strMicroscopic evaluation of the lesion in our case revealed stromal tissues with a fibrovascular supporting core. Focally, the stroma was myxoid with bland stellate cells extending up to the epithelial stromal interface. A section through the stalk of the polyp showed squamous epithelium surrounding a fibrovascular stalk with numerous thick walled vessels Figures  and4.In addition to histopathologic evaluation, imaging is important in the diagnostic work up of fibroepithelial stromal polyps. It allows for evaluation of blood supply and flow and demonstrates the origin and extent of the lesion. Although CT and MRI may be used, they are not as cost effective or widely available as ultrasonography. As a reThe table below shows the clinical presentation and hisopathologic features of the site-specific mesenchymal lesions of the vulvovaginal region that must be considered in the differential diagnosis of fibroepithelial stromal polyps Table .Botryoid Embryonal rhabdomyosarcoma is another differential that should be considered. However, these tumors are typically diagnosed in pre-pubertal females and they lack the characteristic hypercellular subepithelial layer and specific markers of skeletal muscle differentiation.Although rare, fibroepithelial polyps can recur, especially if they are not completely excised. There are reported cases of such recurrence. There iFibroepithelial stromal polyps are benign, mesenchymal lesions that typically occur in women of child-bearing age. These polyps have a predilection for the vulvovaginal region and although they typically do not exceed 5 cm in diameter they sometimes can grow as large as 390 grams and 18.5-cm in diameter as seen in our presenting case. Although benign, the polyp mimics some more serious and malignant growths in appearance and as a result, microscopic evaluation of the polyp is critical in the exclusion of malignancy.Written informed consent was obtained from the patient for publication of this Case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.OSM-L interviewed the patient, performed the literature review and drafted as well as revised the manuscripts. RG performed the excisional procedure and proof read all editions of the manuscript. GS participated in the interview of the patient, proof read all editions and contributed to the flow of the manuscript. All authors read and approved the final manuscript.


Varicella-zoster virus and herpes simplex virus types 1 and 2 are neurotropic viruses that can be reactivated after a surgical or stressful intervention. Although such cases are uncommon, consequences can be debilitating, and variable treatment responses merit consideration. We describe a 41-year-old male with a history of varicella-mediated skin eruptions, who presented with continuing right arm pain, burning, and numbness in a C6 dermatomal distribution following a C5-6 anterior cervical discectomy and fusion and epidural steroid injections. The operative course was uncomplicated and he was discharged home on postoperative day 1. Approximately ten days after surgery, the patient presented to the emergency department complaining of severe pain in his right upper extremity and a vesicular rash from his elbow to his second digit. He was started on Acyclovir and discharged home. On outpatient follow-up, his rash had resolved though his pain continued. The patient was started on a neuromodulating agent for chronic pain. This case adds to the limited literature regarding this rare complication, brings attention to the symptoms for proper diagnosis and treatment, and emphasizes the importance of prompt antiviral therapy. We suggest adding a neuromodulating agent to prevent long-term sequelae and resolve acute symptoms. Varicella-zoster virus (VZV), herpes simplex virus type 1 (HSV-1), and herpes simplex virus type 2 (HSV-2), members of the Herpes virus family, are a group of neurotropic viruses that infect neurons, remain dormant in dorsal root ganglia, and by axoplasmic transport, can become reactivated during times of stress or immunocompromised states in the axonal terminals causing neuralgia, and a cutaneous rash most often in a segmental or radicular distribution. Although afferent sensory neurons are most often affected, motor neuron involvement has been reported in 0.5–31% cases of Herpes Zoster [We present the case of a 41-year-old male with a history of herpetic shingles, who had previously undergone a C5-6 foraminotomy two years prior to presentation, which had failed to relieve his right arm pain. Of note, after this surgery he experienced a recurrence of his shingles, which subsequently resolved. He presented to our clinic with continued pain and numbness in a C6 dermatomal distribution, as well as a burning sensation in this distribution, despite the previousely mentioned intervention. Conservative management including epidural steroid injections had failed to improve his symptoms.On physical examination, he demonstrated full strength in all muscle groups bilaterally. He had no evidence of myelopathic signs. MRI of the cervical spine upon initial presentation to our clinic showed degenerative disk disease at C5-6, with bilateral foraminal stenosis.Given that he had already undergone attempted foraminal decompression posteriorly, it was decided to proceed with C5-6 anterior cervical discectomy and fusion. The operative course was uncomplicated, the patient tolerated the procedure well, and he was discharged home on postoperative day 1.Approximately ten days after the procedure, the patient presented to the emergency department with complaints of severe pain in his right upper extremity and a vesicular rash from his elbow to his second digit . This waAt the follow-up visit, his vesicular rash had completely resolved. However, the upper extremity pain, which he had preoperatively, continued. Therefore, the possibility of neuropathic rather than radiculopathy was raised. He was started on neuromodulating agents including Lyrica and nortriptyline for chronic neuropathic pain.In the cases we reviewed, patients manifested VZV or HSV outbreaks from 2 days to 10 months after the inciting incident, which ranged from an epidural steroid injection to surgical manipulation. However, after surgical intervention, we noted that outbreaks or its resulting deficits occurred most often 9/13 cases) at 2–7 days postoperatively , 5, 7, 9/13 casesIn many cases, surgical manipulation of nerve roots led to the development of shingles or herpes radiculitis in dermatomal distribution of the same manipulated nerve roots or those in adjacent levels , 5, 7, 9A recent case report demonstrated the successful usage of epidural corticosteroid injections in the vicinity of the affected spinal cord root in a patient with VZV-mediated radiculitis . The proWe encountered several cases of herpetic outbreaks following craniospinal interventions that utilized different treatments with variable success . AcyclovIn a case series of postoperative neurosurgical patients who developed VZV or HSV reactivation, oral or IV Acyclovir was used successfully in the resolution of symptoms and lesions . InteresIn the reviewed cases, although the herpetic outbreaks were treated with an appropriate antiviral agent either topically, orally, or intravenously, only a few tried to prevent postherpetic neuralgia with a neuromodulator, that is, amitriptyline and/or gabapentin , 5, 9. GVZV- and HSV-mediated radiculitis and associated lesions are rare events which occasionally occur after surgical manipulation or steroid injections in the spinal canal. In cases with successful resolution, oral or intravenous antiviral agents, most commonly Acyclovir, have been used. Neuromodulating agents such as gabapentin and/or amitriptyline were used in some cases to prevent or decrease the severity of postherpetic neuralgia. This case report adds to the limited literature regarding this rare complication, brings attention to the symptoms for proper diagnosis and treatment, and emphasizes the importance of prompt antiviral therapy. We suggest the addition of a neuromodulating agent to prevent long-term sequelae and resolve acute symptoms.


Radionecrosis  is a complication of (chemo) radiotherapy for hypopharyngeal cancer that is difficult to differentiate from tumor recurrence.A 67-year-old Japanese man presented with a condition extremely difficult to diagnose differentially as radionecrosis or tumor recurrence after radiotherapy for hypopharyngeal cancer. Although tumor recurrence was suspected from clinical conditions and computed tomography findings, pathologic analysis revealed no evidence of tumor recurrence, and successful therapy with steroids and antibiotics reduced the mucosal edema.Our findings emphasize the wide spectrum of radiographic presentation of radionecrosis after chemoradiation of stage IV hypopharyngeal cancer. Adverse reactions to radiotherapy can include both early and late complications. Late complications may arise more than several months after the completion of radiotherapy, even in patients who show no evidence of complications during exposure. These complications are generally irreversible, progress gradually, and cause crucial organ dysfunction. Late radiotherapy complications involving the head and neck area include disturbances of salivary secretion, jaw necrosis, chondronecrosis, hypothyroidism, subcutaneous tissue fibrosis, and development of second cancers. Improvements in radiotherapy seemed to have reduced the incidence of radiotherapy-related adverse reactions, from 5% during the 1970s to 1% during the 1990s . ConcomiA 67-year-old Japanese man visited our department complaining of pharyngeal pain. He had no appreciable medical or family histories, had smoked 30 cigarettes per day for 35 years, and had no drinking history. The patient had become aware of pharyngeal pain and had visited his general practitioner, but his condition did not improve.2 docetaxel on days 1, 8, 15, 22, and 29, and 3D radiotherapy, consisting of 2Gy fractions once daily for five days per week, for a total dose of 62.0Gy in 31 fractions. The dose to the whole neck was 40.0Gy, and the dose to the primary site was 62.0Gy. Although the patient complained of mild pain in the throat, he was able to eat a sufficient number of light meals.At his initial visit to our department, laryngopharyngeal fiberoptic endoscopy revealed a neoplastic lesion in the left pyriform recess Figure . Vocal cAt approximately one month after completing radiotherapy, we took a biopsy sample of his left hypopharynx under direct laryngoscopy to evaluate response to therapy, as biopsy is done after initial treatment in the UMCC (University of Michigan Comprehensive Cancer Center) protocol 9520 [Later, as an outpatient, he gradually developed pharyngeal pain and dyspnea. Laryngopharyngeal fiberoptic endoscopy showed mucosal swelling in the pharynx and larynx. CT images of his neck, taken approximately eight months after the completion of radiotherapy, revealed a suggestive space-occupying lesion in the right lateral pharyngeal wall at the level of the epiglottis and a suggestive circumferential space-occupying lesion in the mucosa and airway constriction at the level of the thyroid cartilage. In detail, CT scans showed mixed masses of enhanced and non-enhanced lesions at both the epiglottis and thyroid-cartilage levels, strongly indicating tumor recurrence. Although we observed swelling of the surrounding soft tissues and segmentation or collapse of the thyroid cartilage, we did not observe defluxion of the arytenoid cartilage or abnormal gases contacting the cartilage Figure . DyspneaTwo years after primary treatment with radiation, no evidence has been found of tumor recurrence. The patient's speech and deglutition were preserved, and his voice quality was within normal limits.Radionecrosis is one of the late complications of radiotherapy. Although its incidence is approximately 1% , it is pThe clinical manifestations of radionecrosis, including hoarseness, difficulties with oral intake, pharyngeal pain, dyspnea, and skin fistula, are similar to those of tumor recurrence . In addiIn addition to the similarity of clinical conditions and CT findings in patients with radionecrosis and recurrent lesions, some submucosal recurrent lesions may not be detected by biopsy under direct laryngoscopy, especially in patients with significant mucosal edema. Moreover, in some patients, radionecrosis and recurrent tumor may occur concurrently. Thus, differential diagnosis between radionecrosis and tumor recurrence is considered extremely difficult. Positron emission tomography- (PET)-CT is an alternative imaging modality that has been successfully used to differentiate postradiation changes, radionecrosis, and tumor recurrence. Furthermore, Fludeoxyglucose- (FDG)-PET scanning after radiation can predict tumor regrowth three months later . HoweverPatients with T3/T4 hypopharyngeal SCC usually require total laryngopharyngectomy. Because our patient initially had bulky stage IV disease, associated with frank thyroid cartilage invasion, total laryngopharyngectomy was applicable. However, the patient desired organ preservation and therefore chose chemoradiotherapy as an alternative to total laryngopharyngectomy . As a reA patient developed a condition after chemoradiotherapy for hypopharyngeal cancer that required differential diagnosis between radionecrosis and tumor recurrence. Our findings emphasize the wide spectrum of radiographic presentation of radionecrosis.CR: complete response; CT: computed tomography; SCC: squamous cell carcinoma.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.The authors declare that they have no competing interests.All authors provided an equal intellectual contribution to this manuscript. All authors read and approved the final manuscript.


An 82-year-old woman presented with a high-grade fever of 40°C and was admitted to our institution for intensive examination and treatment. Noncontrast abdominal computed tomography (CT) revealed low-density masses at segments 5 and 8, suggestive of a liver abscess. On further examination, a contrast-enhanced abdominal CT showed a 30 × 30 mm mass with an enhanced margin at segment 8 in the arterial phase; the contrast agents were washed out in the venous phase. In addition, a 63 × 52 mm mass with a density lower than that of liver parenchyma was observed at segment 8 in the portal phase. On the basis of these findings, either a liver abscess or hepatocellular carcinoma was suspected. To confirm the diagnosis, a fine needle biopsy was scheduled. Histopathological analysis of the biopsied specimens confirmed the diagnosis of diffuse large B-cell lymphoma. Chemotherapy was not indicated owing to the patient's age and poor performance status; thus, best supportive care was planned. On day 22 after admission, the patient died of pneumonia. We experienced a case of PHL that was difficult to discriminate from a liver abscess. Imaging alone is insufficient to diagnose PHL; therefore, fine needle biopsy is recommended for a definitive diagnosis. Primary hepatic lymphoma (PHL) is a rare entity comprising only 0.48% of all malignant lymphoma. PHL is sometimes difficult to diagnose accurately as there are no specific imaging characteristics associated with this disease and confirmation requires a fine needle biopsy. Here we present a case of PHL that was difficult to discriminate from a liver abscess; fine needle biopsy facilitated diagnosis confirmation.2; blood pressure, 120/67 mmHg; heart rate, 81/min; respiratory rate, 14/min; body temperature, 38.0°C; saturated oxygen in arterial blood, 96% (room air). Mild anaemia was evident in her palpebral conjunctiva. Chest auscultation revealed no abnormal findings. The abdomen was soft and flat, with normal bowel sounds; slight tenderness was observed over the upper abdomen. Leg oedema was not evident. Chest radiography revealed a cardiothoracic ratio of 50.0%, without evidence of pulmonary congestion or pleural effusion. Abdominal radiography revealed no abnormal gas distribution. Noncontrast abdominal computed tomography (CT) revealed low-density masses at segments 5 and 8, suggestive of a liver abscess  and predominantly occurs in men . Its cli8 years aThe imaging findings for PHL comprise a low-density mass on noncontrast CT, a marginally or internally enhanced mass on contrast-enhanced CT, and a homogeneously low-echo mass on ultrasonography. It is impossible to confirm a PHL diagnosis by imaging alone as there are no characteristic imaging findings associated with this disease. While images of vessels penetrating tumours are suggestive of PHL, these vessels have a relatively low impact on the vascular structure of the liver. For a definite PHL diagnosis, histopathological examination of a fine needle biopsy is mandatory and has a reported accuracy of 85% . The risPHL treatment options include resection of the affected lesion, a combination of chemotherapy and radiotherapy, and a combination of resection and chemotherapy, although no established treatment regimen exists. Niimi et al.  reportedWe reported a case of PHL that was difficult to discriminate from a liver abscess. Imaging alone is insufficient to diagnose PHL; therefore, fine needle biopsy is recommended for a definitive diagnosis.


Coccidioidomycosis is an endemic fungal infection in the southwestern of United States. Most infections are asymptomatic or manifest with mild respiratory complaints. Rare cases may cause extrapulmonary or disseminated disease. We report two cases of knee involvement that presented as isolated lytic lesions of the patella mimicking neoplasms.The first case, a 27 year-old immunocompetent male had progressive left anterior knee pain for four months. The second case was a 78 year-old male had left anterior knee pain for three months. Both of them had visited general physicians without conclusive diagnosis. A low attenuation lytic lesion in the patella was demonstrated on their image studies, and the initial radiologist’s interpretation was suggestive of a primary bony neoplasm. The patients were referred for orthopaedic oncology consultation. The first case had a past episode of pulmonary coccioidomycosis 2 years prior, while the second case had no previous coccioidal infection history but lived in an endemic area, the central valley of California. Surgical biopsy was performed in both cases due to diagnostic uncertainty. Final pathologic examination revealed large thick walled spherules filled with endospores establishing the final diagnosis of extrapulmonary coccidioidomycosis.Though history and laboratory findings are supportive, definitive diagnosis still depends on growth in culture or endospores identified on histology. We suggest that orthopaedic surgeons and radiologists keep in mind that chronic fungal infections can mimic osseous neoplasm by imaging. Coccidioides immitis  or posadasii (endemic to other regions mentioned above) spores. It has an estimated incidence of over 100,000 cases annually in the U.S. with most of these infections  manifesting subclinically or with only mild, isolated respiratory complaints [Coccidioidomycosis is an endemic fungal infection in the southwestern United States, Mexico, and some areas of Central and South America . It was mplaints -6. Rare mplaints ,7,8. Skimplaints . We presA healthy 27 year-old immunocompetent male was referred for orthopaedic oncology evaluation of a possible neoplasm involving the inferior pole of his left patella. The man described a four month history of progressive anterior knee pain and swelling. Suspecting a knee infection, his orthopaedic surgeon performed two separate aspirations for culture, both of which were negative for any microorganisms including fungus. Radiographs demonstrated a lucent lesion in the inferior pole of the patella, and a CT and MRI of the knee were ordered. The initial radiologist’s interpretation was suggestive of a primary bony neoplasm, and orthopaedic oncologic consultation was obtained.Coccidioides spp. by sputum culture. He was treated with a 6-month course of oral fluconazole with complete resolution of all symptoms. Notably, he never had any musculoskeletal complaints during that episode. On review of systems he described a 10 to 15 pound weight loss over the past month with intermittent nocturnal fevers and sweats.The patient presented to our clinic with left anterior knee pain and limited range of motion. He reported an episode of “Valley Fever” two years previously when he worked in the Central Valley of California. The isolated pulmonary infection was ultimately confirmed to be On physical examination, the patient walked with an antalgic gait. There was a left knee effusion and warmth. He had localized tenderness along the inferior pole of his patella. His passive range of motion was limited from 5 to 95 degree. There was no palpable mass about the affected knee.Radiographs of his left knee demonstrated a joint effusion and lucency involving the inferior pole of patella, which was visualized best on the lateral view Figure . On CT p3) with a normal polymorphonuclear cell differential (66%) and a mildly elevated monocytic differential . His coccidioides antibody serology tests were positive by complement fixation (CF) method  as well as by the enzyme immunoassay method to IgG  and IgM  antibodies.Laboratory data at our institute revealed a mild elevation in the C-reactive protein level of 3.0  and the Westergren erythrocyte sedimentation rate of 22 . He had a normal white blood cell count  method  as well as qualitatively by the enzyme immunoassay method to IgG but not to IgM.Open biopsy was performed, and gross examination of tissue from the lesion was most consistent with infection. Frozen section analysis was non-diagnostic. Limited curettage of the lesion through the open biopsy tract was therefore performed. Final pathology revealed spherules filled with endospores, classic for coccidioidomycosis Figure . CultureThe patient noted immediate improvement of his knee symptoms post-operatively. One month follow-up revealed resolution of the patellar tenderness and normal knee function. The patient was seen by an infectious disease specialist and initiated on a 6 month course of oral fluconazole.Coccidioides spp., was once rare [Individuals at risk for Coccidiomycosis dissemination include persons of Filipino or African ancestry, pregnant or postpartum women, and immunocompromised patients -5,10,11.nce rare . The knence rare -9,12. Ofnce rare . Coccidince rare . A histoCoccidioides in culture [To formally establish a diagnosis of coccydiomycosis, Maves et al. proposed serologic testing, histopathologic confirmation, or growth of  culture . A posit culture ,15. Sero culture ,5,9,10. Imaging findings in musculoskeletal coccidioidocomycosis are nonspecific . The mosThough our first patient presented with a prior history of coccidioidomycosis, failure of the culture result and previous occult lab findings were obfuscating. Our second patient had no antecedent history of fungal infection; however, he did live in an endemic area. In both cases, the presence of an isolated osteolytic lesion made the distinction between infection and tumor more challenging.We are aware of two case reports describing chronic coccidiodomycosis of the knee ,16. In t“Written informed consent was obtained from the patients for publication of these case reports and any accompanying images. A copy of the written consents is available for review by the Editor-in-Chief of this journal”.Financial competing interestsNoIn the past five years have you received reimbursements, fees, funding, or salary from an organization that may in any way gain or lose financially from the publication of this manuscript, either now or in the future: NoIs such an organization financing this manuscript (including the article-processing charge): NoDo you hold any stocks or shares in an organization that may in any way gain or lose financially from the publication of this manuscript, either now or in the future: NoDo you hold or are you currently applying for any patents relating to the content of the manuscript: NoHave you received reimbursements, fees, funding, or salary from an organization that holds or has applied for patents relating to the content of the manuscript: NoDo you have any other financial competing interests: Non-financial competing interestsNoAre there any non-financial competing interests  to declare in relation to this manuscript: All authors reported that they have no financial interests or relationships that pose a potential conflict of interest with this article.YCL, GC, and RLR contributed to all aspects of the manuscript. CJH and KBJ participated in data analysis, drafting and revision of the manuscript, and final approval of the manuscript before publication. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2342/14/8/prepub


Tumefactive multiple sclerosis is a demyelinating disease that demonstrates tumor-like features on magnetic resonance imaging. Although diagnostic challenges without biopsy have been tried by employing radiological studies and cerebrospinal fluid examinations, histological investigation is still necessary for certain diagnosis in some complicated cases.A 37-year-old Asian man complaining of mild left leg motor weakness visited our clinic. Magnetic resonance imaging demonstrated high-signal lesions in bilateral occipital forceps majors, the left caudate head, and the left semicentral ovale on fluid-attenuated inversion recovery and T2-weighted imaging, and these lesions were enhanced by gadolinium-dimeglumin. Tumefactive multiple sclerosis was suspected because the enhancement indistinctly extended along the corpus callosum on magnetic resonance imaging and scintigraphy showed a low malignancy of the lesions. But oligoclonal bands were not detected in cerebrospinal fluid. In a few days, his symptoms fulminantly deteriorated with mental confusion and left hemiparesis, and steroid pulse therapy was performed. In spite of the treatment, follow-up magnetic resonance imaging showed enlargement of the lesions. Therefore, emergent biopsy was performed and finally led to the diagnosis of demyelinating disease. The enhanced lesion on magnetic resonance imaging disappeared after one month of prednisolone treatment, but mild disorientation and left hemiparesis remained as sequelae.Fulminant aggravation of the disease can cause irreversible neurological deficits. Thus, an early decision to perform a biopsy is necessary for exact diagnosis and appropriate treatment if radiological studies and cerebrospinal fluid examinations cannot rule out the possibility of brain tumors. Tumefactive multiple sclerosis (tMS) is a demyelinating disease. Because of its tumor-like features on magnetic resonance imaging (MRI) ,2, histo201Tl scintigraphy in both early and delay phases. However, the retention index  was 0.88, which was too low for malignant brain tumors to be suspected  scale ,11. MRI A few days later, he was admitted to our hospital because of progression of his left leg motor weakness . The day after admission, he exhibited mental confusion and left hemiparesis , and three-day consecutive steroid pulse therapy (1000 mg of methylprednisolone sodium succinate and 8 mg of dexamethasone per day) was applied. Despite the treatment, his symptoms did not improve, and MRI showed further enlargement of the lesions Figure . TherefoHistological investigation showed perivascular proliferation of lymphocytes without atypical features, and Kluver-Barrera staining displayed sporadic absence of the myelin sheath, suggesting demyelinating disease Figure . The majThe term 'tumefactive MS' is used when the clinical presentation and MRI findings are indistinguishable from those of a brain tumor . RecentlTo diagnose tMS without histological investigation is an initial approach to the disease. However, early biopsy should not be delayed if radiological examination failed to confirm the diagnosis.CD: cluster of differentiation; CSF: cerebrospinal fluid; MRC: Medical Research Council; MRS: magnetic resonance spectroscopy; MRI: magnetic resonance imaging; PET: positron emission tomography; tMS: tumefactive multiple sclerosis.Written informed consent was obtained from the patient for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SY was a major contributor in writing the manuscript. SMY performed surgery, analyzed the data, and revised the manuscript. HN and MM managed the patient, planned imaging studies, and analyzed the data. KH contributed to the conception and interpretation of the disease on the basis of several articles. AM revised the manuscript and provided important intellectual content. KY and YI performed the histological examination and diagnosed the demyelinating disease. All authors read and approved the final manuscript.


Mucinous cystic neoplasms are rare tumours of uncertain histogenesis. They arise from the ovaries, pancreas, and other intra-abdominal sites but more unusually from the mesocolon. They can present with abdominal pain, distension, or a palpable mass but are commonly an incidental finding. We describe the case of a 48-year-old woman who was found to have an incidental left pelvic cyst on computed tomography. Subsequent laparoscopic excision and histological analysis demonstrated the cyst to be a borderline malignant mucinous tumour arising from the mesocolon. Mucinous tumours should be considered in the differential diagnosis of all intra-abdominal cysts and treatment should be by surgical complete excision. Mucinous cystic neoplasms (MCNs) can arise from the ovary and other extraovarian sites including the pancreas, liver, kidneys, and appendix but more rarely from the mesentery. These mesenteric neoplasms are classified into benign cystadenomas, borderline tumours, and invasive carcinomas according to the presence of malignant features on histology. There are very few reported cases of mucinous cystic neoplasms of the mesocolon in the literature; moreover, those with features of malignancy are rarer still.A 48-year-old woman presented to our urologists with haematuria secondary to a renal calculus. Computed tomography (CT) revealed a 5 mm ureteric calculus and an incidental 71 mm by 57 mm cyst in the left pelvis that was initially believed to be an ovarian cyst . She was asymptomatic with respect to the cyst and had no relevant medical problems. There was a strong family history of pancreatic cancer on her paternal side and her father died of pancreatic cancer aged 57. There was minimal tenderness on deep palpation of her left iliac fossa. Routine blood tests were normal, and tumour markers CA19.9 and CEA were within normal limits.Transvaginal ultrasonography revealed a left adnexal cystic mass with slight thickening of the walls and anterior wall trabeculae. It was unclear whether this cystic mass was arising from the ovary itself. Magnetic resonance imaging of the abdomen was organised to define the anatomical relationship between these structures, which suggested a large simple cyst, possibly left paraovarian. It had increased in size to 82 mm × 65 mm × 105 mm since the initial CT scan six months earlier.At laparoscopy, the cyst was attached to the sigmoid mesocolon. The cyst was enucleated and 700 mls of fluid aspirated for cytology. The sigmoid colon and its mesentery were viable; thus, resection was avoided.Macroscopic examination showed a grey thin-walled, unilocular cyst, which was microscopically composed of dense fibroconnective tissue and ovarian-type stroma. The cyst was lined by mucin-secreting epithelium of intestinal type, including goblet cells. In the majority of areas, there was variable cellular stratification with formation of fused, cribriform structures and arborizing papillary formations. There were varying degrees of cytological atypia associated with increased mitotic activity. On immunohistochemical staining, there was widespread positivity to both cytokeratin-7 and -20.She was discharged home after an uneventful postoperative period. Her histology was discussed at our multidisciplinary meeting where it was recommended that she have a follow-up CT specifically focusing on her pancreas given her positive family history. Mucinous cystic neoplasms of the mesocolon are rare intra-abdominal lesions in the spectrum of mesenteric cysts . The majMCNs are histologically similar to ovarian mucinous cystadenomas . The cysThe treatment of choice is complete surgical excision given the malignant potential of these cysts . It permMCNs are uncommon tumours that are difficult to diagnose preoperatively. Their pathoneogenesis remains unclear. Given their malignant potential, they are an important differential for all intra-abdominal cysts. We recommend that the definitive treatment for all MCNs should be complete excision. This can be performed openly or laparoscopically depending on the size of the cyst, its location, and the skill of the surgeon.


Haemangiopericytoma (HPC) is a rare soft-tissue tumour with great histological variability and unpredictable clinical and biological behaviour. HPC of the bladder is exceedingly rare and carries uncertain malignant potential. The current study reports a case of HPC of the bladder in a 48-year-old female, who was admitted to the Sir Run Run Shaw Hospital  due to a large bladder mass. The patient exhibited no mass-related symptoms, such as pain, gross haematuria or urinary irritation. Seven years prior to admission, the patient underwent surgical resection of a bladder mass, which was determined to be HPC. Computed tomography scans showed a well-defined, heterogeneously enhancing solid cystic mass in the bladder. The patient underwent complete excision of the tumour and a partial cystectomy. The histopathological diagnosis was HPC of the bladder. The post-operative recovery was uneventful and no evidence of recurrence or metastasis was identified during two years of follow-up. The clinical and histological features, and the treatment and prognosis of this tumour are discussed together in the present study, with a review of the literature. The majority of primary bladder tumours are transitional cell  tumours. Cases of squamous cell carcinoma, primary adenocarcinoma or small cell carcinoma are encountered much less frequently . HaemangA 48-year-old female patient was admitted to the Sir Run Run Shaw Hospital  due to a large mass in the bladder identified during a health examination in June 2011. The patient exhibited no mass-related symptoms, such as pain, gross haematuria or urinary irritation. Seven years prior to admission, the patient underwent surgical resection of a bladder mass, which was diagnosed as HPC of the bladder. However, the patient did not attend regular follow-up examinations after the surgery. The patient was otherwise healthy. Computed tomography (CT) scans showed a well-defined, heterogeneously enhancing 6.2×5.0-cm solid cystic mass in the bladder . CystoscThe histopathological examination revealed a neoplasm consisting of spindle-shaped cells, which were arranged around the vasculature, with a ‘staghorn’ configuration . The imaThe post-operative recovery was uneventful, but the patient refused further adjuvant radiotherapy. To date, the patient has been followed up regularly with no evidence of recurrence or metastasis. Written informed consent was obtained from the family of the patient.HPC is a rare soft-tissue tumour, first described by Stout and Murray in 1942 . HPC was, attributed to the extensive metabolism of glucose within the tumour, was present in one case . I–9. I2–9)one case . In one one case . HoweverImaging is important in the diagnosis and management of HPC by demonstrating the vascular nature of the tumour and revealing the exact source of its blood supply, its size and its association with the adjacent organs. However, no characteristic signs of HPC have been recognised on ultrasonography, CT scan or magnetic resonance imaging. Commonly, previous studies have depicted a large mass, but with no pathognomonic features. Cystoscopy may reveal no intravesical pathology, but evidence of compression of the bladder wall.et al, in which the patient underwent a transurethral resection and the tumour recurred two years later . Since recurrence and metastasis may occur after a number of years, lifelong regular follow-up is necessary. To date, the current patient has been followed for two years and no evidence of local recurrence or metastasis has been identified.HPC of the bladder is an extremely rare tumour with unpredictable clinical and biological behaviour. Radical surgical excision is considered to be the cornerstone of treatment. Radiotherapy is reserved as the adjuvant therapy in cases of incompletely excised lesions and for recurrent or inoperable tumours. The efficacy of classical chemotherapy appears disappointing. In addition, since recurrence and metastasis may occur after a number of years, lifelong regular follow-up is necessary.